Botswana’s “opt-out” HIV testing or “informed consent”, which makes it routine but not compulsory in medical settings, has proved to be one of the effective preventive strategies, say University of Botswana lecturers, Elizabeth Busang and Dr. R. A. Kumar.
Commenting on Botswana’s ethical and human rights issues in prenatal HIV testing counseling in Gaborone last week, Busang and Kumar said, according to epidemiological research, the HIV testing “opt-out” policy is critical to both HIV prevention and treatment.
They further contend that testing identifies symptomatic and asymptomatic individuals with HIV and provides an entry point to care.
Patients must, however, retain the right to refuse testing, i.e. to “opt-out” of systematic testing, in settings where provider-initiated testing, whether for purposes of establishing HIV status as part of an individual’s clinical care and treatment or offering pre-natal anti-retroviral treatment (ART) to pregnant women, should they be found to be HIV-positive.
“However, the policy makes it clear the “opt-out” testing can only take place in a setting where mechanism exist for counseling and referral for medical and psychosocial support after testing. The pre-test counseling may be cut short, compared with voluntary counseling and testing (VCT) but sufficient enough to provide informed consent,” say Busang and Kumar. “Informed consent refers to a patient or client being given information on knowing one’s status, having and understanding of the HIV testing procedure and then taking the decision to be tested for HIV. The ethical issues include respecting the decision of an individual and protecting people who may lack capacity due to the situation they are in.”
Busang said for informed consent to have the best results, incumbents should address emergent challenges by equipping the service provider with adequate information, motivate adherence to ethical issues and keeping standards as well as assuring quality in any action taken.
She said in 2004, Botswana’s former President Festus Mogae declared the country’s commitment to the “opt-out” HIV testing policy and national compliance of international obligations when addressing the 17th International AIDS Conference in Mexico in 2008. Mogae had said HIV testing in Botswana should be routine and not compulsory in medical settings and stressed that whilst the government must remain committed to the country’s comprehensive treatment programme, hopes of ever overcoming HIV/AIDS lie in controlling transmission. Botswana has, however, been at the forefront in its response to the HIV/AIDS epidemic led by a strong political commitment with a comprehensive plan of action with Mogae as chairman of the National AIDS Coordinating Agency (NACA).
The India-born Kumar, who has acquired worldwide experience from working in UN agencies and the African Union, said UNAIDS/WHO policy statements introduced the practice of routine, provider-initiated “opt-out” testing as a preventative strategy. As far as the international guidelines on HIV testing are concerned, the cornerstones scale up must include protection from stigma and discrimination at the same time allowing access to integrated prevention, treatment and care services. The conditions of testing must be anchored in a human rights approach, which guarantees and protects individual rights and pays due respect to ethical principles.
“Based on the informed consent under the WHO “opt-out” policy, incumbents should be aware of the clinical and preventative benefits of testing; the right to refuse; and the follow-up services offered. In the event of a positive test result, there is need to inform anyone with an ongoing risk, who would otherwise not suspect he/she was being exposed to HIV infection,” said Kumar.
“Globally, HIV-testing is a pre-requisite to scale up the response to HIV/AIDS and to access treatment. It must be grounded in sound public health practice and also respect the protection and fulfillment of human rights norms and standards. The voluntariness of testing must remain at the heart of all HIV policies and programmes, both to comply with human rights principles and ensure sustained public health benefits.”
Kumar added that, according to UNAIDS, health practitioners should ensure an ethical process for conducting a test, defining the purpose and benefits of testing; as well as assurances of linkages between the sites where the test is conducted, upholding confidentiality of medical information. Addressing the implications of a post test result such as access to sustainable treatment and care; erasing HIV/AIDS-related stigma and discrimination at all levels within the health care settings; and ensuring a supportive legal policy framework within the response is scaled up, safeguarding the human rights of those seeking services and adequate post-diagnostic infrastructure, form UNAIDS’ key factors.
Due to the infinitesimally low opt-out rates during HIV testing ranging from 6.8 percent to 11.2 percent for the mid 2000s and beyond, the government has been able to obtain fairly accurate estimates and declared HIV/AIDS a national emergency calling for an aggressive and expansive multisectoral response to fulfill the long-term vision of having no new HIV infections by 2016,based on the 2008 Epidemiological Fact Sheet on HIV and AIDS showing the HIV rate in Botswana at a glance, close to 300 000 adults aged 15 to 49 or 23 percent of the population were living with the virus. Out of these estimates, around 15 000 were children aged 15 and below. Deaths due to HIV/AIDS related illnesses amounted to an average of 11 000. There were about 95 000 orphans and vulnerable children (OVC) aged 17 and under.
As one of the first African countries to establish free national ART programme covering over 80 percent of those in need, Botswana with a population of around 2 million has seen the number of HIV-related deaths decline from a peak of over 15 500 in 2003 to under 7 400. Allowing room for new infections, the need for ART is, however, expected to increase by 60 percent by 2016.