Compulsory HIV Testing

No one can argue that HIV testing is a bad thing. Knowing one’s status allows a person to access treatment earlier, change risky behaviors, or rest assured that he/she is indeed HIV negative. With that said, why not make HIV testing mandatory for everyone? Hello, I am Katie Morris and this is The AIDS Pandemic, a podcast hosted by Dr. Dave Wessner, associate professor of biology, and his students at Davidson College.

Compulsory HIV testing—which requires that the entire population, or at least certain high-risk groups, is tested for HIV—has gotten a bad reputation in recent years from human rights activists who argue for a person’s right to choose to know whether or not they have HIV. However, studies have shown that usually, once a person knows he/she is HIV positive he/she will change his/her risky behaviors to avoid transmitting it to anyone else. Would compulsory testing not at least hinder the spread of HIV among populations? I fully support the freedom of choice, however I also support the right to live and if compulsory testing can reduce the number of people dying from AIDS it should at least be considered by policy makers around the globe.

One of the largest barriers to HIV research and prevention programs in the developing world is a lack of knowledge of the specific epidemics in each country. By requiring people to be tested for HIV, the public health community would gain valuable information on how many people are infected and what groups are most at risk, significantly aiding prevention programs. Bill Clinton, the former President of the United States and founder of the Clinton foundation, which funds a great number of HIV/AIDS programs around the world, is an advocate for mandatory testing in developing countries with high HIV prevalence rates. In a statement made to Reuters, he said, "[W]e can save people's lives, and we can reduce the stigma. There is no way we are going to reduce the spread of this epidemic without more testing because 90% of the people who are HIV-positive don't know it." Everyone who is sexually active, injecting drugs, receiving blood transfusions, or breastfeeding is at risk for contracting HIV, regardless of their age, skin color, education, financial status, or sexuality. Therefore in order to increase more individuals’ knowledge of their statuses so that they do not unknowingly spread HIV, testing needs to go beyond voluntary clinics.

In the aforementioned quote, President Clinton made a statement about reducing the stigma around HIV by implementing mandatory testing. This statement is contrary to what many human rights groups argue. Their concern is primarily with confidentiality breaches, especially in the developing world where the poor infrastructure cannot guarantee secure record keeping and adequate training for counselors. While a valid concern, so much of stigma surrounding HIV in the developing world involves testing itself. People are reluctant to be tested because they associate HIV testing with people who are promiscuous, homosexual, or drug users. By requiring everyone to be tested, the stigma associated with those walking into an HIV testing clinic is eliminated. Also, in places like sub-Saharan Africa where many countries have HIV prevalence rates above 5%, mandatory testing has the possibility to normalize being HIV positive. Of course this requires time and the decision by people to be open about their status but there is potential to show that everyone and anyone can contract HIV and that good things—like treatment, support groups, and advocacy opportunities—can result from knowing your status earlier.

Unfortunately, once you get into the implications of such a policy, things do not remain so straightforward. In the developed world, many argue that compulsory testing is simply a waste of money. That same Reuters report found that in order for population-wide mandatory testing to be cost-effective, the prevalence rate should be above 5%. In the United States where HIV prevalence is believed to be less than 0.004%, mandatory HIV testing may not be the most financially wise decision even though the U.S. is one of the few countries that can actually afford to successfully implement a compulsory HIV testing program. It should be noted that there are certain high-risk groups in specific regions of the U.S. with prevalence rates above 5% that could benefit from mandatory testing. However, requiring testing of one group and not another can be considered discrimination and stigmatize or alienate certain people.

In the developing world where, again, many countries, particularly in sub-Saharan Africa, have HIV prevalence rates above 5% and could seemingly benefit from population-wide HIV testing, new issues arise. First and foremost, these countries lack the resources to be able to test everyone. HIV tests are expensive and require sanitary facilities, laboratories, and trained professionals to draw blood. With this blood test, it can take up to three months to obtain results, creating a large loss due to follow-up. Furthermore, what happens next? HIV testing is only beneficial if it is accompanied by proper education and counseling. These are additional costs and require more trained professionals that are difficult to find in the developing world. If a person tests positive, where do they go from there? Will policies be enacted that require the person to disclose their status to their friends, family, or sexual partners? How will this be enforced? What if ART is not available or affordable to the person who tests positive? Their positive test results have just come as a death sentence, which can lead to a fatalistic attitude and discourage behavior change. If a person tests negative, there is a danger of developing a complacent attitude—since he/she does not have the virus, he/she may feel no responsibility to the HIV epidemic.

Although the benefits to compulsory HIV testing are clear, the realities of implementing a population wide mandatory testing campaign around the world make it not the best option at this point in time. In the developed world where prevalence rates are low, the cost of HIV tests outweigh the benefits of finding the few positive people. This might not always be the case in the future with treatment regimens improving and the early-detection of HIV reducing the long-term opt-out costs of ART. In the developing world, infrastructure, financial, and human resource barriers raise concerns to human rights groups and make the implementation of such a program a nightmare. Also, there remains the question of what to do from a policy standpoint for the people who do test positive. Compromises can be made to reap some of the benefits of compulsory testing without requiring all of the necessary resources. First, there are certain groups that should be required to have HIV tests—pregnant mothers to prevent transmission of HIV to their babies, health professionals to reduce the risk to patients, and sex workers in areas like the Netherlands where their profession is regulated. Second, opt-out HIV testing policies (administering an HIV test to everyone except those who specifically ask not to be tested) are a great way to encourage more HIV testing without requiring it. This is more effective in the developed world where people go for annual health check-ups but there are creative ways to bring opt-out to the developing world through mobile clinics strategically placed in markets, farms, churches, or schools. Compulsory HIV testing is a messy topic but that doesn’t mean the discussion should end there. We should continue to find ways to have as many people as possible aware of their HIV status in hopes of slowing the spread of the HIV epidemic.

Katie Morris, & David R. Wessner (2010). Compulsory HIV Testing The AIDS Pandemic