Recommend Mandatory HIV testing for Couples

HIV - PMTCT

The proposed HIV Prevention and Control Bill is before the public for consultation. One of the contentious issues in it is the mandatory HIV testing for pregnant women during uptake of ante-natal care (NV July 18th). This proposal has generated genuine concerns over ethical principles, notably; autonomy, confidentiality and informed choices. The civil society organizations have picked on these issues well. Our moral sense must be governed by categorical imperative not to harm the unborn fetus and the mother.

 The civil society organizations also highlighted several social-cultural imperatives that places the woman at a heighten risk of vices such as domestic violence, stigma, victimization, alienation from marital home and property; and getting punished unjustly physically and emotionally by the social system that views women as sole gateway to HIV infection.

Arguably, there is a moral to the perspectives of the civil society organizations, but there is also an imperative on the side of government to take bold measures to curb down the rising trends of HIV infections. No doubt, installation of mandatory testing requirements creates many barriers to using healthcare services; it is unethical and violates many international standards. But this is also the ethical dilemma that a need for such drastic measure may generate.

The underlying reason for the provision of mandatory testing during interface with the healthcare system is because Uganda has enrolled in the WHO option A of the Prevention of mother to child transmission of HIV. This option requires the measure of CD4 before a mother or anyone as such, can get enrolled for the Anti-Retroviral Treatment (ARTs).

Recognizably, there is pressure on most sub-Sahara Africa to put in place frameworks to reduce the transmission of HIV from mother to Child. Significant results have been recorded already in this area in Malawi and Botswana where there is an increased uptake of HIV testing by over 93% of pregnant women. Malawi now boost of 3% reduction of mother -to-child HIV infection through its bold implementation of WHO recommended ART B/B+ option treatments, despite having this measure in only limited number of districts.

HIV testing is a tough personal and intrusive process that plays out on the human emotions and generates fear. Laws requiring mandatory HIV testing become insensitive to the autonomous nature of humankind. It deprives one of pre-testing services and violates the principles of confidentiality.

Best practices world-over is such that everyone is accorded a just environment to make informed decision during such moments of vulnerability. Therefore this debate is indeed an ethical one which must be handled rationally and with an ethical decision making framework for its a buy-in and sustainability.

There is merit for every pregnant woman to know her health status and this includes her HIV status. This merit extends beyond the pregnant woman but to the general populace. When the pregnant woman comes to know her HIV status, she begins ante-retrovirus treatment (ART) early with a possibility of experiencing less stressful pregnancy. This also benefits the mother-child dyad by enhancing the prevention of transmission of the virus from mother to child.  

To add value to the proposed Bill, a national consensus has to be built around early detection of HIV and sexually transmitted diseases to reduce the rampant maternal-child mortality that has haunted our society. A regular, at least thrice a year complete medical examination including HIV status must be encouraged for a population that exists in precarious moral situations like it is in Uganda.

The Bill’s focus on HIV prevention must be rooted in social cultural realities that focuses on four players; the unborn fetus, the mother, the father and the community from which the couple belong.

The intricate complexities involving these players, ensures that HIV prevention is not merely a medical issue, but a social one as such. To provide effective HIV testing and prevention services, there is need to move the services to the communities because it is within these communities that issues of stigma and victimization takes place.

Further, reports show that men tend to resist HIV screening, as a result, statistics show disproportional numbers of women to men, as living with HIV and yet it is more likely that a man uses multiple partners than a woman. There must be HIV family centre testing requirements that compels every couple to pre-test counseling and HIV testing irrespective of pregnancy. This approach may lessen the blame burden on the woman and provides her with the confidence to enjoy her reproductive rights without fear.

Case studies

Lessons from Malawi, Ghana, Kenya, Tanzania, Rwanda and Botswana can attest to these. In Malawi the controversy over mandatory testing was resolved by creating an alternative pathway service delivery in their PMTCT national guidelines. Each pathway is provided with pre-test counseling services for individual and family to attend clinics with their sexual partners. A pregnant mother is offered counseling before testing, if they consented to testing and found to have positive HIV results; they were put on WHO option B+ ART therapy and provided support by trained community agents through the pregnancy. The mother remained on ART for life.  

The Option B+ does not require CD4 count like it is for Option A that Kenya, Uganda, Tanzania and South Africa are adopting, and it is cheaper to administer. In the second pathway option, pre-counseling was provided to the pregnant women and family irrespective of level of literacy. If she or her family declines, she is processed through the system and provided counseling at every point of contact with the healthcare system while being reminded that they can decline to HIV tests. These services extend to the community.

According to UNICEF and UNAIDS 2013 reports, Malawi’s approach initially reduced the uptake of antenatal services, but after a short period, a surge was registered because of the benefits that some of these communities started seeing – that children are being born without HIV while the mothers on ART remained healthy to nurse and nurture their children. Over 90% of women are using HIV testing services and are getting enrolled and the Maternal-Child transmission has reduced to <5% in both Malawi and Botswana.

While there is a focus on ensuring that pregnant mother's get the treatment that they need, and that HIV transmission to the child is prevented, the law must propose a comprehensive family oriented approach. To ensure that women do not become victims of HIV testing, the law must encourage couples to undergo tests during visits to ante-natal clinics following counseling.

In places like Canada, once found to have any sexually transmitted disease, one is required to disclose recent sexual partners for follow-up by public health. This is largely because it is against the law to knowingly infect another person and is punishable by jail if found to have been negligent.

Uganda may not be bold enough to enact such a law, but under the current situations, there must be an integrated approach to HIV care which combines a number of fronts and yet very rational and ethical in all its vestiges.

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Ticker: Exploring Critical Issues on HIV/AIDS Fight in Uganda

HIV/AIDS

The cloud of gloom has yet transcended upon Uganda as global experts fear that the country is losing its gains in the fight against HIV/AIDS. Over the years, experts like Festus Mogae and Stephen Lewis have shown pessimism that Ugandans have become complicit to the advent of anti-retroviral medication that provides hope for a prolonged onset of AIDS. Further, the political will that previously elevation and sustained a high profile of HIV/AIDS among the population has been usurped by corruption and ideological disunity that threatens human rights.

This article intends to bring a critical perspective in the HIV/AIDS discourses and it intends to point out the critical gaps where current health service orientations have been unable to cover. There are fundamentally three areas that requires urgent attention if Uganda is to gain its stead to return to its glory path of curbing HIV. These areas are an investment in an integrated behavioural change approaches; adhering to strict and accurate data collection and management and; expanding existing healthcare systems to care for communities, rather than individuals.

Behaviour change

The Daily Monitor newspaper on May 18^th, 2013 quoted Mr. Musa Bungudu, UNAIDS country coordinator as casting fear on the rising prevalence rate of HIV in Uganda.  New cases of HIV infection show an increasing trend, from 124,000 in 2009 to 145,000 by 2011. On the average 353 Ugandans are infected daily and over 60,000 Ugandans die annually from HIV/Aids related ailments. Prevalence rates continue to vary from place to place, peaking at fish landing sites, conflict studded areas and urban centers. These are not small numbers, but they also don’t tell the entire truth due to many factors, but mostly that many Ugandans are still not testing their status.

Further, complacency to anti-retroviral medication treatment, sustained beliefs in mysticism and witchcraft as well as partaking in risky sexual expeditions are key domains of Uganda’s regular lifestyles. And yet it is empirically known fact that the most common route of HIV infection is through the sexual route and blood transfusion. Somehow, irrespective of unintended accidents, HIV can majorly gain entrance in the human body through the body fluid – blood.

In the early 90s, it was excusable for anyone to conduct themselves dangerously as to have unprotected sex with an excuse that they didn't know how to access and use condoms. Many did not have explicit access to HIV screening or testing services. These arguments should be stale in the current epoch because condoms have been with us for the last 30 years and with the advances in media coverage and telecommunication system in Uganda, not using condoms or testing for HIV and other preventable diseases is no longer justifiable.

Therefore, a behaviour change effort must be made through a combination of policies and a deliberate reflexivity from cultural standpoints if we are to tackle the HIV scourge.

Further, Ugandan society is still largely patriarchal along its social and cultural landscapes. What this means is that age and gender remains major factors of subordination. Males are still repressive of the females and older individuals are still suppressive of the younger ones. In essence, women and young people – both boys and girls- continue to internalize their position in society as that of being submissive to the older and more so when they are men, making them easy prey. This fact also corresponds to high prevalence rates among this group (15-19 at 7.3% and women at 8.3%). Further, the people on retroviral treatment appear to be healthy and yet, their health also becomes the resource for their silence that leads to the spread of the virus – most especially when they are “loaded” or acting as sugar-mommies.

Research have found that it is the men who are more reluctant to seek HIV testing and even when they know that they are infected, they still blame it on their sexual victims who happen to be women or younger individuals than them.

This brings me to the issue of HIV prevalence and incident rates. These are epidemiological terms meaning “new” and “existing” cases of HIV among a population of 1000 people. In Uganda, the estimated national prevalence rate is about 7% and the total estimated number of people considered to be HIV carriers are 2.2 millions as of 2012.

These figures are contestable irrespective of whether they are World Health Organization's estimates or from Ministry of Health in Uganda. My contentions are as follows; most of Ugandans who seek HIV screening are Urbanites and often they chance on the results upon seeking treatment for other symptoms.

 In as long as Ugandans are asymptomatic, they would endure all sorts of silent killer diseases, like hypertension, diabetes and HIV infection, without seeking care. It is during this time that they will also distribute the virus indiscriminately. Therefore, most HIV statistics are taken at focal points when it is too late and yet it is very difficult to draw inferences for deaths outside the hospital where rural autopsy would consign it as witchcraft, poisoning or suicide. Therefore, a conservative estimate would say that the national prevalence rate is about 13% and the total number of incidences of HIV at about 5 million people!

Healthcare system’s deficit

Further, the failures of our healthcare system to succinctly capture, record and follow children who are born with the virus adds weight to the numbers dilemma. In the early 90s when Rakai was symbolic of the HIV/AIDS debacle, we were shown so many orphans whose parents had died due to HIV/AIDS. Most of these children were born with the infection. Today, they have become of age and some of them are pretty humbled by their modest upbringing under churches and orphanages. Many of them are virgins while a host o f them are the ones jumping helter skelter on the street with mind blowing minis and stilettos.

Unfortunately, the state cannot account for these and yet they are occasionally adding to the increasing number of HIV prevalence in Uganda.

The fight against HIV/AIDS is failing, not because of a single factor, but a multiplicity. This also means that the solution to the HIV problem should be an integrated approach that focuses on behavioural change at all levels of society. Ugandans must become bold to reclaim their moral aptitude and begin to conduct themselves with some sense of purpose beyond hedonism.

The Uganda of today is as tense as and worse off than Biblical Soddom and Gomorrah with promiscuity. Literally every married couple is a cheat and every person in authority is corrupt. In essence, Uganda is a country where both the cat and the mouse fight to swallow each other, such that each has become fearful of the other. The elders who should reinforce morals are themselves so devoid of such authority and yet the young people, in whose hands our futures should behold, are running amok with a life so precariously!

Integrated systems

Finally, the healthcare system requires restructuring to ensure that it is expanded outwardly to treat the community more than the individual. A combination of community based medical model which integrates social behavioural and biomedical sciences can help mediate between individuals and their precarious cultures. This model offers a formidable fruitful venture in healthcare investment, at public and private sector levels. This will also imply that we stop treating symptoms, but we treat the disease, the people and community all at once and it comes at a lower cost to the public purse.

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