|Title||Author(s)||Year of Publication||Main Themes|
|1. Legal and Ethical Implications of Opt-Out HIV Testing||Hanssens C .||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 .||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. ||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. ||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. ||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 .||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. ||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 .||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 .||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 .||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. ||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. ||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 .||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. ||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 .||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. ||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. ||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. ||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. ||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. ||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 .||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.