Scaling Up HIV Prevention: Why Routine or Mandatory Testing Is Not Feasible for Sub-Saharan Africa

Article excerpt

Introduction

Global HIV incidence may have peaked (1) but calls for scaling up prevention have not diminished. The number of new infections worldwide remains high (4.1 million in 2005) with some regions previously unscathed experiencing rising incidences of HIV. (2) The number of patients presenting late at health facilities with advanced HIV/AIDS is also a cause of concern. In general, there is a growing sense of frustration that global efforts to prevent HIV/AIDS are being outpaced by the spread of the pandemic. (3) Consequently, calls have been made for a more pragmatic approach to containing the disease, with routine and mandatory testing gaining increasing attention. The US Centers for Disease Control and Prevention (CDC) recently proposed a new approach for HIV testing in adults, adolescents and pregnant women under which testing will be routinely offered in all health-care settings. No signed consent from patients would be required under this new proposal; the general consent for medical care would be considered sufficient to encompass consent for HIV testing. (4,5) Former US President Bill Clinton has also lent support for mandatory HIV testing in countries where the prevalence rate is 5% or higher. (6) Political support for mandatory testing has been seen in countries like India, where the state government of Goa has proposed mandatory premarital testing, and in China, which plans to test all workers in the tourism industry. (7) But would routine or mandatory testing make any difference in preventing HIV/ AIDS in sub-Saharan Africa?

Access to treatment

HIV testing and treatment are inextricably linked; access to treatment and medical care is as essential to encouraging testing as testing is essential to expanding treatment. While recent debate about scaling up HIV/AIDS prevention has passionately focused on expanding testing, especially in sub-Saharan Africa, calls for scaling up access to treatment on the continent have been less vigorously heeded. This is not to say that no progress has been made in expanding access to treatment. There have been significant improvements following the "3 by 5" initiative, but even with those improvements, only 18 out of the 53 countries in Africa had 25% or more antiretrovirai (ARV) coverage in June 2006. (3) The "3 by 5" initiative, albeit laudable, appears to have suffered a late similar to other impressive but unrealistic ideas of the WHO, including the health for all philosophy. Fig. 1 shows estimated access to antiretroviral therapy by geographical region in 2005.

The unmet ARV needs of sub-Saharan Africa remain disproportionately high. About 4.2 million people in need of treatment were without access to ARV therapy in June 2005. In countries such as the Democratic Republic of the Congo, Ghana and the United Republic of Tanzania, ARV therapy coverage was below 5%. (8) In contrast, about 70% of the estimated 15 310 people living with HIV in Australia in 2005 were receiving antiretroviral treatment. (9)

There is no denial that even without treatment, testing and knowledge of one's HIV status are important because a positive HIV test could activate behaviour modifications that may reduce the risk of onward transmission of the virus. However, while some individuals even without access to treatment may have incentives to know their HIV serostatus, the logic of undergoing testing when there is clear evidence of no access to treatment may seem perverted at best to many people. Whether routine or mandatory, the rationale behind avoiding HIV testing where there is no hope for treatment, if needed, is not hard to digest. Scaling up access to treatment therefore is a vital step towards encouraging testing in sub-Saharan Africa and dispelling the misconception that HIV/AIDS is a "death sentence"--a misconception that increases fear and obstructs testing. (10)

Weak health systems

African health systems are abysmally weak; inadequate health workforces, poor management, and inefficient resource allocation and utilization have severely weakened the capacity of most health systems on the continent. …