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
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
"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 "...data on the results of current policy recommendations
are urgently needed before any major change in policy is implemented."
Ann Intern Med 1998;128760-767.