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Universal AIDS testing: should we save the many at the cost of harm to the few?

In a paper published in the Lancet yesterday, a group of WHO scientists
have suggested that a radical change to HIV testing would be necessary
to combat the epidemic. The authors published details of a mathematical
model of “universal voluntary testing” and early drug treatment of all
those found to have HIV in a country with HIV levels similar to those
present in Southern Africa. They present striking and provocative
evidence that this approach could reduce dramatically the incidence and
mortality from HIV within a fairly short period. The major ethical
question raised in response to their proposal is whether such a
strategy would violate the rights of individuals, and impose harms on
them in order to secure greater benefits for others.

“If we could eliminate HIV this way would we, given the will needed, and
should we, given the conflict between utilitarianism and
individualism inherent in this strategy?” Geoffrey Garnett

The fundamental problem with all of the current strategies for tackling the HIV epidemic are that they look like an attempt to close the stable door after the horse has bolted. Transmission of HIV in epidemic areas is largely heterosexual. Patients don’t get tested until quite late in their illness (if at all), and they may have already infected their partners. 4 out of 5 people in these areas do not know that they have HIV. At the moment treatment with anti-retroviral drugs is reserved for those whose immune system is starting to flag, but again this means that they remain infectious for a longer period.

The only way to stop the epidemic is to reduce the “case reproduction number” (the number of other people on average who catch HIV from each infected person) to less than one. The new strategy would do this by detecting people much earlier in their illness, and by immediately giving them drugs that reduce the chance of their passing on the virus.

So what is the problem? There are concerns with both parts of the proposed strategy. One reason why HIV drugs are given relatively late in the illness is that early on there aren’t many symptoms of the disease. So if patients take the drugs at that stage they may get just the side effects of treatment without the benefits. They would be less infectious but, the argument goes, that benefit is for other people – rather than for the patient themselves.

This argument may be flawed both on factual and conceptual grounds. There is increasing evidence that the HIV virus causes illness in patients before they get to the point of being diagnosed as having AIDS (when treatment is normally started). And patients may have strong personal reasons not to want to spread the virus – to their partners or to their children. The patient would be (hopefully) getting the drug later in any case.

The second concern is about the voluntariness of testing. The scientists refer to ‘voluntary universal testing’, and in their model assume that all adults and adolescents in the population are tested. We may have questions about how realistic this proposal is. (A recent project to provide ‘universal’ testing in Lesotho has failed dismally). But we might also wonder whether these two properties are not mutually exclusive. We might achieve (with great effort) high levels of voluntary test uptake, but that would not be universal. Alternatively we could achieve universal testing – by making it non-voluntary. One of the comments in an editorial accompanying the Lancet article suggested a type of slippery slope argument – that the benefits of universal testing would lead to enforced testing and treatment.

There is no question that if at all possible universal testing and early treatment should be done in a way that respects the freedom of individuals, avoids stigmatisation and minimises risks to them. Compulsory testing might be self-defeating, since it may lead to individuals refusing to take treatment that was prescribed. But what if some degree of reduction of freedoms, or some harms were necessary in order to achieve the goal of stopping this epidemic?

It has been suggested that we wouldn’t contemplate such violations of ‘individualism’ in the UK – so we shouldn’t in our solutions for HIV in Africa. But I think that faced with an epidemic of such disastrous proportions in the UK we would be prepared to forego some of our liberties and experience some harms for the greater good. Imagine for a moment that in the UK there are 12 million people infected with HIV. It causes almost half of all deaths – 405000 people die of HIV/AIDS related illnesses each year. There are over one million orphans due to HIV. Would we still be so precious about contemplating solutions that may harm the few to benefit the many?

The figures presented in the Lancet paper are dramatic. The suggestion is that universal testing and early treatment would prevent millions of deaths from HIV. It is important that we consider whether such projections are realistic, and seriously consider how we could resolve the enormous practical difficulties in achieving this. However the importance of this problem is such that we cannot ignore any options.

Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model Lancet Nov 2008

Treating our way out of the HIV pandemic: could we, would we, should we? Lancet

Can antiretroviral therapy eliminate HIV transmission? Lancet editorial Nov 08

Mass testing plan to tackle Aids
Guardian Nov 26

Universal test ‘would slash Aids’ BBC News Nov 26

Universal AIDS testing scheme fails in Lesotho: rights groups

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