Monday, June 04, 2007

Rethinking mandatory HIV testing

Bioethics expert calls for mandatory HIV testing

A Queen’s philosophy professor and expert in bioethics is calling for a public policy shift towards mandatory HIV testing of pregnant women in areas where the disease is rampant.

In a paper published on-line from the July issue of the American Journal of Public Health, Dr. Udo Schuklenk, a world leader in the study of health-care ethics related to policy, argues that a mandatory approach to testing and treatment could significantly reduce perinatal transmission of HIV – which results in babies with an average life expectancy of only two years. He also promotes the view that mandatory testing is morally necessary if a number of conditions can be met.

“The scale of the problem demonstrates individual tragedies on an overwhelming scale and a threat to the public health of the communities in question,” says Dr. Schuklenk, Ontario Research Chair in Bioethics. In 2004, this mode of transmission resulted in up to 2.8 million HIV-infected children worldwide.

Co-author of the paper is Anita Kleinsmidt, a human rights law expert from Witwatersrand University in South Africa. Dr. Schuklenk was a professor with Glasgow Caledonian University when the paper was written.

About 35 per cent of newborns born to HIV-infected women contract the virus from their mothers if efforts to prevent mother-to-child transmission are not in place. While research has focused on obstetric care of pregnant women in high-prevalence areas, “treatment is contingent upon the pregnant woman seeking antenatal care, being screened for HIV, and agreeing to medical intervention,” says Dr. Schuklenk. “The continuing high number of children born with HIV attests to failures at various stages of this process.”

The authors suggest several conditions that must be met before the introduction of any mandatory testing and treatment programs:

· The woman has voluntarily chosen to carry the fetus to term
· She would have had a reasonable alternative to this course of action (e.g. abortion
at least until the point of fetal viability)
· Continuing voluntary treatment with HAART (highly active antiretroviral therapy)
would be available to her
· Ideally, the confidentiality of the woman’s HIV status is maintained, during as well as after her pregnancy.

Dr. Schuklenk proposes pilot studies introducing mandatory testing and treatment programs at a number of sites in Botswana and South Africa, where the HIV antenatal prevalence rate is 30 per cent. “This would allow us to establish how such programs can best be implemented, and to investigate stigmatization as it affects women giving birth within these programs,” he notes.

While not a panacea for the “continuing pandemic” of perinatally-transmitted HIV, mandatory testing and treatment regimes should be considered, whenever feasible, by governments and other health-care providers, says Dr. Schuklenk.

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