To screen or not to screen for HIV in Zambia

Former pilots Stanley Kingaipe (r) and Charles Chookole (l) are at the centre of a debate in Zambia about mandatory HIV screening

A landmark court case in Zambia is sure to reignite a debate about the pros and cons of mandatory testing for HIV.

Zambia Air Force (ZAF) officers Stanley Kingaipe and Charles Chookole say they were tested and treated for the virus without their knowledge.

ZAF has now been ordered to pay them compensation for mental anguish.

The controversy about compulsory testing has been smouldering for some time.

It was a stray remark by the minister of health at a HIV conference late in 2008 that started it.

Kapembwa Simbao was reported as saying that too few Zambians were voluntarily going for an HIV test and that they should be compelled to do so.

Knowing their HIV status would, he said, help them to make informed decisions about their lives.

It is estimated that one in seven Zambian adults have the virus, yet only around 15% have gone for voluntary counselling and testing (VCT).

The minister's suggestion drew scorn, anger and concern.

"You can't drag people to a testing site. It's never been done anywhere in the world," argues Elizabeth Mataka, the UN secretary general's special envoy for Aids in Africa.

"I know we have a crisis on our hands," she continues.

"But I don't think this is the best way of dealing with it. It's a violation of the person."

Human rights activists agree.

"This is an issue of privacy and of the dignity of an individual," says lawyer Abraham Mwansa.

"Where mandatory testing is imposed by law, where the issue of record-keeping is suspect, where the confidentiality of the results is an issue, it will just encourage stigmatisation."

He fears families - the backbone of Zambian society - will be destroyed as a result.

'Easy targets'

"Here's a person who is happily married, who is not aware of their partner's HIV status," Mr Mwansa says.

"If they find out, there's a likelihood the marriage will just crumble. But if they don't, chances are they'll stay together."

Wives are more vulnerable than their husbands, according to Malala Mwondela, executive director of the Zambia AidsLaw Research and Advocacy Network (Zaran).

"Sometimes when women inform their partners that they are HIV positive, they face violence and some are abandoned," she says.

If testing were mandatory, Ms Mwondela believes that women would be among the easiest targets.

Most will attend a clinic when pregnant and could then be forced to undergo a test.

Some think families, including Stanley Kingaipe's, risk being broken up by mandatory HIV testing

In fact, expectant mothers are already being routinely checked for HIV, though they can - and sometimes do - opt out.

Dr Swebby Macha, a former president of the Zambia Medical Association, favours using a similar approach across the board.

"The HIV test should be a basic test carried out on any patient visiting a hospital, just as we test for malaria and check urine and haemoglobin levels," he says.

"We should not even have to ask the patient.

"I don't see it as an infringement of their rights, because we are trying to save lives.

"If you are going to tackle a disease lightly, you are not going to achieve any meaningful results.

"Burying our heads in the sand like ostriches will get us nowhere. Only when you know your status can you access treatment."

But some worry that the sick would simply avoid going to see a doctor.

Mr Mwansa believes that conducting routine HIV tests on patients would end up making the health situation worse: "In my view, it would mean some people would not go for treatment for fear of learning their status.

"And the end result would be that the purpose of the law would not be achieved."

'Stamped foreheads'

Dr Macha disputes that: "I don't think any well-meaning person would shun a hospital, because that's where salvation is.

"There might be a bit of resistance initially but I think people will accept routine testing as time goes on," he says.

Would people avoid going to hospital to learn their HIV status?

But what would it achieve? Testing the nation would be a mammoth exercise and, some argue, a futile one.

"One can be HIV negative now and engage in risky behaviour the same evening. What's there to stop the transmission of HIV?" questions Ms Mataka.

She explains that HIV can be in the bloodstream for three months before being detected, which means a comprehensive plan would involve testing the entire population every 12 weeks.

"That would be a very expensive exercise," points out Ms Mwondela.

There is psychology to consider, too.

Many doctors are convinced that a person has to be mentally prepared to accept a positive test result and to commit to taking anti-retroviral drugs.

They stress the value of going voluntarily for a blood test and the importance of the pre- and post-test counselling.

Even then, people can be reluctant to tell their partners about their status.

"We have no way of policing those who are positive," says Ms Mataka.

"So how are you going to protect the public? Unless you are going to stamp it on their foreheads. That would be a terrible, draconian measure to take against people."

The lure of mandatory testing is that it looks like a quick fix to a devastating problem.

But the ruling in Stanley Kingaipe and Charles Chookole's case will bolster the arguments of those who believe compulsory HIV testing is too blunt an instrument for such a complex issue.