Opt-out HIV testing

Should HIV testing be mandatory for certain populations? If so, how do we determine those populations? Should we base it on risk or just focus on those groups that are known to currently have higher HIV prevalence rates? Are there other factors we should be considering?

These were all questions swirling around in my mind as I went for a recent HIV test. I am a Caucasian, heterosexual, Canadian citizen in a long-term monogamous relationship. I am not a member of a population that is experiencing high HIV prevalence. I have not engaged in injection drug use. All of my unprotected sex was happening with one, monogamous long-term partner. I am about as low risk as it gets outside of a monastery.

So why did I find myself waiting in an uncomfortable plastic chair? I was pregnant.

Now, technically, HIV testing wasn’t mandatory for me. In most Canadian provinces, including Alberta, HIV testing for pregnant women happens on an opt-out basis. Good pre-natal care means that I’m going to sit in those uncomfortable plastic chairs a few times over this 9-month period but when my doctor wrote up my requisition form for these tests I could have declined the HIV test. The only problem was that he didn’t tell me about it.

Lest you think that this is an isolated case, a pilot study of ten Canadian women revealed that only four were offered the option of testing. Of the remaining six women, one already knew she was HIV positive, two were under the (uncorrected) impression that testing was mandatory and three had never been informed that HIV testing would be taking place.

Wondering what the reason for testing pregnant women in the first place is? The great reason for testing all pregnant women for HIV is that if a mother is HIV positive, HAART can dramatically reduce the risk of mother-to-child transmission. It is entirely possible for HIV positive women to deliver healthy, HIV negative babies.

Great reason, right? Wondering now what the issues with opt-out testing are? The primary issue is that finding out the results of an HIV test carries implications that go far beyond other test results. Learning that you are HIV positive isn’t the same as hearing that you’re anemic or even have gestational diabetes.

An HIV test should always be preceded by informed consent and pre-test counseling. Think for a minute what it would be like to receive an HIV diagnosis without even knowing that you had undergone a test.

Fortunately for my doctor I work at AIDS Calgary and know the ins and outs of HIV. I knew that I could opt-out of the test. I didn’t need pre-test counseling. But I am much more likely to be the exception than the rule.

What are your thoughts on opt-out testing? Do you think its effective/necessary in some situations?

For more reading on the issues surrounding HIV opt-out testing for pregnant women, check out the Canadian HIV/AIDS Legal Network’s publication on HIV Testing (Chapter 8). http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=1076

Sources
A Different Kind of Risk? – Pregnant Women’s Experience of HIV Testing in Pregnancy. Canadian HIV/AIDS Policy & Law Newsletter. Volume 5, Number 1. Fall/Winter 1999. Retrieved October 2010. http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=829