EDITORIAL RETHINKING MANDATORY HIV TESTING When the US Centers for Disease Control reported the first AIDS cases in the early 1980s, amid much fear and uncertainty, mandatory universal HIV testing was seri- ously entertained in a number of countries. 1 This public health response was eventually rejected as an inefficient means to achieve its objective, namely, to curb the spread of HIV/AIDS. Paternalistic rationales also failed in the early days of the pandemic as there was little or nothing that HIV carriers could do to prevent the onset of AIDS and their typically premature demise. In the absence of substantive medical treatment regimes, mandatory testing threatened to harm HIV carriers without promis- ing them any real gain. State-mandated testing would have forced carriers to suffer this anguish and, perhaps, the devastating social and economic consequences of a positive test result, while in no way benefiting from the result. Indeed, it would have forced carriers to trade in hope for despair. For these reasons, the incursions on individual autonomy involved in mandatory testing were rightly considered unethical. Some years later, mandatory HIV testing was briefly entertained again in developed coun- tries when it was discovered that the transmission of the AIDS virus from a pregnant woman to her fetus could be drastically reduced if she received antiretroviral therapy. This strategy, of course, required the woman to undergo HIV testing. In the end, however, the view prevailed that women’s right to control their own bodies and health overrides any conflicting claims ascribable to the deve- loping fetus. Much has changed since the 1980s, and renewed bio- ethical analysis of mandatory HIV testing is called for. According to a 2009 study, the risk of death increased by 94% for the 9155 patients with a CD4+ count of more than 500 cells/mm 3 who deferred therapy until their CD4+ count fell below 500 cells/mm 3 . The risk of death increased by 69% for the 8362 patients with a CD4+ count of 351–500 cells/mm 3 who deferred therapy until their CD4+ count had fallen to 350/mm 3 or less. 2 In the light of these findings, mandatory testing could now be deployed as much more than a sub-optimal means of curtailing risky behaviour; it could be used as a means of providing critical, life-preserving information. The claim that testing does not benefit HIV carriers is now patently false, given the reduced risk of death that goes hand-in- hand with early detection and treatment. Early HIV detection and treatment are now demonstrably critical to longterm health. 3 Medical care has elevated AIDS from a death sentence to a serious chronic illness, which people can shoulder over long and happy lives. Further, and highly significantly considering the abject failure of preventative HIV vaccine research, antiretro- viral therapy can now render HIV carriers effectively non-contagious. 4 This should have significant implica- tions also for the policy debate on whether or not unsafe sex involving an infected person should be decrimina- lized, given that an infected person with an undetectable viral load is practically incapable of transmitting the virus. A change in law that took into account that even though you are HIV infected, you are actually unable to transmit the virus, would provide an additional incentive for people at risk of HIV infection to get tested and, if infected, treated. Recent mathematical modelling also suggests that the widespread use of testing and immediate treatment could shift the AIDS epidemic towards elimi- nation within a decade, and reduce the overall prevalence of HIV below 1% in the world’s worst-affected regions before 2050. 5 It is self-evident that these recent treatment and pre- vention developments dramatically alter the landscape of the mandatory testing debate, yet surprisingly we were unable to source recent bioethics contributions aimed at revisiting the debate in the light of recent medical advancements. Many of the old arguments against man- datory testing hinge on empirical assumptions that are well and truly outdated. The time has come to reconsider how we as society respond policy-wise to HIV, given that today, in the developed world, AIDS is essentially an infectious, chronic illness that can be controlled and treated fairly effectively. BRENDAN O’GRADY UDO SCHÜKLENK 1 U. Schuklenk. 1998. AIDS: individual and ‘public’ interests. In Com- panion to Bioethics. H. Kuhse & P. Singer, eds. Oxford: Blackwell; 343–354. 2 M.M. Kitahata et al. Effect of Early Versus Deferred Antiretroviral Therapy for HIV on Survival. N Engl J Med 2009; 360 (18): 1815–1826. 3 P.E. Sax & R.B. Lindsay. When to Start Antiretroviral Therapy – Ready When You Are. N Engl J Med 2009; 360 (18): 1897–1899. 4 P. Vernazza et al. Les Personnes Séropositives ne Souffrant d’aucune Autre MST et Suivant un Traitement Antiretroviral Efficace ne Trans- mettent pas le VIH par Voie Sexuelle. Bull méd Suisse 2008; 89 (5): 165–169. 5 R. Granich et al. Universal Voluntary HIV Testing with Immediate Antiretroviral Therapy as a Strategy for Elimination of HIV Transmis- sion: a Mathematical Model. The Lancet 2009; 373: 48–57. Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/j.1467-8519.2009.01765.x Volume 23 Number 8 2009 p ii © 2009 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.