SO, as you all know, I enjoy writing about controversial issues in medicine. A debatable topic in medicine is whether HIV testing should be mandatory or optional when it comes to pregnant women.
In a book I recently read, Patient as victim and vector: ethics and infectious disease, the authors outline varying reasons for and against mandatory HIV testing. Their argument for mandatory HIV testing is solely based on the success rates of such implementations. They noted that with HIV testing and treatment in the USA, the probability of a woman transmitting her HIV vertically dropped from one-third to nearly zero. Looking at other locations such as Sub-Saharan Africa, where nearly 700,000 children acquire HIV vertically, testing and treatment of HIV would save thousands of lives and help start a prevention campaign. With the use of one single dose of AZT, a drug used to treat HIV, on an HIV-positive pregnant woman and subsequent doses on the newborn baby, studies have shown that HIV acquisition of infection in the newborn was reduced from 25% to 8%. Specifically, for women who were being tested for the first time while in labor, and treated with the anti-ARV therapy, the probability of maternal-to-child transfer of HIV was reduced to under 3%. The rapid testing technology that we have acquired with the latest research and technology allows for immediate preventative treatment for the child, if the mother tests positive for HIV. Such information supports the ideology on mandatory HIV testing. Ethically speaking, the fetuses have a right to be protected from a deadly infection and their health should not be held in the hands of a woman who is refusing to be tested for HIV whether it be for social, personal or economic reasons.
Testing the woman would be considering her a vector, however treating her would be considering her a victim. This is important to keep in perspective when ethically looking to mandate a mandatory HIV-testing policy. We cannot neglect that though the mother is a vector, she is also a victim. Patient activists, according to the authors, argued that such mandatory testing would be violating the woman’s autonomy and rights to her own privacy. To bioethicists, the solution to this would be to allow for voluntary approaches to testing. In a perfect world where everyone was educated with the risks of HIV, AIDS and data on transmission, this would work because then women would opt for getting tested – based on their knowledge of the situation. However, we live in a world where although there are many privileged first-world countries, there are also many third-world countries that do not provide their populations with such education. And, unfortunately, these third-world countries are the locations where HIV is most prominent because of a lack of detection and treatment. Nonetheless, we must also take note to what would take place if a mother tested HIV-positive during labor and the country that she lived in was unable to provide adequate HIV therapy. According to the authors, such a situation would lead to “troubling results.” If a woman tested HIV positive and lived in a community that has very conservative and strict cultural values, she would potentially have to live in an uncomfortable and possibly dangerous environment where those that’re around her might respond negatively to the situation (e.g. her husband might abuse or abandon her, the villagers might avoid any possible contact with her because of lack of education on how the disease is spread, etc.).
As an aspiring medical provider, I am a strong advocator for mandatory HIV testing – especially if I were in a country where HIV rates are extremely prevalent and on-the-rise. Many people can go years asymptomatic with HIV and a pregnant woman could have the disease without actually knowing it. This puts her life and her baby’s life at risk. If I had the ability to provide treatment and decrease the risks that her and her child will have HIV, then why would I not be supportive of mandatory HIV testing? To explain HIV testing and its advantages to a woman who is in labor is not ideal; she is not going to be in a state of mind with clear thoughts on what to do. Though she might accept, she might refuse and that would be putting the child at a very dangerous health-risk.
To rightfully and ethically make a decision about what would be done in such a situation, one must look at the end possibilities of each option. If we were to instantaneously test the mother that is in labor, we would know whether she has HIV or not. If she does, we would be able to immediately treat her and later her baby when delivered. If we were to let the mother choose to not get tested, then we would be risking a chance of her having HIV and us not knowing. This can put the baby’s life at risk later on in life and the baby could also live asymptomatic and not know that he/she has HIV. To not test the woman for HIV would be unethical. We have the means of helping her and her child; therefore, if we do not do so then we are ethically not providing the best care possible. Of course, there is a possibility of her being HIV-negative, but why would we risk that? Why would we risk her baby’s health and her own health because she does not want to complete one simple test, possibly because of lack of knowledge and education?
It would be one thing if the testing and treatment that we have wasn’t advanced and was still unreliable, but that is not the case. We live in a time where medicine and technology is better than it has ever been. We have more than one way of checking and double-checking if the HIV is positive. When a student takes an oath in the field of medicine, they swear to provide the patient(s) with all they can and to do their very best to treat them. Not testing a patient that comes into my clinic in labor would be a way of me denying them the best care possible – and as a medical provider, that is something I cannot and will not do.
Often times, it’s hard to agree on a happy medium when it comes to controversial topics. You may agree with my thoughts in these IOPs, but you also might totally disagree – and that is a-OKAY. These topics are DEBATABLE and controversial for a reason. I’d love to hear from you all, so reach out! 🙂