Compulsory HIV testing for pregnant women in NJ on the cards

Anita Kleinsmidt sent this news item... interesting.

New Jersey Aims At Compulsory HIV Test For New Borns, Pregnant Women

New Jersey plans to become the first state in the United States to make HIV testing mandatory for pregnant women and newborns, under a proposal introduced Thursday. The new proposal, which was suggested by Senate President Richard J. Codey, D-Essex, eyes at introducing legislation for compulsory HIV testing for all pregnant women and newborns, unless the mother refuses in writing.

Currently four states, Arkansas, Michigan, Tennessee and Texas, have a legislation that requires health-care providers to test a mother for HIV, unless the mother refuses to do so in writing. The only two states that have compulsory HIV test for newborns are Connecticut and New York.

Strongly advocating his views for a compulsory HIV test, the Democratic leader believes that early detection and treatment can save lives of many by reduce their infections and improve the quality of life.

The bill, if passed would make an HIV test compulsory for all pregnant women as early as possible in their pregnancy and again during their third trimester. Also, each birthing facility in the state would have orders to test every newborn in its care for HIV.

According to AP reports, the current law in the New Jersey only requires HIV testing to pregnant women. The Center for Disease Control and Prevention says that early detection can prevent many HIV-infected women from transmitting the virus to the infant.

Experts believe that drugs during pregnancy can minimize mother-to-child HIV transmission to 2 percent, compared to 13 percent if no drugs are used until labor and delivery. It was also found that the HIV risk was reduced to 25 percent if no drugs are ever used.

According to the Kaiser Foundation, New Jersey has about 17,700 AIDS cases, which includes about 5,800 women. It is the fifth-highest total for women in the United States. It was also found that 772 pediatric AIDS cases in the state make it the third highest in the nation behind New York and Florida.

New Jersey also had 409 child HIV cases in 2005, which is the second highest in the nation behind New York.

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Stuart Rennie on HIV Prevention

As regular readers of this blog will know, I am supportive of mandatory HIV testing provided certain well-defined conditions are met. Stuart Rennie seems to disagree. Here I reproduce his take on the issue. It's well worth reading. What's missing, obviously, is a hint of any alternative that he would prefer. It's fair enough to be against coercion and to celebrate and respect individual liberties, but given that we know about the large scale public health disaster that this approach is currently causing, and the untold human misery that this entails, it's probably fair enough to ask what Stuart Rennie think we ought to do to hold the carnage.

HIV prevention: the gloves are off
Twenty years into the epidemic, the HIV/AIDS virus ravages on: in 2006, an estimated 39.5 million people in the world were living with HIV, 4.3 million were newly infected, and 2.9 million AIDS-related deaths. Of the deaths, 2.1 million occurred in sub-Saharan Africa. As for new HIV infections, South Africa alone is estimated to have 1500 ... per day. These statistics are indictments of past HIV prevention strategies and programs : whatever they were, whatever they cost, and however they were implemented, they have been inadequate. The question then becomes: what strategy changes should be adopted?

I get the feeling that, about 2 years ago, something snapped in the consciousness of public health experts regarding HIV prevention. Enough was enough. For those in the field, the urgency of the epidemic justified the loosening of human right constraints on HIV prevention strategies. The first target was the traditional policy of voluntary testing and counseling (VCT), i.e. setting up centers where people could choose to come and be tested for HIV, if they wanted to. Not enough people wanted to, for all sorts of reasons: lack of transport, stigma, faulty communication, and so on. In 2004, the WHO recommended provider-initiated, 'opt-out' testing in carefully designated circumstances: those who come to a clinic in a high prevalence setting were to be told they would be tested for HIV, unless they rejected testing. The CDC soon followed suit with similar policies. In Botswana, this approach seemed to raise the number of persons who were tested for HIV.

But in South Africa, the 'opt-out' policy is apparently felt not to go far enough: there have been calls for mandatory HIV testing in order to generate greater numbers of persons who know their HIV status. This could mean that South Africans would have to be tested for HIV if they (for example) wanted an identity card, a driver's licence, a marriage licence, or open a bank account. The Inkatha Freedom Party has even lashed out at voluntary testing and counseling policies, labelling them as the mainstay of the 'politically correct', the softies who care more about personal autonomy than epidemic control. VCT, in other words, is for pussies. Not everyone is buying it, of course.

Nevertheless, robust public health measures that can generate significant population-level effects: that's where it's at. Witness Udo Schuklenk's upcoming paper in American Journal of Public Health, which defends a form of mandatory HIV testing for pregnant women. Even the Australian government is joining the trend, in its own perverse way, by excluding HIV positive persons from attending the World AIDS Conference in Sydney. Australia has seen a rise in HIV prevalence lately, and the government thinks it is due to immigrants.

Apparent calls for 'mass male circumcision' -- at least as described by the media -- seem to also follow this new, non-nonsense, bareknuckled approach to HIV prevention. Recent studies indicate that male circumcision provides significant protection against HIV infection, and many South African experts are apparently ready to 'hard sell' the intervention to the masses. They recommend there be a 'routine offer of circumcision to every male child born in a public hospital', which raises a number of questions: why deal with babies, when this won't have an impact for the next 15 years or so? How will communities respond to such aggressive policies? Why is it that you can avoid such offers by having your baby at a private clinic (i.e. being wealthy)? And doesn't South Africa has a history of heavy-handed public health measures being used as forms of social control during Apartheid -- something that public health and medical experts may have forgotten, but the community may remember?

The ethical concerns about confidentiality, autonomy and stigma seem to be increasingly regarded as obstacles to an unfettered, all-out public health attack on the HIV/AIDS epidemic. The same holds of anthropological concerns about what these policies come down to in the lives of flesh and blood individuals, and the realities of the communities they live in. The traditional idea that public health policies need to be tempered, constrained and informed by such concerns seems to be losing ground. Will these 'tough love' approaches to HIV prevention turn the tide? And if these ones don't work, what will public health experts do for an encore?

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.

Rethinking Mandatory HIV Testing

Anita Kleinsmidt and I have a paper in the AMERICAN JOURNAL OF PUBLIC HEALTH in which we propose to consider introducing mandatory HIV testing of pregnant women in high HIV prevalence areas (eg in Southern Africa). The available evidence suggests that the uptake of HIV testing increases the more difficult the state makes it for pregnant women to avoid it. We think that if women are given the option to have an abortion, and if they insist on carrying the fetus to term, they have some responsibility toward it. This includes the responsibility to ensure that the newborn they want to come into being has a good shot at a life worth living.
Anyway, check it out, the paper is currently available online in a First Look version. The final printed version should be available in the July issue of the journal.