Table 1 Ethical arguments for or against the Provider Initiated Opt – Out Prenatal HIV Screening
Title | Author(s) | Year of Publication | Main Themes |
|---|---|---|---|
1. Legal and Ethical Implications of Opt-Out HIV Testing | Hanssens C [13]. | 2007 | - Rigid application could trigger legal claims - Risk of breaching informed consent, - Disregard or emotional and mental risks - Could disregard autonomy and dignity |
2. Desperately seeking targets: the ethics of routine HIV testing in low-income countries. | Rennie and Behets [40]. | 2005 | - Cannot be effective since clients are generally unaware of the meaning of the opt –out approach - Conflict /balance between promoting good (conscious and unconscious coercion from training of health care staff and insistence on right to refuse test (wrong message that test is unimportant). - Reduction of HIV – AIDS related stigma - Not adapted to areas characterized by high poverty levels, gender inequalities, weak health care infrastructure and poor access to treatment |
3. HIV testing of pregnant women: an ethical analysis. | Johansson et al. [12] | 2011 | - Most effective strategy - Recognize flip side of the strategy becoming involuntary in the clinical setting - Availability and effectiveness of inexpensive drugs makes intrusiveness of test less important that hypothetical preference of the child to be born healthy. |
4. The Uptake of Integrated Perinatal Prevention of Mother-to-Child HIV Transmission Programs in Low- and Middle-Income Countries: A Systematic Review. | Tudor Car et al. [5] | 2013 | - 11 % of women delivered in labor rooms do not know their HIV results and did not participate in any HIV prevention programme - High uptake of the Provider Initiated Opt – Out prenatal screening approach (96 %) - Retention in Prevention of Mother to Child Transmission of HIV Interventions low (17 % of Antenatal care attendees). |
5. Routine offer of antenatal HIV testing (“opt-out” approach) to prevent mother-to-child transmission of HIV in urban Zimbabwe. | Chandisarewa et al. [11] | 2007 | - More mother/infant pairs receive treatment when screened using the opt – out approach - Greater compliance with the opt – out screening approach - Greater reported satisfaction with this approach compared to the opt in approach - Lower reported rates of spousal abuse |
6. Consent and antenatal HIV testing: the limits of choice and issues of consent in HIV and AIDS | Sherr at al [14]. | 2000 | - Poor information transmission from health care providers to pregnant women with regards to HIV transmission risk and obtaining consent in antenatal settings could be counterproductive in terms of: a. Test uptake b. Optimal goal of minimizing maternal/fetal transmission. |
7. Could you have said no? A mixed-methods investigation of consent to HIV tests in four African countries. | Obermeyer et al. [16] | 2014 | - Underscores HIV testing with current opt – out approach without any consent from pregnant women (7 %) - Health care providers actively influence the choices of clients (21 %) - Quality of questions asked to evaluate the informed consent procedure is of utmost importance - Retrospectively asking clients if they would have said no overestimates measured levels of coercion |
8. Rethinking HIV exceptionalism: the ethics of opt-out HIV testing in sub-Saharan Africa. | April [18]. | 2010 | - Opt – Out testing could increase survival only with effective case management and sustainability plans - Opt – out screening encourages test acceptance, while opt – in screening could increase test refusal rates - Opt – out screening restricts autonomy, but justifiable on ethical grounds based on the theory of libertarian paternalism |
9. Opt-out HIV testing: an ethical analysis of women’s reproductive rights. | Fields and Kaplan [23]. | 2011 | - Screening approach is at odds with true informed consent - Reproductive rights principles risk being disregarded if counseling is not properly done - Increases testing rates and permits appropriate reproductive choices to be made by mothers - Suggests training of health care staff to offer ethically acceptable counseling and testing, as well as societal actions to decrease HIV associated stigma and discrimination |
10. The sexual ethics of HIV testing and the rights and responsibilities of partners. | Dixon-Mueller [54]. | 2007 | - Rights of individuals to refuse testing ignores the rights of other sexual partners to be informed of the health risks they are exposed to. - With the Opt – out testing approach, breaching autonomy could also go against the right not to know of the clients. - Opt – out approach justified on grounds of doing no harm to the fetus |
11. Program synergies and social relations: implications of integrating HIV testing and counselling into maternal health care on care seeking. | An et al. [36] | 2015 | - Integration of HIV testing with routine care improves confidentiality, more convenient and less stigmatizing - Opt – out HIV screening within the prenatal care package is perceived as compulsory - Lack of trust in health care staff and non – supportive health care provider – client relationships aggravates stigma and favors loss to follow up. - Social relationships between clients and health care staff must be well understood and acted upon for this approach to be ethically acceptable |
12. Is ‘Opt-Out HIV Testing’ a real option among pregnant women in rural districts in Kenya? | Ujiji et al. [15] | 2011 | - HIV test is considered compulsory by most clients with only 17 % thinking it is optional. - High coverage of HIV testing appears to be achieved at the cost of pregnant women not understanding that testing is optional |
13. Routine antenatal HIV testing: the responses and perceptions of pregnant women and the viability of informed consent. A qualitative study. | De Zulueta and Boulton [25]. | 2007 | - No pregnant woman tested fulfilled the standard criteria for informed consent - Routine testing (Opt – Out) compromises informed consent - Almost no understanding or false beliefs with regards to a positive HIV test result amongst most participants |
14. An offer you can’t refuse? Provider-initiated HIV testing in antenatal clinics in rural Malawi. | Angotti et al. [17] | 2011 | - An HIV test is a compulsory precondition to receive antenatal care - Benefits of antenatal HIV testing are more important than choice - People may increasingly avoid government hospitals for antenatal services to escape what they perceive to be a mandatory testing requirement. |
15. Rethinking mandatory HIV testing during pregnancy in areas with high HIV prevalence rates: ethical and policy issues. | Schuklenk and Kleinsmidt [56]. | 2007 | - Prevalence rates of HIV in test refusers generally greater compared to accepters. - Argue from a purely consequentialist perspective: stress of subjecting clients to mandatory test is far less (outweighed) by the benefits of knowing infected mothers status and implementing appropriate prevention and treatment strategies - Provide four preconditions for mandatory screening in high HIV prevalence settings: woman voluntarily decided to carry fetus to term, have reasonable alternative courses of action (eg abortions), available and voluntary HAART treatment and confidentiality should be guaranteed. |
16. The complexity of consent: women’s experiences testing for HIV at an antenatal clinic in Durban, South Africa. | Groves et al. [47] | 2010 | - Generally, some women have a clear choice to get tested, others not very sure and others feel they have no choice. - Direct and indirect coercive techniques employed by heath care staff to get them tested. - Further studies to develop mechanisms to simultaneously meet up with public health goals of widespread test coverage while respecting women’s autonomy. |
17. From caution to urgency: the evolution of HIV testing and counselling in Africa. | Baggaley et al. [45] | 2012 | - Provider Initiated Testing and counseling generally acceptable throughout Sub – Saharan Africa - Women generally not aware of the fact that they can decline an HIV test |
18. Practicing provider-initiated HIV testing in high prevalence settings: consent concerns and missed preventive opportunities. | Njeru et al. [48] | 2011 | - Limited pre and post - test counselling with the provider initiated opt – out approach. - Relative neglect on insistence on preventive measures - Clients frustrated with inability to opt – out - The opt – out model in prenatal settings deserves to be revisited and acted upon to maximize protection of client autonomy and access to effective prevention practices |
19. Opt-out HIV testing during antenatal care: experiences of pregnant women in rural Uganda. | Larsson et al. [39] | 2012 | - Clients consider test as compulsory - Benefits of getting an HIV status result not fully discussed to clients and not understood by clients - Compulsory testing could deter clients from seeking antenatal care - Gender sensitive models need to be recognized to encourage partner screening |
20. HIV/AIDS Stigma and Refusal of HIV Testing Among Pregnant Women in Rural Kenya: | Turan et al. [61] | 2011 | - Women who recognize getting stigmatized if partners know their results are more likely to refuse an HIV test, or be compliant to treatment - Anticipated stigma could be barriers to accepting HIV screening by pregnant women - The Opt – Out approach if compulsory without taking into account this reality could aggravate stigma and thus become counterproductive. |
21. An Ethical Analysis of Opt-Out HIV Screening for Pregnant Women | Wocial and Cox [27]. | 2007 | - Opt – out approach justified on the basis of the potential good to the general public (beneficence). - Respects autonomy since it is not a discriminatory process - Everyone is screened without discrimination nor neglect of marginalized individuals (justice). - Effective counseling empowers women to take more rational decisions and reduce transmission to their infants - Opt – Out approach considered to be ethically defensible, especially if counseling of women is effectively acted upon. |