That was the question at the International AIDS Conference session on "HIV Testing the Era of Treatment Scale Up." As ARVs become more widely available, more people need to take HIV tests to get started in treatment programs. But should Voluntary Counseling and Testing (VCT) be replaced by "Routine Offer" or "Routine Testing" programs? Routine Offer refers to testing programs where all clinic visitors, or those meeting certain risk guidelines, are offered a test. Routine Testing means that all people are routinely tested at clinics unless they opt out.
Botswana is tackling this issue head on. The session began with a presentation by the Honorable Minister of Health, Sheila Tlou, who described the stakeholder process undertaken in Botswana to decide to use Routine Offer. Under the program, 89% of clinic goers accept testing. To be successful, health workers must understand the policy and the human rights issues of testing, such as stigma and discrimination. The Minister acknowledged that the program was not perfect, but that they had no example of other countries to follow, and they had to learn as they went.
After Minister Tlou, Grace Sedio and Christine Stegling, activists from Botswana, gave a more critical perspective of the Routine Offer program. Sedio pointed out that women use health clinics, not men, so mostly women were being tested, which opens them up to discrimination. Also, many women do not feel empowered to refuse an HIV test. Stegling noted that better protection for HIV positive people is needed. What was most amazing about the session was the frank discussion and repartee between Minister Tlou and advocates who sat next to her and disagreed. It seems all too rare that ordinary citizens can speak freely and openly to their leaders and be treated with such respect.
Most others on the panel expressed concern about a move to Routine Offer or Routine Testing. Sophia Gruskin of Harvard noted that more research is needed to understand if people are really giving informed consent for testing. All speakers noted that human rights and public health approaches to testing need not be opposing principles -- rather, the human rights of patients must always be considered. Mark Hayward of the AIDS Law Project of South Africa stressed the need for counseling, noting that new testing programs often leave out pre- and post-test counseling. He suggested studying VCT to understand why people do not take advantage of it, rather than abandoning the approach.
Audience questions brought out more burning issues: should teenagers be allowed to receive an HIV test? Do parents or spouses need to be notified of an HIV test? What does informed consent really mean? What happens to people who test positive in countries that criminalize certain behaviors like commercial sex work, men having sex with men, or drug use?
WHO did not sit on the panel (although Kevin De Cock was invited), but is pushing for Routine Testing. This "opt out" approach carries considerable risk to an uninformed, un-empowered population, as health workers may not truly give patients the right to opt out. It is too bad that Dr. De Cock did not attend, as he would have heard considerate, thoughtful discussion on how to consider the rights of the mostly women who attend public health clinics. I only wish all sessions encouraged such an active and respectful dialogue, as demonstrated by the delegates of Botswana. This debate will surely continue...