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Ending AIDS

Gaborone, Botswana

Imagine that fully one-quarter of the adult citizens in your country had ticking time bombs in their back pockets due to explode sometime in the next ten years. And suppose that the ticking was so quiet that the carriers might not even be aware of the bombs' existence. That's very much the situation in Botswana, which boasts one of the highest rates of HIV/AIDS of all African nations. Some 280,000 people--approximately 25 percent of the adult population--are infected with HIV/AIDS, yet most don't even know it. Tens of thousands have died. Continent-wide, the virus has killed 15 million people, infected an additional 25 million, and orphaned 12 million children. If current trends hold, the virus could kill more than 60 million people in Africa by 2030.

Because of its vital economy, its vast natural resource wealth, and its strong civil society, Botswana should be leading the charge to end the scourge of AIDS in Africa. But, to date, Botswana's efforts to control the virus have been largely unsuccessful. Along with Brazil, Botswana leads the world in providing innovative antiretroviral (ARV) treatments for those suffering from the virus and spends large sums on care for the sick. But the prevalence of the virus in the general population remains near its historical peak.

Part of the reason is that Botswana, like most countries, has relied on sex education--preaching a combination of abstinence and safe sex--to control the spread of AIDS. In Botswana, language differences, cultural differences, illiteracy levels, gender inequalities, and general funding problems have prevented education alone from solving the problem. Given this situation, the most effective way to curtail the spread of AIDS in a country experiencing a severe, deadly epidemic is a radical one: compulsory testing and notification of every citizen.

The international community has invested heavily in fighting AIDS in Botswana. The United Nations (through its UNAIDS group), the World Health Organization (WHO), the Centers for Disease Control and Prevention, Bill and Melinda Gates' foundation, Bill Clinton's foundation, and hundreds of other well-meaning nongovernmental organizations are actively involved with the Botswana government in developing the country's strategy for dealing with the illness. In addition, these international organizations provide tens of millions of dollars each year for prevention and treatment programs in the country.

The focus of these groups is on caring for the sick, at which they do a magnificent job. But, if the objective is to end the AIDS epidemic, then just caring for the sick is not enough. Action must be taken to reduce the new infection rate.

It is the nature of the HIV virus that it typically lies dormant in an individual for a period of five to ten years before symptoms appear. Because young, sexually active adults, ages 16 to 25, are the most likely to transmit the virus, this means that many young people may unknowingly transmit the virus to others before they realize that they themselves are infected. Currently in Botswana--and in most of the developing world--testing and notification are voluntary. Hospitals and clinics began testing patients for HIV as a matter of course in 2004, and the detection rate increased from one in twelve to four in twelve, but patients can still opt out of the procedure if they so choose. And those who do consent make up only a fraction of the population. A deadly epidemic will never be stopped by dealing with only a portion of the public.

Therefore, Botswana should annually test all of its citizens over the age of 12. Under a system of universal, confidential, compulsory testing, each citizen would be issued an HIV/AIDS status card that clearly identifies his infection status as positive or negative. To prevent discrimination by employers or insurance companies, the cardholders would not be obligated to share the information with anyone other than potential sex partners, who would have the right to see the card. (For children, age 12 to 18, initial notification could be made to their parents.)

Once notified, the infected would be required to begin compulsory ARV treatment within two months of notification. (In addition to halting the disease's damage, it also reduces the likelihood of transmission.) Those who do not would be subject to fines. Pregnant mothers with AIDS would no longer have the choice to refuse ARV treatment prior to delivery; they would have to consent to treatment for the health of their babies. (Transmission of the illness to the newborn baby can be prevented in 98 percent of cases through a one-week ARV regimen directed at the mother and baby during and immediately after labor and childbirth.) It would also become mandatory that infected persons not engage in sex without the use of condoms. Though admittedly impossible to enforce, this law would let citizens know squarely what the government's position on the issue is and may provide support for future civil lawsuits by the newly infected. (Seat belt laws work in the United States even though they are rarely enforced by police.)

If successful, these actions would result in an almost immediate decline in the disease's prevalence levels. It is not overly optimistic to think that such measures could lead to the complete annihilation of new infections in less than five years.

For Botswana, a country of 1.7 million people, a system of universal testing, along with attendant treatment and support services, would be costly--possibly as much as $200 million per year. But the cost is insignificant relative to the damage the virus is exacting currently. Productivity growth in Botswana is negative, and life expectancy has declined from 62 to under 35 years. The country has run government deficits in two of the last three years, since AIDS spending is the single biggest line item in the federal budget. Even more populous countries would be well advised to enact universal testing if a significant percentage of their populations--more than 5 percent, say--became infected with AIDS.

So why isn't Botswana enacting universal testing and notification? The greatest impediment, ironically, is the international aid community. United Nations policy is explicit that countries should "discourage mandatory testing." UNAIDS holds the view that "there is no evidence that mandatory testing achieves public health goals. UNAIDS therefore discourages this practice." The WHO has stated that "Mandatory testing and other testing without informed consent has no place in an AIDS prevention and control programme." The Council of Europe has resolved that "Compulsory testing is unethical, ineffective, unnecessarily intrusive, discriminatory and counter-productive." American doctors, through the American Medical Association, and American nurses have also spoken against compulsory testing as a violation of informed consent for patients.

None of these organizations, however, has cited a single study or piece of hard evidence to support their far-reaching claims. Surely that is because universal, mandatory testing has not been tried anywhere with a verifiable epidemic. Yet, where it has been tried, compulsory testing is not as ineffective as its critics claim. It is no coincidence that Hungary, which boasts one of the lowest reported levels of HIV/AIDS in the world, had mandatory nationwide testing until 2003 (when it was overturned to favor informed consent, not because it had failed). Other countries have also tried to stanch the spread of AIDS through compulsory testing of at-risk groups, particularly prostitutes. Though this is controversial because it can create a social stigma, testing at-risk groups has proved a successful strategy in Cuba, which has avoided the epidemic levels of AIDS that have afflicted other Caribbean island nations. Cuba has a smaller and better-defined prostitute population than Botswana does, however, making such a targeted approach to testing impractical in Botswana.

And countries without universal testing that are the aid community's supposed success stories in the fight against AIDS, such as Haiti and Uganda, are not what they seem. It is true that they have seen some declines in HIV/AIDS prevalence, but they are experiencing this fortuitous outcome in large part because so many of their infected are dying. (Uganda has also benefited from changes in sexual behavior.) It is one of the true ironies of the AIDS pandemic that the primary accepted measure of a country's health, namely its HIV prevalence statistics, improve when its citizens die from the illness. It is disturbing that the HIV prevalence targets in the U.N.'s Millennium Development Goals--which aspire to halt and reverse the spread of AIDS in developing nations by 2015--may be achieved globally not through progress toward ending the epidemic, but through the deaths of millions worldwide.

The main argument against compulsory testing comes from people who are focused on the treatment side of AIDS; many of them are medical doctors. Doctors are trained to believe in the sanctity of patients' rights. The simple assumption that individuals know best what is right for them is the basis of any civil society and any good democracy. But democratic governments are formed on the basis of performing some compulsory actions under the law that benefit the great majority of its citizens, even if some individual rights are violated. With proper search warrants, for example, the police can search you, your car, and your home if they have valid reasons to believe you pose a threat to others.

Contagious epidemics like AIDS--those ticking time bombs in people's back pockets--are exactly the type of threats that force society to recalibrate the balancing of civil liberties against national objectives. Minor impositions to individual citizens' liberties can be justified if greater freedom and safety results for all.

Human rights specialists who insist that testing and treatment be voluntary, that results need not be disclosed even to the patient, that no actions be taken against the infected for fear of creating a stigma, and that all behavior modifications must be voluntary do not truly understand the basis of human rights in a society.

Human rights extend to all in a country, not just the infected. The uninfected have rights too--including the right to stay that way. Medical doctors are slow to allow special measures to be applied solely to the sick because they view the sick as innocents and not transgressors. But, in a highly contagious epidemic, the sick are both victims and transgressors, and tough actions must be taken to end the epidemic. Caring for the sick and protecting only their rights is not going to achieve that goal. The human rights of all must be protected, and the greatest of these is life itself.

By John R. Talbott