Clinton Stirs Debate With Backing For Mandatory HIV Testing

Bill Clinton may no longer be an elected politician, but the outspoken former US president has stepped into an ethical quagmire by expressing support for the controversial idea of mandatory HIV testing in countries with a high prevalence of infection.
Speaking to a group of journalists in London recently, he endorsed Lesotho's pioneering programme launched last November to offer universal testing, and suggested other countries and companies should launch extensive efforts to diagnose HIV.
His comments come at a time when several countries have raised concerns that although they are scaling up Aids treatment, they are still losing the battle to reduce rates of HIV infection, which are causing widespread economic damage.
For a long time, the idea of widespread diagnosis made little sense in the developing world, where confirmation of HIV was simply a death sentence, with no prospect of treatment. But that has changed significantly since the turn of the millennium.
Malawi, which has significantly increased its HIV treatment in recent months, has toyed with an "opt-out" system to identify infection during patient check-ups unless they specifically refuse.
Kevin de Cock, head of the World Health Organisation's HIV/Aids programme, said he supported such an "opt-out" system, but only on condition that it was voluntary and linked to patients being able to get treatment if found to be HIV positive. "That is a valid type of informed consent," he said. Lesotho's programme does just that in principle, with the aim of providing universal treatment by 2007, although some observers suggest that social pressure may mean voluntary agreement is in practice partly coerced.
Mr Clinton suggested he might support programmes that went still further, explicitly requiring mandatory testing and even compulsory disclosure of positive HIV results to the partners of those found to be infected.
Asked about the ethics of such compulsion, he argued that it could be justified in countries with high infection rates, on condition there was guaranteed diagnosis, treatment and anti-discrimination measures put in place. "In a population with extremely high rates of infection, [mandatory testing] overcomes other reservations," he said, warning of the "social wreckage" devastating poorer countries with widespread HIV incidence.
Cuba launched mandatory programmes for Aids testing and treatment in the 1980s, triggering substantial international criticism at the time, although it appears to have been able to successfully maintain very low rates of HIV infection since.
Its model may attract new interest at a time when the battle against Aids elsewhere remains tough. The latest United Nations figures suggest that despite a sharp rise in international funding, just 1.3m people are currently receiving anti-retroviral treatment for HIV in the developing world, compared with 6.5m estimated to need it.
The Clinton Foundation itself has contributed to an acceleration in treatment by negotiating sharp reductions in the cost of HIV medicines and diagnostic tests in developing countries, as well as launching efforts to strengthen healthcare structures.
However, about 40m people around the world are now living with HIV - the highest number ever, and those newly infected rose last year by another 5m, suggesting that prevention efforts continue to lag behind treatment.
In that context, politicians continue to float more extreme measures. Public officials in the Indian state of Goa became the latest to propose one such initiative - compulsory HIV testing ahead of marriage, for example - although it is unlikely to be implemented.
Richard Coker, a reader at the London School of Hygiene and Tropical Medicine, argues that it is ethically justified for doctors to protect the partner of someone found to be HIV positive by informing them of the diagnosis if their patient refuses.
But he criticises the idea of mandatory testing. "Coercive measures don't work. If you have to launch mandatory programmes, that suggests the person is not persuaded of the benefits and you would have to isolate them or force them into treatment."
He argues that such an approach would be both unethical and counterproductive, since it would probably lead to poor compliance with treatment and discourage people from coming forward for testing.
Many countries in the developing world are still far from achieving any significant coverage of HIV patients with treatment, suggesting it will be a long time before they can justify more aggressive testing programmes backed up with the incentive of drugs.
But as the leaders of the Group of Eight industrialised nations consider how to meet their pledge at last year's Gleneagles summit to try to give HIV treatment to all who need it by 2010, the continuing growth in infection means they will face the still more difficult political and ethical challenges in tackling prevention.
from Financial Times