HIV Testing Helps Reduce the Risk of Aids to Unborn Children
Francis B. Mulekya
2006-03-02
Before 1994, knowledge about HIV and pregnancy was scarce. Evidence suggested that about one-third of babies born to HIV-positive women would be HIV-positive themselves.
There was fear that pregnancy might accelerate the development of Aids in women who were HIV-positive but had no symptoms. Most often, HIV testing was offered only to pregnant women considered to be at risk of HIV, or provided at the request of the patient herself.
By 1999, research in the US and Uganda showed that giving AZT (a drug for
treating HIV) to HIV-positive pregnant women and to their infants after birth
could reduce the rate of HIV transmission from mother to child from 25.5 to 8.3
percent.
Since then, studies have shown that the risk of transmission can be reduced
even further if other preventive measures (such as caesarean delivery) are
taken. This has caused debate about how best to offer HIV testing to pregnant
women, so that women testing HIV-positive can be offered anti-HIV therapy and/or
other measures to reduce the risk of transmission to their children.
Why pregnant women?
All pregnant women should be offered HIV counselling and testing as early in
pregnancy as possible. Several studies have shown that offering HIV testing only
to women considered to be at risk of infection fails to identify many
HIV-positive women. HIV testing of pregnant women makes it possible, for women
who test positive, to initiate preventive measures that can substantially reduce
the risk of transmitting the infection to their newborns.
Only a policy of compulsory testing could ensure that all pregnant women
seeking prenatal care are tested for HIV. However, there are many reasons why
such a policy should not be adopted.
Firstly, a law mandating HIV testing for pregnant women would probably be
unconstitutional, because it violates women's equality and their "security
of the person." Secondly, compulsory testing is not necessary - where
voluntary testing programmes have been well designed and implemented, they have
been effective.
Thirdly, voluntary testing maintains a woman's relationship of confidence in
her physician, a relationship that is necessary for open discussion of the risks
and benefits of antiretroviral treatment and/or other preventive measures.
Fourthly, compulsory HIV testing could heighten the existing mistrust of the
public health system in communities disproportionately affected by HIV, driving
some women away from care. Finally, in contrast to a policy of compulsory
testing, a policy of voluntary testing is respectful of the autonomy of the
woman, treating her as a person in her own right, rather than as a means to an
end (imposing testing on her to potentially benefit her child).
Approach
Given the large volume of patients seen in clinical facilities and the human
resource constraints, an integrated HIV counselling and testing service delivery
model seems practical to increase HIV testing of pregnant women and (of course)
other high risk groups, new approaches have been initiated and have been found
to work.
One such approach is the Routine Counselling and Testing, often referred to
as RCT. Under RCT, HIV counselling and testing is routinely offered to all
patients within the health care setting, as part of the health care services
provided, irrespective of the presenting illness. RCT unlike VCT is provider-centred
approach whilst the latter is patient-centred. The RCT protocol could be
summarised using the acronym ACTS, to mean Assess, Counsel, Test and Support the
patient. RCT is currently being implemented in Mulago and Mbarara teaching
hospitals as well in some district facilities in Mpigi and Kaberamaido. It's the
obligation of the health planners and providers to use this approach in order to
increase access to HIV testing services and care and support.
Is consent required?
The current standard of professional care in Uganda requires that HIV testing
(except for mandatory and HIV testing) be carried out only after the person to
be tested has given informed consent following pre-test counselling.
However, should this requirement be abrogated for pregnant women? No. Ugandan
courts do not consider informed consent a luxury to be abandoned because it is
perceived as too burdensome by clinicians (health care providers). There is no
valid reason to eliminate the requirement for all patients and particularly the
pregnant women.
Indeed, obtaining a pregnant woman's consent and counselling her is
particularly important. The sooner she is informed about the advantages and
disadvantages of testing and available treatments, the more likely she is to
make decisions that will ultimately benefit herself and her child. In addition,
requiring that testing be done only with her specific and informed consent will
enhance the trust necessary for establishing a collaborative relationship with
the physician.
However, the above view is somewhat divergent to the Uganda national
guidelines on HIV testing and counselling (2005, page 12) which stipulates that
full pre-test counselling and specific consent for HIV testing are not required
in RCT as opposed to VCT. Characterising HIV testing as "routine" does
not relieve clinicians (and other health workers) of their obligation to make
sure that women give voluntary, specific and informed consent. However, it
appears that many physicians mistakenly believe that they need not secure the
informed consent of pregnant women to the tests listed on the standard
laboratory requisition form used in prenatal care, because they are so-called
"routine" tests.
A problem with characterising the test as "routine" is therefore
the increased chance that women will be tested for HIV without their informed
consent. Such a policy or practice would be open to legal challenge.
The term "routine" to describe the HIV testing of pregnant women in
our Ugandan situation should be avoided. Remember in most Ugandan families,
decisions about choice of health care by the pregnant women are greatly
influenced by the spouses.
Francis B. Mulekya, is an IPH-CDC Fellow
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