The Ethics of Universal HIV Screening

By Jeffrey Laurence, M.D.

Dr. Roland Merchant

May 13, 2011— Seeking to encourage earlier and more widespread HIV testing, in 2006 the U.S. Centers for Disease Control and Prevention (CDC) recommended an “opt-out” approach to testing, whereby healthcare workers would inform patients that they would be tested unless they declined. The aim of the new guidelines was to expand the number of HIV infections being diagnosed—considered a key to slowing the spread of the virus—and to get people into treatment earlier, thereby reducing the level of virus in their bodies and rendering them less infectious to others.

Yet few national professional organizations have endorsed this recommendation. amfAR-supported researcher Dr. Roland Merchant of Brown University, writing in the April issue of the American Journal of Bioethics, addresses the ethical concerns surrounding such testing. Merchant and colleagues from Brown and Wheaton College note that critics have focused largely on the possibility that the CDC guidelines could be implemented improperly rather than on the ethics of the recommendations themselves.  In the CDC’s opt-out scheme, HIV antibody testing of all 13- to 64-year-olds in healthcare settings in the U.S. is recommended. Testing should occur without regard to a person’s medical condition or actual or perceived risks for infection. In addition, the guidelines state that HIV prevention counseling at the time of testing should be optional; instead patients can be referred to other providers or counseling can be scheduling for a later time, depending upon an individual’s needs.

Inclusion of the HIV test along with other routine medical tests, the CDC reasoned, could also help remove the stigma that has often been associated with HIV testing. And removing the requirement to provide counseling with HIV testing would save time and effort, making it more feasible in busy offices and emergency rooms.

Critics argue that this opt-out approach—“I am going to test you for HIV today, unless you decline” is a suggested phrase to be used by doctors—places a greater burden of refusal on patients than an “opt-in” approach, whereby a physician might ask, “Would you like to be tested for HIV today?” But Merchant notes that many individuals are concerned about what their doctor might think of a request to be tested. The opt-out approach relieves the patient of that burden. In addition, patients may prefer not to discuss specific HIV risk behaviors with their physicians and so may be more likely to opt for testing if counseling is not required.

Merchant and colleagues conclude that if properly implemented, the CDC recommendations on universal testing could benefit both individuals and society.  They emphasize that patients must be informed clearly that testing will take place, provided with informational materials about HIV and HIV testing, and told that they have the right to refuse testing.  If the new HIV testing recommendations are otherwise ethically acceptable, their adoption should require only these sorts of safeguards to assure they are properly implemented.

Dr. Laurence is amfAR’s senior scientific consultant.

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