Prenatal HIV screening of pregnant women in Ethiopia using ‘opt-out’ approach : the human rights and ethical concerns

Following the recommendation of the WHO and UNAIDS the Ethiopian Government revised its guidelines on Prevention of Mother-to-Child Transmission to adopt a routine provider-initiated ‘opt-out’ HIV testing approach to all maternal health care services. The testing approach requires all pregnant women to be provided with HIV test unless they expressly decline it. This thesis examines the human rights and ethical implications of the implementation of this HIV testing approach within the maternal health care settings in Ethiopia to screen pregnant women. It argues that this HIV testing approach may be able to meet the pressing public health imperatives presented by the incidence of HIV in Ethiopia. However, a full understanding of the context in which this testing takes place reveals that, the implementation of this testing approach can result in the denial of pregnant women’s rights to informed consent, to have access to adequate counselling and to ensure confidentiality of their HIV test results. This thesis argues that the implementation of routine provider-initiated ‘opt-out’ HIV testing approach in the maternal health care settings is affected by the weak health system, the feminization of poverty, and the persistence of HIV related stigma and violence as well as gender inequality. The fieldwork undertaken in the Tigray region provided insights into the subjective experiences of women in relation to their ability to make autonomous decisions regarding the HIV test offered during their pregnancies. It involved in-depth semi-structured interviews with pregnant women and key stakeholders as well as non-participatory observation. In addition, the normative and conceptual aspects of human rights and ethical principles inform the thrust of discussions and arguments in this thesis. This thesis concludes that although the HIV testing approach adopted by the Ethiopian Government to screen pregnant women for HIV infections does not violate human rights requirements, its implementation in the context Ethiopian socio- economic, cultural and legal context raises serious concerns. The study therefore recommends that attention must be paid to balancing the scaling up HIV testing of pregnant women in Ethiopia to prevent vertical transmission of HIV and respecting the individual’s rights to make their own medical decisions including refusing the HIV test