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Frerichs, R.R. Voluntary versus mandatory HIV testing of pregnant women.

SEA-AIDS Network, May 4, 1998.

R.R. Frerichs Posting

The debate over mandatory versus voluntary HIV screening of pregnant women usually centers on coverage issues -- i.e., what percentage of HIV infected women can be reached. Here in the United States, given our history of participatory democracy, we tend to favor voluntary policies, using education to increase participation. We have used this approach to decrease smoking, reducing excess drinking, promote use of seatbelts and the like. Alternatively, we have used a mandatory approach to ensure childhood immunizations (using schools as the compliance agent) and to screen for various conditions at birth.

The benefits of voluntary HIV screening of pregnant women is described in the current Annals of Internal Medicine (see below). Given very high voluntary compliance, the authors have concluded that there is little additional benefit to be gained from mandatory action.

Of course in other countries where compliance is less, the debate will likely continue. Finally, the authors noted that more research is needed on the impact and consequences of the current voluntary policy before any change in policy is recommended. Their call for local demonstration projects and research prior to the implementation of national policy is good advice for all countries to follow where mother-to-child HIV transmission is a problem.

"Voluntary, Not Mandatory, HIV Testing Preferable In Pregnant Women" (Reuters, May 4, 1998)

WESTPORT, May 04 (Reuters) - The Centers for Disease Control and Prevention (CDC) currently recommends a policy of voluntary HIV testing for pregnant women. The results of an decision analysis published in the May 2nd issue of the Annals of Internal Medicine that compared models of voluntary versus mandatory HIV testing in pregnant women supports this position.

The efficacy of antiretroviral therapy in reducing vertical transmission of HIV has made the issue of HIV screening in pregnant women the subject of much public policy debate, Dr. David G. Smith of Abington Memorial Hospital in Pennsylvania and colleagues observe. In the current study, they evaluated the relative benefits and risks of voluntary and mandatory HIV testing in pregnant women. One factor in their decision analysis was the "threshold deterrence" rate, "...defined as the percentage of women who, if deterred from seeking prenatal care because of a mandatory HIV testing policy, would offset the benefit of zidovudine in reducing vertical HIV transmission." They also estimated the number of HIV-positive infants or dead infants resulting from the two approaches. Overall, Dr, Smith's team found that "...a voluntary policy is preferable to a mandatory policy over a broad range of variables used in the analysis."

Important variables included the acceptance of voluntary HIV testing, the deterrence rate associated with mandatory testing, and the prevalence of HIV infection. "Increasing voluntary HIV testing to 97% significantly reduced the benefit of mandatory testing, even when the model was stacked against voluntary testing and when the deterrence rate was assumed to be 0.0%" In addition, they found that outreach and education could "substantially" improve HIV testing acceptance and had the largest effect on reducing the number of HIV-positive infants.

"Such an approach would also circumvent the potential adverse effect of deterrence from prenatal care as a result of a mandatory policy." In conclusion, they believe the findings support current CDC recommendations and argue against "...the implementation of a mandatory testing policy." In addition, more " on the results of current policy recommendations are urgently needed before any major change in policy is implemented."

Ann Intern Med 1998;128760-767.