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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