Zambia is the second country this year to propose introducing forced HIV testing and treatment in the name of “public health”.
Zambian President Edgar Lungu announced last week that the country would mandatorily test anyone using health facilities. Anyone who tested HIV positive would also be put on to antiretrovirals with or without their consent, and Lungu threatened to shut down any private health facility that refused to follow the policy.
After strong objections from civil society organisations, the country’s Human Rights Commission and opposition parties, Health Minister Chitalu Chilufya has backtracked on the president’s pronouncement. He affirmed that informed consent will continue to be respected in the country where healthcare personnel are encouraged to offer HIV counselling and testing to patients whenever they visit.
Like many countries that have done the same, Zambia is hoping this will increase HIV testing rates and allow more people to start antiretroviral treatment as soon as they are diagnosed — an approach known as “test and treat”.
Although Chilufya’s assurances are a relief, it was shocking to witness the readiness of some organisations and the president himself to abandon the commitment to informed consent, an established principle in law, human rights and healthcare ethics.
More troubling still may be the fact that they are not alone.
A man waits inside an HIV testing centre in Zambia where the Constitutional Court ruled mandatory HIV testing was a human rights violation in 2010. (Gianluigi Guercia, AFP)
Earlier this year, Malawi made a similar proposal — to introduce forced HIV testing for women going for antenatal care, members of the military and domestic workers and to criminalise people who did not take their antiretrovirals. As in Zambia, Malawi’s proposals to violate people’s rights were met with strong civil society resistance.
This is not the first time these two countries have mooted mandatory testing. In 2003, Malawian lawyers hit back at a decision by the Living Waters [Pentecostal] Church requiring all couples to test for HIV testing as a prerequisite to marriage. In 2010, Zambia’s Constitutional Court ruled that the mandatory HIV testing of employees was a human rights violation.
Today, neither the World Health Organisation nor the United Nations Joint Programme on Aids condone forced HIV testing. But many who are hoping to reintroduce calls for mandatory testing claim it will help the world to fast-track progress towards the international HIV “90-90-90” targets.
As part of these goals, countries have committed to ensuring that, by 2020, 90% of all people should know their HIV status and 90% of HIV-positive people are on antiretrovirals. The targets also say that 90% of people on treatment should be virologically suppressed by 2020 — meaning they are doing well enough on antiretrovirals to bring the levels of HIV in their blood to very low levels and make it impossible to transmit the virus.
The 90-90-90 targets are ambitious and important goals that recognise the progress that has been made in recent years to improve and expand access to treatment.
But abandoning the protection of people’s rights, including the right to informed consent, in pursuit of the targets is dangerous and misguided.
There is no evidence to show that coercing people to test for HIV and start treatment will result in improved uptake of services and adherence. There is similarly no research to justify the assumption underlying the resurgence in proposed mandatory testing policies: that human rights and public health are in opposition.
Protecting the right to informed consent has been a critical battle for HIV and human rights activists since the early days of the epidemic, even when antiretrovirals weren’t broadly available.
To revive efforts to coerce people into testing and treatment more than three decades later is to revive the hysteria and stigma that drove discriminatory and fear-based responses to HIV in its early days.
And these policies shift our attention away from the difficult work of addressing overburdened, underfunded health systems and discriminatory laws in pursuit of better health for all. Instead efforts like these attempt to place the burden on individuals. These declarations conceive of people living with HIV – and women in particular – as objects of contagion, not human beings worthy of dignity and capable of determining their own best interests.
We must jealously protect the right to informed consent in all aspects of healthcare, including HIV testing and treatment, and sexual and reproductive healthcare services.
Instead of abandoning people’s rights in a misguided attempt to reach international targets, we should be creating enabling environments for improved communication and trust between healthcare personnel and users.
The denial of informed consent is a form of discrimination that cannot be allowed in healthcare systems.
Annabel Raw is a health rights lawyer at the Southern Africa Litigation Centre and Michaela Clayton is the director of the Aids and Rights Alliance for Southern Africa.
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