Opt-out testing for the human immunodeficiency virus (HIV) incorporates testing as a routine part of health care for all patients unless they refuse. The ethics of this approach to testing in sub-Saharan Africa is a source of controversy. Opt-out HIV testing is expected to improve survival by increasing case detection and thus linking more HIV-infected people to earlier treatment, provided there is effective patient follow-up and programme sustainability. At the population level, these benefits will likely outweigh the potential negative consequences of individuals experiencing HIV-related stigma, according to this article. These justifications appeal to consequentialist moral theories that the acceptability of an action depends upon its outcomes. On the other hand, liberal moral theories state that the autonomy of individuals should always be protected unless restricting autonomy is necessary to protect the welfare of others. Opt-out consent may restrict autonomy and it is unclear whether it would benefit people other than those being tested. Yet, the doctrine of libertarian paternalism proposes that it is justifiable and desirable to use unobtrusive mechanisms to help individuals make choices to maximise their own welfare. Central to this idea are the premises featured by supporters of opt-out consent that individuals will not always make the best choices for their own welfare but they may be influenced to do so in ways that will not compromise their freedom of choice. Also important is the premise that all policies inevitably exert some such influence: opt-in consent encourages test refusal just as opt-out consent encourages acceptance. Based on these premises, the article argues that opt-out testing may be an effective and ethically acceptable policy response to Africa’s HIV epidemic.
Values, Policies and Rights
SECTION27 hosted a Right to Food seminar on the 4th of November. This afforded the organisation and other stakeholders the opportunity to form a strategy to ensure the realisation of this critical but legislatively and judicially undefined right. The presentations given during the seminar can be accessed on the site. Attendees came from numerous organisations such as Action Aid, New Women’s Movement, COPAC, the Treatment Action Campaign, Foundation for Human Rights, Lawyers for Human Rights and Wits university.
PHM would like to invite civil society organizations, interested individuals and groups to participate in discussing the possibility of hosting such a campaign in South Africa. It would also contribute to building civil society for the Third People’s Health Assembly, planned for 2010 at an African venue (to be determined). This edition of Critical Health Perspectives sketches the background to the campaign and some of the thinking behind it.
Can court enforced health rights improve health policy and priority setting in poor countries? This multidisciplinary project aims to systematically investigate whether litigation can make health policies and -systems in poor countries more equitable by forcing policy-makers and administrators to take seriously their human rights obligations. Most of the world's governments are obliged through international treaties or national constitutions, or both, to respect, protect, promote and fulfill the human right to health. In most cases, this has not been an enforceable legal right. However, cases regarding the right to health care are increasingly brought before the courts. In a number of low- and middle-income countries - first in Latin America, later in Africa and Asia, court decisions have granted access to certain forms of medical treatment. These are decisions with potentially great implications for how health sector resources are prioritised and allocated, but so far there is little systematic knowledge of the actual effect of such cases on health policy formation, implementation and spending. Do they have a significant effect in practice? And, if so, do they contribute to more - or less - justice in health service delivery?
African governments are failing to offer even the most basic healthcare that could save lives, speakers warned a civil society meeting in the Kenyan capital, Nairobi. Delegates spoke particularly of the failure to uphold women's right to sexual and reproductive health services, calling for a response that takes into consideration the need to empower women. They noted that there is often no access to medical screening and treatment services for illnesses like cervical cancer, which affect large numbers of women but are rarely offered free of charge in pubic health centres.
This publication is a situational assessment, carried out between May and June 2008, of the sexual health and rights of sex workers in Botswana, Namibia, and South Africa, where sex work is illegal. It is based on interviews and focus groups with 87 female, transgender, and male sex workers, as well as 11 non-governmental organisations (NGOs) in the region that work with sex workers. Sex workers suffer unequal access to health care and social services, lack of access to reproductive health, including HIV prevention and treatment, and discrimination by health workers, police and communities. The report highlights opportunities for NGOs, governments, donors and UN agencies to expand rights-based approaches to sex work that will ultimately improve the health and well-being of sex workers.
Community participation, the central principle of the primary health care approach, is widely accepted in the governance of health systems. Health Committees (HCs) are community-based structures that can enable communities to participate in the governance of primary health care. Previous research done in the Cape Town Metropole, South Africa, reports that HCs' potential can, however, be limited by a lack of local health providers' (HPs) understanding of HC roles and functions as well as lack of engagement with HCs. This study was the first to evaluate HPs' responsiveness towards HCs following participation in an interactive rights-based training. Thirty-four HPs, from all Cape Metropole health sub-districts, participated in this qualitative training evaluation. Two training groups were observed and participants completed pre- and post-training questionnaires. Semi-structured interviews were held with 10 participants 3–4 months after training. Following training, HPs understood HCs to play an important role in the communication between the local community and HPs. HPs also perceived HCs as able to assist with and improve the quality and accessibility of PHC, as well as the answerability of services to local community needs. HPs expressed intentions to actively engage with the facility's HC and stressed the importance of setting clear roles and responsibilities for all HC members. This training evaluation reveals HPs' willingness to engage with HCs and their desire for skills to achieve this. Moreover, it confirms that HPs are crucial players for the effective functioning of HCs. This evaluation indicates that HPs' increased responsiveness to HCs following training can contribute to tackling the disconnect between service delivery and community needs. Therefore, the training of HPs on HCs potentially promotes the development of needs-responsive PHC and a people-centred health system.
The primary objective of this study was to explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland. During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. A total of 1,244 respondents were included in the study. Using the survey data, the researchers then analysed the association between childhood sexual violence and several potential demographic and social risk factors. They found that, compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence, likewise with those who had had no relationship with her at all. In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey, who were emotionally abused as children, and who knew of another child who had been sexually assaulted or was having sex with a teacher. Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time. Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence, the authors conclude, calling for greater educational opportunities and improved mother-daughter relationships.
Three countries in Southern Africa have the highest adult HIV prevalence in the world: Swaziland (25.9%), Botswana (24.8%), and Lesotho (23.6%). Fiscal policy is crucial for addressing this HIV and AIDS crisis, the authors of this paper argue. Utilising a calibrated model, they investigated the impact of fiscal policy on reducing the HIV and AIDS incidence rates in these countries. In particular, they studied the welfare impact of different taxation and debt paths in reducing the HIV and AIDS prevalence rates. This is particularly important given the current concerns about dwindling foreign aid (especially the Global Fund), and fiscal deterioration and sustainability in these countries. The results show that acting optimally has not only positive societal welfare effect but also positive fiscal effects. For example, it will alleviate the debt burden by 5%, 1% and 13% of the GDP respectively for Botswana, Lesotho and Swaziland by the year 2020. Thus, at a time of fiscal crisis in developed countries and dwindling international HIV and AIDS resources, the future of effective and efficient HIV and AIDS intervention in Africa is clearly domestic, they conclude.
Rwanda's national condom awareness campaign has failed to include messages designed for people with disabilities, despite their risk of HIV being the same as the rest of the population. Many disabled people are sexually active and may take part in unprotected sex, according to Jacques Sindayigaya, coordinator of the HIV programme for the non-governmental organisation, Handicap International. A three-month government campaign, which mainly used radio and television spots as well as billboards and more than 200,000 posters to spread information on condoms, ended in February 2010. According to government sources, it was successful in raising awareness. However, this article points to the need for such campaigns to also target the specific needs and situations of those with disability.