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Africa's HIV/AIDS epidemic has stimulated calls for increased resources,1-3 science-based public-health interventions,4-6 and access to treatment.2,7 The declaration of commitment8 from the United Nations General Assembly Special Session on HIV/AIDS in 2001 called for a 20% reduction in the proportion of infants infected with HIV by 2005, and 50% by 2010 (in this article, HIV is used to mean HIV-1 and HIV-2). Describing lack of access to antiretroviral therapy as a global emergency, WHO and UNAIDS launched an initiative to treat 3 million people by 2005.7
To address prevention and care, WHO estimated that up to 180 million individuals per year will need HIV testing by 2005.9 Current practice around HIV testing, counselling, and consent is an obstacle to scale-up of services and attainment of targets. How to use testing is perhaps the most challenging question in HIV/AIDS policy today. We argue that universal voluntary knowledge of HIV serostatus should be a prevention goal and that facilitation of HIV testing is central to responding effectively to the epidemic in Africa.
Rights, liberties, and informed consent
HIV testing raises concerns about stigma and infringement of the rights of HIV-infected people. Central issues are autonomy and privacy, or, clinically, informed consent and confidentiality. Outside of health care, diagnosis of HIV infection is self-initiated. In clinical practice, consent is assumed for non-invasive investigations that form part of standard care. The provision of information with ability of patients to decline HIV testing, informed right of refusal or the opt-out approach, balances autonomy with usual medical practice and meets ethical standards of informed consent.
Advocates for care have emphasised social and economic rights, including the right to treatment, citing the 2001 declaration of commitment8 and other covenants and conventions, including those relating to women and children. Focusing on positive aspects of rights rather than negative consequences of public health action, and strengthening efforts to prevent discrimination, offer synergy between science-based HIV prevention and increased access to care. Proposals to ease HIV testing policies satisfy preconditions for potentially burdensome public health action required by the Siracusa principles.10 These are that the intervention (HIV testing) should be sanctioned by law, aimed at a legitimate public health goal, necessary to achieve that goal, no more intrusive or restrictive than necessary, and non-discriminatory in...