Rethink mandatory HIV testing

Pregnant women living in areas with high HIV prevalence should have to be tested

Charmaine, left, who gave only one name, has blood samples taken for testing in Johannesburg, South Africa, Monday, Dec. 6, 2004. The day she found out she was pregnant, a doctor told her she was HIV-positive. She tried an AIDS drug called nevirapine to protect her newborn girl.
Charmaine, left, who gave only one name, has blood samples taken for testing in Johannesburg, South Africa, Monday, Dec. 6, 2004. The day she found out she was pregnant, a doctor told her she was HIV-positive. She tried an AIDS drug called nevirapine to protect her newborn girl.
Credit: 
AP Photo/Denis Farrell
Professor Udo Schuklenk, PhD
Professor Udo Schuklenk, PhD

A lot has changed since the early days of the HIV epidemic and the heydays of AIDS activism. Today we know a lot more about how the bug takes out the immune system of infected people. We also manage to keep most people with HIV infections alive for many years, thanks to medication that has been developed during the last 10 to 15 years. It’s probably fair to say that biomedical research is just keeping ahead of the ever mutating virus, so nobody can tell whether or not we will win this race in the end.

What is interesting is that the advent of available medication hasn’t changed the debate about mandatory HIV testing at all. In the early days of the epidemic there was a consensus in liberal Western democracies that we should not force anyone to have an HIV test against his or her wishes. The reason for this had much to do with the idea that we should respect the decisions autonomous, competent, informed adults make with regard to this matter. There was also an­—albeit grudging—realization that there wasn’t much we were able to do against insurmountable obstacles.

The advent of successful treatments makes this last point less convincing, but as a general rule, we do not force competent adults in democratic societies to accept treatments or health tests if they do not want them.

Remarkably, the advent of treatment—treatment that needs to be introduced in a timely fashion—did not have much of an impact in terms of the HIV testing debate. Political philosopher John Stuart Mill’s arguments in favour of negative liberty—freedom from interference by others—have pretty much won the proverbial day.

As a society we are prepared to see people die preventable deaths from AIDS rather than interfere with their individual liberties. I do not wish to seriously challenge this consensus as far as societies are concerned where the prevalence of HIV is very low, as it is in Canada, Western Europe, Australia, etc.

Important aspects are different in countries where HIV infection is rampant. In South Africa where I worked for a number of years, the HIV antenatal prevalence rate is approximately 30 per cent. According to government figures the average life expectancy in the country is just slightly above 50 years of age. Much of this is due to AIDS-related mortality. South Africa, after much incomprehensible governmental foot-dragging, has finally begun to roll out antiretroviral treatments to stop the AIDS-related carnage that is taking place in the country.

South African lawyer Anita Kleinsmidt and I have proposed in an article in the American Journal of Public Health’s July 2007 issue that we should rethink mandatory HIV testing, and possibly treatment, of pregnant women in societies with a very high HIV prevalence. The argument for this radical change of direction—in a nutshell—goes like this: provided that abortion is freely available as an alternative course of action, and provided that access to life-preserving medication can be guaranteed to the women in question, pregnant women who decide to continue their pregnancy have a moral responsibility to give their offspring to-be a reasonable shot at a life worth living.

Pregnant women in high-HIV-prevalence areas subject their newborns to a high risk of becoming HIV infected, because they are at a substantial risk of being infected themselves. If antiretroviral treatment is taken by an infected woman during the last few weeks of her pregnancy the risk of her newborn being HIV infected is reduced radically.

Although one perfectly understands the anxieties anyone would have in a society where HIV infection is highly stigmatized, it seems to me that if a pregnant woman voluntarily decides to carry her fetus to term, such anxieties must not be permitted to override the future offspring’s interest in living a healthy life.

Importantly then, the argument is not about the moral status of the fetus at all. I strongly support traditional pro-choice arguments as far as abortion is concerned, but do think that once a voluntary decision in favour of having the baby has been made by the pregnant woman, she has responsibilities toward her future offspring during her pregnancy, involving having an HIV test done.

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Udo Schuklenk is a professor in the philosophy department at Queen’s, specializing in bioethics.

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