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 "...data 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
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
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.