Mandatory HIV testing will backfire

"Testing for HIV is more than a mere biological test"   
Last month, India's Karnataka State proposed mandatory HIV testing for couples. This month, Andhra Pradesh State suggested mandatory testing before marriage following a similar move by Goa in April 2006.But will mandatory HIV testing alone reduce the rate of new infections? Public health experts and advocates say it won't.

"We need to raise awareness about HIV, reduce stigma associated with HIV, especially stigma within health-care settings (which keeps people away from accessing these services) ?, strengthen primary healthcare services and raise sensitivity to the issues of confidentiality and dignity of life of those living with HIV," said noted health care rights advocate Jashodhara Dasgupta of SAHAYOG and Health Watch. The progress we have made towards integrating HIV prevention and treatment is at risk of being lost if Indian states start promoting HIV prevention strategies while completely ignoring the need to treat, support and care for people living with HIV (PLHIV).

But Andhra Pradesh Chief Minister Y S Rajasekhar Reddy was quoted by Rediff News on 17 April as saying, "I fail to understand the reasons behind the objections raised by some human rights activists on the government's initiative for making HIV/AIDS tests mandatory for couples before marriage." India is at a new crossroads in HIV control with serious divisions emerging between the promoters of mandatory testing and the supporters of voluntary options.

Human rights advocates warn Dr Reddy that the impact of a positive HIV diagnosis on an individual's life is enormous. The stigma, discrimination and denial often associated with an HIV positive status can affect a patient in many ways. What programmes are there for people who test positive? Will they be left to face life without access to even primary health care services?

As we prepare to complete disregard the confidentiality guidelines of the National AIDS Control Organization (NACO) and allow information on the HIV positive status of potential brides and grooms to be shared among their communities, are we prepared to meet the health care needs of the people who test positive? And are we prepared to ensure that they will not be forced to lead a life adversely affected by stigma, discrimination and denial? An official from the Joint United Nations Programme on HIV/AIDS (UNAIDS) has said that India needs to consider the fact that mandatory HIV testing may prove to be counter-productive as it violates a patient's right to privacy, stigmatizes whole families and "tends to create a black market in false HIV test results." Senior Advocate Colin Gonzalves has also argued that "any mandatory testing is wrong. Couples should rather be counselled and educated," adding that, "If they want to get a testing done by choice after that, it's their business. But a mandatory test can't be imposed on them".

NACO guidelines add that, "Testing for HIV is more than a mere biological test for it involves ethical, human and legal dimensions. The government feels that there is no public health rationale for mandatory testing of a person for HIV/AIDS. On the other hand, such an approach could be counter productive as it may scare a large number of suspected cases from getting detected."

HIV testing alone does not result in the types of behavioural changes that will prevent the transmission of the virus. It should be an integrated part of comprehensive control programmes that promote behavioural change by providing social support and the means and skills to reduce or eliminate the risk of transmission. "Otherwise such testing can drive the target people underground and make it more difficult for launching intervention," according to one NACO official. As access to antiretroviral treatment increases, we have the opportunity to simultaneously expand access to HIV prevention programmes, which continue to be the mainstay of the response to the HIV epidemic. Without effective HIV prevention, increasing numbers of people will require treatment. Among the intervention methods that play a pivotal role in both treatment and prevention, HIV testing and counselling stand out as paramount.

The current reach of HIV testing services remains poor. The reality is that stigma and discrimination continue to discourage people from being tested. To address this, HIV testing programmes must include improved protection from stigma and discrimination, especially within the health care setting, as well as assured access to integrated prevention, treatment and care services. Earlier this month, a pregnant woman with HIV died after being denied medical attention in Indore. It is clear that India has a long way to go before it has a public health system strong enough to deliver effective health care to the most under-served communities. Mandatory HIV testing alone will certainly not provide a short-cut.

Bobby Ramakant-CNS