Former colleague Chris Blattman has just blogged a remarkable legal initiative under consideration in Uganda: the criminalization of "intentional" HIV transmission. "Intentional" transmission is defined as knowing that one is HIV-positive and failing to communicate that fact to one's sexual partner. According to the article, parliamentarians are responding to higher perceived rates of new HIV infection by proposing, on the one hand, to protect the HIV infected from various human rights abuses and, on the other hand, to protect the uninfected from "intentional" infection.The first part of this effort is widely supported in the international AIDS community, but the second is often decried. For decades, the rights of the HIV-infected person to control the information about his own infection have trumped the rights of the uninfected to know that their sexual partner is endangering them with every unprotected sex act. For example, in many countries including the United States, a doctor who treats both members of a couple and learns that one is HIV infected and the other is not is forbidden by law from informing the other member of the couple of his or her risk.Unfortunately this bill as it is described in the press would not have a clear beneficial effect on either HIV testing or on HIV prevention.Features of the bill which protect the rights of the HIV-infected, by outlawing employment discrimination etc., can reduce the stigma associated with the disease and thus might encourage HIV testing. However, someone who suspects his or her own infection might put off seeking a test in order to avoid having to choose between revealing an infection to his partner and illegally hiding that information.According to the newspaper article, "[the bill] comes at a time of growing anxiety among public health specialists over the stagnation of the country's HIV prevalence rate at around 6.5 per cent and evidence of rising year-on-year infections." However, the proposed bill does not have clear beneficial effects for HIV prevention either. To the extent that peoples' risk behavior is inhibited by fear of the stigma of being HIV infected (as distinct from fear of infection itself), the bill's provisions to improve the rights of the HIV infected might actually increase risk behavior. Even if the bill encourages HIV testing, the evidence that knowledge of one's infection status leads to reduced risk behavior is quite weak. After all, anonymous HIV testing increases the asymmetry of information between the tested person and everyone else. Whether in the context of a health insurance contract or a sexual partnership, asymmetric information is a "market failure" and reduces the efficiency of the transaction.The bill omits a key provision that would both encourage HIV testing and protect the uninfected partner: the promotion of so-called "couple-testing", where two sexual partners seek testing together and agree to learn the HIV status of both partners. As I argue at greater length in a paper called "The public interest in a private disease: An economic perspective on the government role in STD and HIV control," couple-testing has the advantage of decreasing information asymmetry within a single couple. When both members of a couple test negative, couple testing should provide incentives for fidelity. With proper counseling the same could be true when both test positive. The so-called "sero-discordant" couples present more of a challenge. But the probability of a harmonious and HIV-prevention enhancing outcome are improved when the news that one is infected is delivered to both people by a counselor as compared to one being required by law to inform the other outside the counseling setting. In general rewards work better than punishments. In this case, a bill embodying both rewards and punishments might work better than either alone.
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