This review highlights a number of findings about scaling up HIV testing in Burkina Faso, Kenya, Malawi, and Uganda. First, the scale, design, availability, and quality of HIV services are changing rapidly in these settings. As a result empirical evidence about HIV services may become outdated within a short period of time, which is one important limitation of this review. Second, there is great variety in the ways in which HIV testing and counseling services are delivered – both among and within the countries profiled in this paper. There is also a diversity of quality of care, outcomes for patients, provider practices, and the extent to which patients access treatment and care after being diagnosed with HIV. In other words, there is no monolithic “resource poor setting”. A systematic analysis of how these differences affect key ethical questions is beyond the scope of this paper, but it is an important issue for researchers to address in the future.
Regarding the ethical dimensions of HIV testing, this review suggests a number of findings. First, ethical concerns voiced at the international level do not always correspond to debates on the ground, as illustrated by the decision by governments in Kenya, Malawi, and Uganda to implement routine PITC even before WHO and UNAIDS issued their 2007 guidelines [2
], despite international controversy over this approach. The most salient policy questions about HIV testing in these countries is no longer whether
to scale up routine PITC (and other strategies), but how.
Instead, individuals, health care providers and policy makers are struggling with a host of difficult ethical questions about how to protect rights, maximize benefits, and mitigate risks in the face of resource scarcity.
The international ethical discourse about HIV testing has focused on four main questions: how do different testing policies and practices undermine or strengthen informed consent and medical confidentiality? How well do different modalities of testing provide benefits that outweigh risks of harm? To what degree do current testing policies and programs provide equitable access to HIV services? And finally, what lessons have been learned from the field about how to improve the delivery of HIV services to achieve public health objectives and protections for human rights?
Concerns that routine PITC might undermine informed consent have some merit, as illustrated by women in ANC who believe that HIV testing is mandatory for pregnant women. On the other hand, routine PITC may have strengthened women's ability to make autonomous decisions about their own health in settings where, prior to routine PITC, women believed that they did not have the right to test without their husband's or family's consent. A comparative analysis of consent in the four MATCH countries has shown high levels of consent across modes of testing (86%), with the level only slightly lower (83%) among PMTCT testers [64
]. Routine PITC has complex implications for autonomous consent: while these policies make it harder to say no for those women who wish to decline or are ambivalent, they make it easier for those who wish to know their status to say yes. This has been most clearly demonstrated for women in antenatal care, but it may apply to other groups and testing modalities as well. For example, authors of a ten country study in southern Africa concluded that large proportions of the population want to know their status but “may not feel empowered to get themselves tested” [18
With regard to risks and benefits, some evidence suggests that negative life events following HIV disclosure are less common than once feared [107
], and it is possible that stigma and discrimination may decline as access to testing and treatment expands. Meanwhile, expanding access to testing and treatment in these four countries has made the biomedical benefits of HIV testing increasingly clear for individuals, their children, and their partners. WHO estimates suggest that the greater availability of ART has helped reduce AIDS related mortality globally, and within sub-Saharan Africa specifically, where an estimated 30% fewer people died from AIDS-related causes in 2010 than in 2004, following the dramatic expansion in access to ART in that region [6
]. Moreover, evidence about the potential public health benefits of testing and treatment is changing rapidly. Until recently, researchers believed that expanding testing could reduce HIV prevalence primarily by encouraging people to reduce high risk sexual behavior [4
]. However, research published in 2011 found that early treatment of those who tested positive reduced transmission to partners by 96%, suggesting that testing combined with early treatment has enormous untapped potential for prevention [154
]. As the knowledge base on treatment as prevention grows, policy makers will have to address questions about the ethical and public health rationale for eligibility requirements that delay treatment until patients meet criteria based on CD4 counts [155
]. At the same time, individuals who test positive for HIV in these four countries often face serious barriers to care, and expanded testing will not provide full benefits for those living with HIV until health systems can address the systemic, social and economic challenges that undermine linkages to care [77