August 18, 2006—In the debate over whether to make HIV testing a mandatory part of medical care, all eyes in Toronto this week looked southeast, to Botswana. The Texas-sized country of 1.7 million people began offering routine opt-out testing in 2004.

Botswana's rationale for adopting the policy was simple: Slowing the spread of HIV in the country with perhaps the highest infection rate in Africa meant that everyone first must know their status. Although free antiretrovirals were widely available, few were taking advantage of them. The government’s hope was to put more people on treatment and make the disease seem more acceptable.

Some Botswanans at the International AIDS Conference here say it hasn't always worked out that way, however. Christine Stegling, the director of the Botswana Network on Ethics, Law and HIV/AIDS, sees clients as often as twice a day who've been fired for having the virus. "HIV-related discrimination does happen,” she says. “And to this day, Botswana has not enacted any legislation that protects the rights of those infected with HIV.”

Much of the opposition to mandatory testing in the developing world focuses on the shortage of health care resources: What good is knowing your status if there are no meds? But human rights activists also argue that routine testing will boost opportunities for discrimination against those who test positive.

Also, they say, routine testing shifts the burden of consent to the patient, who may not always be in a position to argue—especially if she’s an African woman. "It seems that the missing link in the many debates about testing is the discussion about the societal context that testing takes place in," says Stegling.

Grace Sedio, an HIV positive officer with the International Community of Women Living with HIV/AIDS in the capital of Gaborone, says, "Culturally or socially, women in Botswana have difficulty [refusing someone] in a position of power," such as a doctor. That, combined with an incomplete explanation at a clinic, means that patients often don't understand their right to opt out.

The government's more active, involved approach also may backfire. Says Stegling, "We had calls by the police where people were saying, 'We know this woman is on PMTCT but she’s breast feeding. Should we arrest her?'"

It may well be that Botswana doesn’t serve as an ideal bellwether for the global debate on this matter—or for recent moves to implement routine testing in New York State and recommend it at the federal level through the Centers for Disease Control (CDC).

The U.S. and Botswana do share some similarities, including access to testing, treatment and, perhaps, an attitude of ignorance that hastens the disease's silent spread. Maybe a quarter-million HIV positive Americans don't know their status. In Botswana, where more than a third of the population may be infected, 42% say they have avoided a test because they think they have no reason to believe they could be carrying HIV.