Researchers have called for a debate on mandatory HIV testing for pregnant women and newborn children in South Africa to protect both the mothers and their infants from the ravages of the virus.
In an article in the American Journal of Public Health, two former University of the Witwatersrand bioethicists say that between 11 000 and 15 000 babies could be protected against HIV each year if there were a 25% increase in the number of pregnant women tested for the virus.
Udo Schuklenk, one of the researchers who is now at Queens University, Ontario, says there is a need for pilot studies to introduce mandatory testing and treatment in South Africa to assess the potential gains and drawbacks of such policies.
At Johannesburg Hospital the average HIV prevalence is 29,4%. One study found that among women attending the hospital who declined to know their HIV status, but nonetheless gave permission for their blood to be tested anonymously, the level of HIV infection jumped to 44%.
South Africa has an ”opt out” system that offers pregnant women the choice of an HIV test, accompanied by pre- and post-test counselling. An alternative is for HIV tests to be routinely done as part of an antenatal check-up, unless the woman specifically refuses.
It has been estimated that fewer than 30% of pregnant women in South Africa participate in full prevention of mother-to-child-transmission (PMTCT) programmes, which include antiretroviral drugs that lower the chances of a child becoming infected with HIV during the period around birth.
The article says that both ”compulsory testing and compulsory treatment could be defensible in a public health emergency such as that of Aids”.
It argues that mandatory testing and treatment can be implemented ethically in areas of high HIV prevalence provided women are ensured of confidentiality; that they have the possibility of antiretroviral therapy if needed; and that they have the choice to terminate a pregnancy if they so wish. The stigma and risks attached to an HIV diagnosis are real, but research suggests the reality might be less substantial than the fear.
The article points out that worldwide testing rates jump dramatically when an ”opt out” system is introduced. In Botswana, all people seeking healthcare are routinely given HIV tests under the ”opt out” system. While one aim is to reduce the number of HIV-infected infants, another is to encourage people to take advantage of antiretroviral therapy.
Earlier diagnosis of HIV allows people to start antiretroviral treatment before he or she becomes extremely sick with Aids. A pregnant woman who knows she is HIV-positive can choose treatment that will reduce her child’s chances of HIV infection during birth and breastfeeding. Research has shown that having an HIV-positive mother increases child mortality even if the infant itself does not have the virus.
Some doctors argue that mandatory testing for HIV among newborn children could be the easier and more practical measure.
Matthew Chersich, of the Kenyan International Centre for Reproductive Health, argues that domestic and international laws create a legal obligation for healthcare workers to find out a child’s HIV status immediately after birth and to administer the appropriate treatment.
Clinical trials in South Africa and Malawi have found that giving newborns such drugs within two or three days of birth can protect them against HIV. This form of post-exposure prophylaxis (PEP) against exposure to HIV in the birth canal applies even if the mother herself was not given any antiretrovirals and works on the same principle as PEP that is given to rape survivors.
On the ethical problem that testing a newborn for HIV automatically reveals the status of the mother, Chersich says it is important that women benefit directly from knowing their status to ”avoid instrumentalising women and treating them as conduits for healthy babies”.
But, he says, while improved healthcare for the mother is the most obvious benefit, other gains for her include preventing the emotional distress, care and costs of having a chronically sick child. In some communities ”a chronically sick child can be a source of stigma and is highly suggestive of HIV infection, undermining confidentiality”.
He argues that while a mother ”may avoid an HIV diagnosis, as she feels unable to cope with it, she expects her child to have to deal with it, should that child become infected”.
With ”HIV testing remaining a major bottleneck to PMTCT entry” in sub-Saharan Africa, where UNAids estimates that only 11% of women have access to PMTCT programmes, Chersich says a legal challenge on behalf of HIV-infected or exposed children could drive a policy shift.