KHOPOTSO: In January of this year (2004), under a decree by President Festus Mogae, the government of Botswana introduced the policy of routine testing for HIV as part of its response to the AIDS epidemic. In a country where an estimated 37.4 % out of a population of 1.7 million people is infected with HIV, the argument justifying the need for such a policy is that the more people get to know their status, the easier it will be to direct them to appropriate services. Dr Patson Mazonde is the Director of Health Services in Botswana.

DR PATSON MAZONDE: For instance, we have the prevention-of-mother-to-child-transmission programme. We have the introduction of antiretroviral therapy. Now, in order for patients to be able to access these services, they need to know their status. And secondly, of course it is important that if we must be able to prevent further infections people should know their HIV status. It is for this reason that we thought that we needed to introduce the issue of routine testing.

KHOPOTSO: Mazonde says routine testing has benefits far beyond the medical.

DR MAZONDE: Furthermore, it must be understood that routine testing normalises HIV/AIDS and therefore, helps de-stigmatise the problem.

KHOPOTSO: A view fervently held by Dr Ernest Darkoh, Operations Manager of Botswana’€™s National Antiretroviral Programme.

DR ERNEST DARKOH: We want to make the HIV test as routine as any other medical examination that’€™s necessary for the diagnosis and management of a health condition. So, in the same way that you get your blood routinely taken and analysed for chemistry, haematology, etc, we want HIV to be reviewed just in that same way’€¦ to de-stigmatise, but also to de-mystify this whole thing. Part of what we’€™ve experienced is that HIV has become too special, too exceptional ‘€“ to the point where, frankly, even common sense things are not being done anymore. People come in with clear signs and symptoms of HIV, but they don’€™t get tested because people are uncomfortable to directly just address the fact that this person standing in front of you is weighing the weight of a 12-year-old kid and it’€™s a 35-year old man.                  

KHOPOTSO: He explains how routine HIV testing works compared to voluntary counselling and testing.

DR ERNEST DARKOH: The only testing that used to exist was voluntary opt-in. Now, we’€™re saying routine opt-out. The difference between the two is the fact that now, what we’€™re telling people is that ‘€œif you come in with any sign or condition that is suspect of HIV, you are offered the test as a matter of routine.’€ So, across the board everybody who comes in to the hospital is basically offered the test and told ‘€œwe’€™re going to do the following tests on you ‘€“ A, B, C, D, E, F, G, – one of which of which may be the HIV test.’€ Now, it would be for the patient to say, ‘€œdoctor I don’€™t want the HIV test.’€ So, they can opt-out. And they’€™ve been informed of their right to opt-out of the test. However, what we’€™ve found is (that) very, very few people opt-out – less than 5 % of people opt-out. So, essentially right now the success of our testing has jumped to 95 % basically’€¦ as opposed to before where it was less than 20 %.            

KHOPOTSO: Dr Darkoh stresses that with the availability of AIDS treatment, it makes no sense to spare patients from knowing their HIV status.  

DR ERNEST DARKOH: For me, any process that keeps the person from knowing their status; that allows them to go home and infect their partner; that allows them to go home and infect their unborn baby or their new-born baby; and you have done nothing about it, as far as I’€™m concerned, in the context of therapy being available, that is called malpractice of the highest grade’€¦ We are dealing with an unprecedented epidemic and therefore, our solutions and our creativity also needs to be unprecedented. You do not address an unprecedented problem by doing what everybody else has been doing which has not worked.    

KHOPOTSO: The Director of Health Services in Botswana, Dr Patson Mazonde, backs this up by saying that routine HIV testing is governed by the rules of ‘€˜Good Clinical Practice.’€™

DR PATSON MAZONDE: We are saying that we should make sure that we are able to test people and offer them the services that they require. This is the way it ought to have been, even when this epidemic began. In fact, I honestly feel that the world must have lost it somewhere when we started over-emphasising that people should not be tested; they should only be tested as a last resort. I think that that was bad clinical practice. And all we are doing as a country is going back to the roots of good clinical practice.

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