HIV testing:voluntary or mandatory?

Sir—In their article on the value of mandatory testing for HIV in a sub-Saharan hospital population, Palmer et al. [1] argue that their study shows the advantages of routine and mandatory HIV testing of all hospitalized patients. However, the authors offer no data on how such testing affects patients, since the patients in their study were not aware that they were being tested and were not informed of the test results. It also needs to be noted that the authors consider one of the “benefits” of HIV testing to be the ability to prevent HIV-positive patients from using scarce hospital services, presumably because such services would be wasted on these individuals. Also, it is well established that HIV testing that is done without patient consent not only is unethical [2] but also can be actively harmful to the patient and counterproductive with respect to prevention efforts [3, 4]. Voluntary counseling and testing (VCT) enables individuals to deal constructively with the possibility that they might be infected with HIV. Studies have shown that VCT may be a cost-effective part of prevention of HIV infection [5]. VCT includes goodquality pretest and posttest counseling and proper referral to follow-up services, which enable clients to (1) prepare for the possibility that the test results could be positive; (2) carefully prepare strategies to mobilize support from a potentially hostile social environment; and (3) become acquainted with the concept of “living positively with HIV” [6]. Thus, mandatory HIV testing is inadequate and unethical, and by no means should it be considered a “simple” shortcut to getting HIV-positive patients to help prevent the spread of HIV to others. HIV testing needs to be part of a “package” of support and care services. These need to begin in the hospital and extend into the community. The article contains 2 more mistaken claims. One claim is that there is no stigma related to HIV in Zimbabwe (for better information, see [7]). The other is that “no national [HIV] surveys have been undertaken.” Indeed, surveys have been done annually from 1991 through 1997. Results of these surveys can be obtained from the National AIDS Control Program Zimbabwe.