Ethical implications of HIV self-testing: the game is far from being over

The use of combined Anti-Retroviral Therapy (cART) has been revolutionary in the history of the fight against HIV-AIDS, with remarkable reductions in HIV associated morbidity and mortality. Knowing one's HIV status early, not only increases chances of early initiation of effective, affordable and available treatment, but has lately been associated with an important potential to reduce disease transmission. A public health priority lately has been to lay emphasis on early and wide spread HIV screening. With many countries having already in the market over the counter self-testing kits, the ethical question whether self-testing in HIV with such kits is acceptable remains unanswered. Many Western authors have been firm on the fact that this approach enhances patient autonomy and is ethically grounded. We argue that the notion of patient autonomy as proposed by most ethicists assumes perfect understanding of information around HIV, neglects HIV associated stigma as well as proper identification of risky situations that warrant an HIV test. Putting traditional clinic based HIV screening practice into the shadows might be too early, especially for developing countries and potentially very dangerous. Encouraging self-testing as a measure to accompany clinic based testing in our opinion stands as main precondition for public health to invest in HIV self-testing. We agree with most authors that hard to reach risky groups like men and Men Who Have Sex with Men (MSM) are easily reached with the self-testing approach. However, linking self-testers to the medical services they need remains a key challenge, and an understudied indispensable obstacle in making this approach to obtain its desired goals.