Routine HIV testing not as straightforward as it sounds

Botswana's decision to introduce routine HIV testing in all its health facilities was driven by the growing realisation that plans to provide anti-AIDS medication were likely to fail unless more people were tested. But activists have expressed concern that the policy could be eroding the patient's right to confidentiality, with the risk of informed consent being compromised. The landlocked Southern African country has all the ingredients for turning the epidemic around: political leadership, optimal use of existing resources and an established treatment plan. But fear of stigma has proved an even bigger hurdle, causing people to wait until they are very ill before seeking treatment. Two years down the line, health officials estimate that up to 35 percent of the 1.7 million Batswana now know their status. At Princess Marina hospital in the capital, Gaborone, acting hospital superintendent Dr Howard Moffat told IRIN that although routine testing was yielding results, implementing it had not been easy. As the only referral hospital in the south of the country, long queues and overworked staff were nothing new at Princess Marina, but throwing the new testing strategy into the mix had been time-consuming, he observed. "We have to keep record of each patient, and it is so difficult because we have to attend to a lot of patients ... [as with] any other ailment, we tell the patients of the test that we will administer, and if they are not ready they can refuse but generally patients agree to be tested," Moffat said. AIDS activists like Christine Stegling, director of the Botswana Network of Law and Ethics (BONELA), are not convinced. She has called on the government to adopt stricter measures for monitoring the testing strategy. Soon after the programme began, BONELA called a meeting with relevant stakeholders to debate the implementation of routine testing in Botswana. Their concern was that the government had failed to launch a public information campaign and BONELA claimed to have received complaints from patients who said they were not thoroughly informed, while others said they were unaware that they had been tested until they received the results. An equally sceptical David Ngele, one of the first Batswana to publicly disclose his HIV-positive status, said he had doubts about "the quality of counselling offered by some people who carry out routine testing", but acknowledged the "normalising" effect it was having, as many more people had been tested since the policy was introduced. "This is quite helpful, as people test in time [and] therefore receive necessary help before their condition worsens," he pointed out. Stegling argued that while it was important for people to know their status, they should have the right not to be tested if they felt they were not ready. According to her, most Batswana have a tendency to obey nurses and doctors without question. "We at BONELA feel that people should be taught, so that they know that they have the right to refuse if they do not want to be tested, and that they should be equipped with the relevant information to help them make informed choices," Stegling maintained. Although Bakang Kgwaane, a builder, was not given much information before his test, he admitted that he had benefited from discovering he was HIV-positive. He fell ill with a persistent cough, swollen feet and weight loss in 2001 and was forced to leave his job. After being admitted to the Bamalete Lutheran Hospital he was treated for TB and advised to be tested for the HI virus. "I was in great pain - my sister was called for discussions. She consented and because I was in pain I just gave in," he said. When the results came back positive, Kgwaane said he felt his whole world was collapsing. "To be honest with you, I was not really prepared to get my results, but they were there and I had no choice."