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Table 1 Ethical arguments for or against the Provider Initiated Opt – Out Prenatal HIV Screening

From: Ethical issues surrounding the provider initiated opt – Out prenatal HIV screening practice in Sub – Saharan Africa: a literature review

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.