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Frerichs, R.R. More thoughts on mandatory HIV testing...

SEA-AIDS Network, May 8, 1998.

R.R. Frerichs Posting

When faced with a myriad of problems, governments must decide which activities to support and which to leave fallow. In the public health arena, decisions are rarely easy, given the some times divergent stance of citizens, scientific experts and others who want to influence public policy. The end point for some may be fewer deaths or longer life, while for others quality of life may rank supreme. Still others may focus on illusive but important concept such as human rights, the promotion of individual freedom, or the emergence of women in the society. What is essential, but perhaps most difficult is for readers of SEA-AIDS to view clearly the goals of those who advocate one position or another, and decide if these goals enhance or hinder the public health of people in South-East Asia.

Recently an article appeared here in the United States that addresses a contentious issue -- mandatory versus voluntary testing of pregnant women for HIV infection. The article stated that in the United States, voluntary testing is best, certainly a non-controversial conclusion for authors to hold who come from a nation that cherishes the Statue of Liberty and stresses the importance of individual rights in her constitution.

But is this the right policy for other countries who have different histories and social traditions? Does one policy fit all, or should the prevalence of HIV and national customs or traditions influence what is to be done?

Here in the United States we have been debating for some time the value of mandatory versus voluntary testing of pregnant women. Still another article on the stance of CDC regarding this issue was described yesterday by Reuters news network (see below).

 "Voluntary HIV Tests Preferable In Pregnancy"

NEW YORK (Reuters, May 6) -- The Centers for Disease Control and Prevention (CDC) currently recommend a policy of voluntary HIV testing for pregnant women. The results of a study published in the May 2nd issue of the Annals of Internal Medicine provide support for this policy. "At high levels of acceptance of voluntary HIV testing, the benefits of a policy of mandatory testing are minimal and may create the potential harms of avoiding prenatal care to avoid mandatory testing," write the researchers.

The efficacy of antiretroviral therapy in reducing HIV transmission from a mother to her fetus 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 Abington, 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 (mother-to-child) HIV transmission." They also estimated the number of HIV-positive infants or infants lost to AIDS resulting from the two approaches. Overall, 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. 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." According to the report, about 7,600 infants are born to HIV- infected women each year in the US, and 2,000 of these babies acquire HIV from their mothers. If all HIV+ pregnant women were identified and treated with antiretroviral treatment, the number of babies who acquire the infection from their mothers would fall from 2,000 to 600.

SOURCE: Annals of Internal Medicine (1998; 128760-767)

What is most interesting about this article is the interplay in the United States between two behaviors that might result from mandatory testing. First, some pregnant women who oppose mandatory testing might avoid any contact with the medical care system during their pregnancy and thus would have offsprings that are both HIV infected and possibly of small birthweight or other factors associated with lack of prenatal care. Yet those who come for prenatal care would by law be tested, and if found to be HIV infected, a high percentage of their HIV infected offsprings would benefit from early zidovudine (i.e., AZT) treatment.

MANDATORY: A tradeoff between more harm from no prenatal care vs. less harm from more diagnosis and AZT treatment. With voluntary testing, there would be no deterrents to prenatal care, so a higher percentage would be expected to visit their doctors during their pregnancy. Yet because testing is voluntary, some might elect not to be tested. If they are HIV infected but don't know it, then AZT will not be used, and more of their offsprings will die.

VOLUNTARY: A tradeoff between more harm from less diagnosis and AZT treatment vs. less harm from avoidance of prenatal care. What the authors concluded is that in the United States where the prevalence of HIV is low (and thus fewer are eligible for the benefits of mandatory test), the avoidance of testing by those who are anxious about a mandatory testing policy does more harm on average to their offsprings than when having voluntary testing, especially if acceptance of testing is reasonably high (i.e., estimates in the USA are now 95% or more). Notice that in America HIV is an uncommon disease among pregnant women. Thus the group that worries about the possible consequences of an HIV test is likely to have more HIV negatives than positives due to the low specificity of self-diagnosis without testing (that is, many false positives).

If in the United States the anxiety surrounding HIV testing were reduced among pregnant women so that fewer would avoid prenatal care if the policy was mandatory, then mandatory testing would work fine.

Of course, if there was less anxiety over testing then voluntary testing would also work fine. To bridge these two positions, some of us in the American public health community call for routine HIV testing, especially in higher prevalence regions of the country. Routine testing, different from mandatory testing, gives women the option of saying "no" if they so desire, but otherwise tests them as part of the usual routine in a medical setting (similar to measuring blood pressure and the like).

Important to note for health professionals in Southeast Asia, the above article is addressing the situation in the USA -- a low prevalence country. The problem facing public health officials in countries such as Thailand, Cambodia or Myanmar are much more complex, where about two percent of pregnant women are HIV infected. The situation is even more complex in areas of Central or Eastern Africa where 20 or more percent of pregnant women are infected. There the mandatory versus voluntary aspects of the equation play out far differently. Nevertheless the decision on what policy is best is also determined by the reaction of pregnant women when faced with mandatory or routine testing.

Thailand, from what I have heard, now does routine HIV testing of nearly all pregnant women. Myanmar and Cambodia do not, more because of expense (i.e., lack of HIV test kits and AZT) than because of concern with the mandatory or voluntary nature of the policy. The need for routine pregnancy testing is negligible in the Philippines and Indonesia, because the prevalence of HIV is low. Other regions or countries such as Yunnan, China; Laos; Vietnam; India; Bangladesh; Papua New Guinea and the pacific islands need to decide based on their surveillance findings and financial resources, which policy is best.

They should not, however, base their decision on what is being done in foreign societies such as the United States, where transmission patterns and societal norms may be different from their own.