The BCCDC is coordinating a provincial pilot project of anonymous HIV testing at testing sites across BC. Anonymous HIV Testing (AHT), which has been long-standing in many jurisdictions, has not formally been available in BC to date. It is often perceived as in conflict with making HIV testing more routine and as having the potential to negatively affect other public health interventions such as partner notification. As part of preparation for the pilot project, we examined these questions and considered whether on an ethical basis there was a role for anonymous HIV testing in BC.
The “Harm Principle”
AHT is ethically defensible. Central to ethics in a public health setting is to come to some understanding of the correct balance between the rights of individuals and the needs of the broader public. Usually these are aligned (what is good and right for the individual is also good for the public) but conflicts can arise. For example, we have to drive on the right side of the road even if we have a personal preference to drive on the left. A concept in ethics called the “Harm Principle” states that society has a right to intervene to protect its members – it does so through rules, laws and robust public health policies.
HIV is a serious disease for both individuals and society. Public health measures such as documenting and reporting the infection, and tracing contacts of newly infected people, are defensible public health measures that take some privacy and liberty away from individuals in the name of the greater good to the larger population. Some people worry that AHT may be granting too much of a concession to individuals and is not in the interest of the greater good as the ability for intervention by providers or public health with someone newly diagnosed with HIV is reduced.
We must consider these apprehensions seriously. To argue against AHT, one must show that it can cause harm. To cause harm it must be shown that if AHT is implemented:
- There will be a significant number of people that will shift from nominal to anonymous testing,
- Within that group, a significant number of them will refuse contact tracing, and
- A significant number of that smaller group will also continue unsafe injection or sexual practices.
There is no evidence of this cascade of events happening. Most people do change their risky behaviours when they learn they are HIV positive, even if they don’t choose to go on to treatment.
Knowing the anonymous tester
There are also concerns about people testing “anonymously” in a clinic where the testing provider knows who they are. There is no nominal reporting of the new infection to a Medical Health Officer, but the care provider knows about the test, and knows the person.
What is the care provider to do if someone tests positive and refuses to get treated or refuses to do contact tracing? These are difficult problems and some clear guidance will be developed on these matters as the pilot project proceeds. But when we get right down to it, this problem has little to do with AHT because a similar scenario can already happen in the existing system.
People who test positive are under some moral obligation to do what they can to prevent the spread of infection, but they are not under any legal obligation: contact tracing and getting treatment are currently voluntary. In a fair and just society, we have to choose how heavy-handed the state can be in making people do things. In this instance, our society (to a large extent) already relies on its members to voluntarily choose to do the right thing, and it also depends on all people taking appropriate precautions to protect themselves when they have sex or share needles.
There does not seem to be any compelling ethical arguments against AHT. But there is an ethical argument that could be made in favour of AHT. Evidence does show that people are delaying getting tested because of a lack of an AHT program. In public health, we have a duty to promote health, prevent harm, and prepare for threats. Part of fulfilling this mandate is to do more HIV testing, and it is hoped that this new Anonymous HIV Testing pilot project will accomplish just that.
For further information
Dr. Unger’s full report can be viewed and downloaded here.