HIV TESTING POLICIES# GUIDELINES
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HIV
TESTING
POLICIES#
GUIDELINES - extracted text
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HIV
TESTING
POLICIES#
GUIDELINES
World Health Organization
Regional Office for South - East Asia
New Delhi
1994
06327
"HIV Testing Policies - An
Overview", Vol. 97, November 1993, pp
HIV
TESTING
POLICIES &
GUIDELINES
World Health Organization
Regional Office for South-East Asia
New Delhi, India
1994
INTRODUCTION
States in 1981. The etiological agent, Human Immunodeficiency Virus (HIV), was isolated
This enabled health care workers to diagnose HIV infection, individuals to know whether
or not they were HIV infected, and most importantly, medical science to understand
the role of HIV testing. These misconceptions were particularly witnessed worldwide
to believe that the spread of HIV can be controlled by identifying people with HIV infection,
and testing of hospital patients or groups of people practising high risk behaviour are often
HIV testing in the overall context of national AIDS control programmes.
PURPOSE OF HIV TESTING
are far more complex. AIDS is invariably fatal and infection is lifelong. No drugs are
available to cure AIDS or to render an HIV-infected person non-infectious. Since HIV is
unfortunately often stigmatized and discriminated against. Such a situation results from
the lack of proper understanding regarding the mode of transmission, particularly the fact
that HIV infection cannot be transmitted by casual social contact or through the respiratory
route. Unlike other diseases, identification of people with HIV infection or AIDS, therefore,
is neither rational nor appropriate.
HIV testing is recommended by the World Health Organization (WHO) only for
sentinel surveillance using unlinked anonymous HIV testing methodology where all
the results of HIV testi i
t
he person - the specific
epidemiological surveillance respectively; (3) diagnosis of symptomatic infection among
among asymptomatic persons who would like to know their HIV status. In the latter two
situations HIV testing is carried out with informed consent and with strict maintenance of
confidentiality. No situation other than the four listed above warrant HIV testing, and there
informed consent. Experience shows that any kind of HIV testing without the full and
PUBLIC HEALTH RATIONALE AGAINST MANDATORY TESTING
behaviour is contemplated. The 45th World Health Assembly, to which all countries were
signatory, noted that "there is no public health rationale for any measures that limit the
basis and with appropriate counselling is more likely to promote behaviour change than
mandatory testing’3’. Furthermore, mandatory testing measures can be counter-productive
of which such persons do not have access to education and counselling programmes.
false sense of security among the general public that all HIV-infected persons are known
testing is an expensive business, not only to National AIDS Programmes because of the
high cost of HIV kits but also to individuals from the psychological point of view when the
maintained. Additional details addressing the question "Can mandatory HIV testing stop
HIV TESTING IN HEALTH CARE SETTINGS
Many health care workers, however, seem to mistakenly believe in programmes of
mandatory HIV testing or of testing without consent because of the fear of contracting HIV
in the health care setting. Although there is a risk of HIV being transmitted in these
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offer facilities for HIV testing, many people, including those with high risk behaviour, may
use these services to determine their HIV status thus compromising/endangering the
safety of blood. In summary, the only roles that HIV testing can play in the health care
compatible with AIDS and to offer voluntary testing services to people who wish to know
their HIV status. In both the situations, the testing should be voluntary with provision of
adequate pre- as well as post-test counselling.
VOLUNTARY TESTING AND COUNSELLING
Voluntary HIV testing always in conjunction with counselling has a place in national AIDS
prevention, care and supports'7’. HIV testing, to be beneficial, should however be entirely
voluntary and anonymous, with no possibility of breech of confidentiality. Voluntary HIV
testing should be part of a comprehensive counselling programme which provides support
counselling on its own is a valuable intervention even if HIV testing is not available or if
the person decides not to be tested.
Thailand. In countries where these services are not yet widely available, their introduction
should proceed cautiously in order to ensure that confidentiality or anonymity is
guaranteed and that the services are delivered in a manner most likely to result in benefits
to the individual and to public health.
programmes. However, it should be carried out in a rational manner and without resort to
coercive approaches. Mandatory testing or testing without informed consent is not only
out only for those purposes which are specific objectives of National AIDS Control
Programmes.
References
WHO Global Programme on AIDS. Recommendations for the selection and use of
(2) World Health Assembly Resolution 45.35, 14 May 1992
WHO Global Programme on AIDS. Global strategy for the prevention and control of
AIDS, 1992 update. AIDS Series No. 12.
(4) Ciesielski C et al. Occupationally acquired HIV infection - United States. 9th
International Conference on AIDS, Berlin, 1993 (Abstract WS-c12-1).
Report of a WHO Consultation on the Prevention of Human Immunodeficiency Virus
Global Blood Safety Initiative. Consensus statement on screening of blood donations
Feb. 1990. WHO/LBS/91.1
WHO Global Programme on AIDS. Statement from the consultation on Testing and
Counselling for HIV infection, Geneva, 16-18 November 1992. WHO/GPA/INF/93.2
HIV Testing Policies and Guidelines
Can mandatory HIV testing stop the AIDS epidemic?
Forcing someone to undergo medical testing of any kind is an invasion of privacy and
countries have taken a strong position against forced testing for HIV. But what about
protecting the health of the public? The following Questions & Answers explain why
exploration in future issues of Global AIDS news.
aggressive enough about finding out who is infected with the human
immunodeficiency virus (HIV). Shouldn't we be testing everyone for HIV - if
If a person tests positive for HIV, it means that he or she has HIV infection and,
scientists believe, will ultimately develop AIDS - a fatal disease for which there is at
prefer to live those healthy years without knowing their diagnosis. In addition, people
So testing for HIV is a very serious matter.
undergo HIV testing is a highly coercive, intrusive measure.
But why worry only about the infected people? Surely compulsory testing is
justified in the case of a fatal epidemic disease?
alone never stopped an epidemic. Testing only helps if there are ways of breaking
HIV Testing Policies and Guidelines
the chain of transmission. For example, when you test donated blood prior to
transplantation, is the only area where testing needs to be compulsory.
Because HIV is different. There is no drug available that can cure the infection or
positive for syphilis can be cured with a short course of antibiotics. A person
someone tests positive for meningitis, the individuals in close contact with him or her
can be treated and/or vaccinated. With HIV, there is no medical way to 'test and
isolated.
Unlike tuberculosis, it doesn't spread through coughing. Unlike typhoid, it can't be
We all have a responsibility to look after ourselves. And the fact that HIV spreads
mainly through sexual intercourse means that uninfected people are not defenseless
against the virus. They have ways of protecting themselves from HIV without locking
up the infected individuals. They can abstain from sex, stay faithful to an uninfected
partner, engage in sex without penetration, or else use a condom every time for
Q. Still, if we could screen the whole population through compulsory testing and
then isolate the infected people for life, it might stop the epidemic.
Mass HIV t
. In practice, its extremely costly, logistically
problems that could be avoided by offering voluntary tests and guaranteeing the
all infected people (clearly, many won't turn up voluntarily to find out their test results)
and isolate them, this wouldn't prevent sexual contact between the uninfected and
testing programme can expect to identify all HIV-infected people. Individuals who
think they might be infected can go to extremes to avoid testing and follow-up, given
of isolation.
Not all HIV-infected people will be identified even if they are tested. Most
commercially available HIV tests work by detecting not the virus itself but antibodies
to the virus which the person's immune system produces following infection with HIV.
during which the infected person continues to test negative.
At best, an HIV test result is <
In any case, periodic testing of the entire population is prohibitively expensive in
terms of staff time, transport of blood samples, and so on. (The actual HIV test kits
account for only a fraction of the total costs). In many developing countries, testing
10
HIV Testing Policies and Guidelines
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No. The financial and logistic impossibility of testing the whole population periodically
budget to testing. And most of these now realize that instead of mandatory testing
- which failed to stop the epidemic - they should use their resources for preventive
transmission, making condoms cheap and accessible, providing school-based
education for young people, and ensuring blood safety.
Even if you can't identify and trace all infected people, you could at least
Apart from being a serious violation of human rights, lifetime isolation would be an
places in Africa, and increasingly in Asia, 10% or more of all young adults are
infected. Isolation means forfeiting their economic productivity during the decade or
families of breadwinners and care-givers. And it means keeping thousands or even
millions of fit individuals fed, clothed and looked after for years on end - at
government expense.
don't even know they have the virus. Granted that isolation makes no sense
and that there is no medical way of curing them or making them uninfectious.
Compulsory testing would at least force them to find out their diagnosis and
take precautions against transmitting the virus to others.
A. In other words, won't people who learn they are HIV-infected through compulsory
testing simply avoid unsafe sex from then on? To begin with, not even voluntary
counselling and testing achieves a uniformity •preventive" effect. When testing is
purely voluntary, and people are presumably well motivated to protect themselves
change their sexual behaviour, others do not.*
couples who seek voluntary testing together and find out that just one of them is HIV-
> compulsory testing likely to be more effective than this in achieving behaviour
(safer sex protects both partners). But the main point is that a permanent, lifelong
commitment. It takes the availability of inexpensive and readily accessible condoms.
partner. The bottom line is that HIV prevention rests on the individual's willingness
Q. True, but even if the infected person doesn't voluntarily adopt safer behaviour,
at least other people can be warned...
Who? Medical test results are supposed to remain confidential. Imagine how
stop seeking medical help for a whole range of problems if we thought our diagnoses
volunteer information about their sex partners if they suspect that those individuals
of voluntary makes it less rather than more effective.
her rejected husband may well find new sex partners - and the epidemic will
continue to spread. Or, if she is infected but doesn't know it, she might infect her new
partners. Secondly, there is ample evidence that in places where test results aren't
kept strictly confidential, people simply avoid HIV testing and continue to behave s
though they were not infected. Helpful behaviour change that might have occurred
as a result of voluntary counselling and testing is thus forfeited.
HIVTesting Polities and Guidelines
In some places, couples have to get tested for syphilis before marrying. Why
not for HIV?
Even with syphilis, a curable disease, experience from around the world shows that
mandatory premarital screening has little or no impact on the public health. For HIV,
disadvantage that voluntary test doesn't entail. Second, why pick the time of
HIV results!). And, most important, sex with other partners can and does take place
But HIV can be transmitted from an infected woman to her fetus or newborn.
Wouldn't it be helpful at least to insist on testing all pregnant women?
Once a woman is pregnant the fetus may well be infected already, although there is
no way to know this. At this stage the only possibilities for prevention are abortion,
delivery (this is still experimental). All these are major decision which cannot be
forced on any woman but which she must take, if at all, voluntarily. Therefore,
In any case, the best time for prevention is prior to pregnancy. Married or unmarried,
people need to be aware of all the implications of HIV infection before they decide
whether to have children.
Some employers test job applicants before hiring them. Does that make
because HIV infection is not “contagious’ and doesn't spread at the workplace. The
emphasis in any form should be on preventing infections among the existing
HIV Testing Policies and Guidelines
workforce, which is always far larger than the number of new staff recruited each
year. Some employers provide their workers with AIDS education, encouragement
for condom use, and care for sexually transmitted diseases (STDs) such as syphilis
and chancroid, which if left untreated greatly increase a person's susceptibility to HIV
good news on two counts. It means employees are less likely to get HIV and, for
restricting compulsory testing to high-risk groups
At first sight this seems more practical than compulsory testing of the general
population testing of the general population, but in fact it's got even more problems.
example, men who have unprotected sex with prostitutes are clearly at high risk - but
how do you identify them? And where do you draw the line? At those who seek out
Yes. If they don't use new or freshly sterilized equipment every time they inject, they
The biggest hurdle for harm-reduction programmes is that drug users live on the
margins of society. Almost everywhere, drug use is secretive or frankly illegal, and
users are mistrustful of authorities. In many places, health workers have to persuade
HIV Testing Policies and Guidelines
bleach or condoms. Any threat of mandatory HIV testing would scare them away
public health.
P 9
. nd endangei
Q. Shouldn't we at least insist that sex workers be HIV-negative?
This is yet another idea that sounds fine in theory but works poorly in practice.
Compulsory testing is as counterproductive for prostitutes as it is for drug users.
their ability to demand condom use by clients. (This is the standard harm-reduction
measure for commercial sex work). If prostitutes are harassed an driven away by the
programmes.
Prostitutes who can't escape testing and turn out to be HIV-positive may be fired (if
they work in a brothel) or lose their registration. But this doesn't protect the public
system of registration, the infected sex workers will join the ranks of unofficial
prostitutes, who generally have even less power to negotiate safer sex. Testing
- and lets the clients know that they are HIV-negative - is sending a clear message
that if a client doesn't want to use a condom, he'll still be safe. Of course, the client
decide not to use a condom, and so on. Testing sex workers even as often as every
3 months still means that, because of the "window period’, they can have HIV for
You may well ask, why test the prostitutes and not their clients?
From the standpoint of common decency, it's just as important to safeguard sex
workers as sex work clients. From the standpoint of public health, protecting the
prostitutes is even more important Besides, there's something illogical about putting
the responsibility for HIV prevention and safe sex on the sex worker. After all, in
almost all cases, whether the prostitute is male or female, it's the client who has to
HIV? After all, they're mostly men. And by coming down with a disease like syphilis
“audience" indeed when it comes to HIV prevention. Attendance at
behaviour?
testing has nothing to recommend it - and multiple disadvantages as compared with
voluntary testing. First, people are hard to track down for compulsory testing, and
expensive to trace for follow-up. Then, what do you achieve? When you find infected
away from harm-reduction and other prevention programmes, and encouraging a
got these disadvantages. Hence, there’s nothing to be gained for the public health,
and much to be lost, by making HIV tests compulsory instead of voluntary and
Yes. It is occasionally necessary to override people's individual rights in tt
vaccination against yellow fever for people travelling from zones where this disease
is endemic. If one day a medicine is found that can make HIV-infected people non
harmful to the public health.
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