Thursday, July 12, 2007

Should rapid tests for hiv infection now be mandatory during pregnancy? global differences in scarcity and a dilemma of technological advance

An excellent paper by Charles B. Smith, Margaret P. Battin, Leslie P. Francis & Jay A. Jacobson on the ethical issues in mandatory HIV testing during pregnancy can be found in the latest edition of Developing World Bioethics.[1]
Abstract and discussion below the fold.

Since testing for HIV infection became possible in 1985, testing of pregnant women has been conducted primarily on a voluntary, ‘opt-in’ basis. Faden, Geller and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that with the development of more reliable testing and more effective therapy to reduce maternal-fetal transmission, testing should become either routine with ‘opt-out’ provisions or mandatory. We ask, in the light of the new rapid tests for HIV, such as OraQuick, and the development of antiretroviral treatment that can reduce maternal-fetal transmission rates to <2%, whether that time is now. Illustrating our argument with cases from the United States (US), Kenya, Peru, and an undocumented Mexican worker in the US, we show that when testing is accompanied by assured multi-drug therapy for the mother, the argument for opt-out or mandatory testing for HIV in pregnancy is strong, but that it is problematic where testing is accompanied by adverse events such as spousal abuse or by inadequate intrapartum or follow-up treatment. The difference is not a ‘double standard’, but reflects the presence of conflicts between the health interests of the mother and the fetus – conflicts that would be abrogated by the assurance of adequate, continuing multi-drug therapy. In light of these conflicts, where they still occur, careful processes of informed consent are appropriate, rather than opt-out or mandatory testing.

Smith et al make the excellent point that:
it is crucial to recognize that a person with a communicable infectious disease is both victim and vector at one and the same time, a person who is both the recipient of infection from someone else and a potential infector of another party. An ethically adequate policy in any context must recognize this fact – even in conditions of scarcity or extreme scarcity, which make it impossible to satisfy fully our social, legal and moral obligations to persons in both these roles. Policies mandating HIV testing in pregnant women typically treat the mother as vector and the child, to whom she might transmit HIV, as potential victim, but they sometimes neglect to see that the pregnant woman is also a victim, the recipient of HIV transmission from someone else, a person in medicalneed. An ethically adequate policy must see her in both these roles.

It is an excellent article which does a good job of balancing justice, the ethical considerations and the situation in the real world. Well worth the read.

[1]Charles B. Smith, Margaret P. Battin, Leslie P. Francis, Jay A. Jacobson (2007)
should rapid tests for hiv infection now be mandatory during pregnancy? global differences in scarcity and a dilemma of technological advance
developing world bioethics 7 (2), 86–103.