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‘We
need privacy, but not secrecy’ By Andrew Jack Published: August 8 2005 22:19 |
Mr Kapira’s cousin is putting at least two people’s lives at risk with his reaction to the results of his HIV test: he has not disclosed the fact to his wife and he does not want antiretroviral therapy himself because she would then find out.
In Malawi, where 15 per cent of the adult population is infected, that sort of attitude convinces officials and health workers that stronger measures – which in some cases would test the boundaries of accepted medical ethics – are needed to limit the spread of the virus.
“Treatment is important but we must also support prevention or this epidemic will become unmanageable,” says Roger Teck, head of Médecins sans Frontières-Belgium’s Malawi operations. “Sometimes there is a conflict with human rights.”
Concerned about patients’ ability to stick to prescribed drug regimes, and with its funds limited, MSF, like Malawi’s government, has had to make choices about who to treat and how to go about doing so.
One decision has been to limit the idea of patient confidentiality by insisting that each person given access to MSF’s programmes must agree to reveal their HIV status to a “guardian” – a relative or friend who can support them and make sure they take all the drugs prescribed them. The aim is to ensure high levels of compliance, reducing the risk of creating drug resistance.
The most lively debate over medical ethics in Malawi has been generated by efforts to increase diagnosis of Aids, with a growing shift by state and non-governmental organisations to change the emphasis from “opting in” to “opting out” of Aids testing. That includes encouragement to take an Aids test for all pregnant women, blood donors and anyone being treated for tuberculosis or a sexually transmitted disease – infections frequently found in patients with Aids.
“We’re shifting strategies to something very new,” says Erasmus Morah, UNAids co-ordinator in Malawi. “If you seek consent [to test], you continue to put up roadblocks. If a doctor gives the choice over testing, you ask whether it is the right thing. It’s a form of intimidation.”
Not everyone is convinced. Tiwonge Loga, head of the National Association for People with HIV/Aids in Malawi, which has opposed routine testing, says: “I don’t think we need it. There is a risk of coercion, especially in rural areas.”
Most controversially, in June the health ministry went as far as calling for “beneficial disclosure”, raising the prospect that a doctor may have the power to inform the partner of someone who has been tested HIV positive. Such moves are seen as particularly important given that up to half of all couples in the country are “discordant”, with one HIV positive and the other not. Insufficient testing, or a refusal to disclose the results and take necessary precautions, risks sending the infection out of control.
“What people were doing wrongly was protecting patients' right to protect their HIV status,” says Dr Morah. “If you know, you have a right to confidentiality but your partner also has a right to know.”
Victor Kamanga, Mr Kapira's colleague at Manet, says: “Human rights includes duties and obligations for patients to protect their spouses. If you are HIV positive and don’t take precautions, it’s a violation of the rights of the other person. We need privacy, but not secrecy that endangers the life of others.”
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