Twenty-six year ago, HIV was thought to be a homosexual and drug user disease. However, the disease is no longer confined as originally thought. HIV is now transmitted more through heterosexual sexual contact than homosexual relationships and drug use. Unfortunately, the only way to eliminate this growing epidemic is prevention. The best place to start prevention is to start with a population that is not infected by any specific behavior on their part – infants who contact HIV through their mother at the time of birth.
The first case of pediatric AIDS was found in the United States 2 years after HIV itself was discovered. In 1992, transmission cases from mother to infant in the time of birth peaked at 25% for known HIV positive women.1 They will grow up waiting to die, essentially. While chances of these infants living to reach adulthood and spreading the disease through sexual intercourse are limited, their care also puts a severe strain on our healthcare system.
By ensuring that the mother has proper HIV treatment throughout her pregnancy, we can decrease that 25% transmission rate to 1-2%.1 Twenty-three to 24% percent of infants otherwise condemned to be born with HIV will have the opportunity to live a healthy life. However, ensuring that all HIV positive pregnant women receive proper treatment is a multifaceted ethical and legal. However, several government agencies already have recommendations and polices that make this legal precedence foreseeable. The CDC has been recommending voluntary testing since 1995, and the Institute of Medicine has been doing so since 1998. 1 Congress already provides funding for prevention of transmission during birth in states with the highest birth transmission rates.1 The CDC has also contacted obstetricians to show their support of universal testing during prenatal care. 1 In 2006, the CDC also published more recommendations on specific trimester screenings based on the woman’s risk for HIV.
There are several ethical and legal factors in the plan to make HIV testing mandatory. Is the fetus’ right to life (though I believe the government feels a fetus does not have a right to life as abortion is still legal, but a fetus will become an infant who does have a right to life) more important than the mother’s right to privacy? Because testing is not voluntary for this specific population, is it right to require physicians to report cases of HIV found only thought prenatal testing to the Public Health Department? Although Congress has already distributed funds for some states, from where will the funds for testing for the rest of the states come? If we do require treatment through pregnancy, is it just for the mother (though it would benefit her also, doesn’t she still have the right to refuse medical treatment?), and how would we enforce her complicance in taking her medication, especially given the strict regiment needed for proper treatment? From where will funds for all the medications come? Would those women who have medical insurance through their employer be required to use their insurance to pay for these medications, which would essentially inform their employer of their HIV status? If the infant does contact HIV through birth, does the child have a right for his or her guardian to know his or her HIV status so he or she can start treatment immediately so the virus can be stymied rather than wait until the virus spreads?
Although there are several very important factors to be considered, the bottom line is that by mandating HIV testing and treatment in pregnant women, we can almost eliminate the spread of HIV in this specific transmission method, and stopping the spread is the only cure we have available. By preventing these infants from contracting HIV, we also prevent the opportunity for them to spread HIV. My personal belief is that the life of these infants who otherwise would have HIV is worth the privacy infringement of the mother, provided that her privacy in other settings can be maintained.
Reference
1. Glenn Folwer M, Lampe MA, Jamieson DJ, Kourtis AP, Rogers MF. Reducing the risk of mother-of-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions. Am J Obstet Gynecol 2007; 197; S3-S9.
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Let me play Devil's advocate for a moment here. I think your proposal
is one meant to preserve the greatest good for the greatest number, but it also seems to me to strike a paternal tone ("We know what's best for you."). This sounds like a modest proposal, but I believe it infringes on some civil liberties and will also be ineffective.
First, how far do we want the government invading our private lives? We have seatbelt laws and helmet laws (in some states), where the government has decreed it knows what's best for us. And these are
effective laws, with statistics to support them. But proposals to ban
the use of cell phones while driving are more controversial. And
proposals like sterilization of some groups of people, while stemming from a similar paternal knowledge, have fallen into great disfavor. (Even though it might prevent children born with certain disabilities, the damage to the adult's autonomy is too great.)
This proposal of mandatory testing seems to me to fall within that arena; it would be helpful to the child but greatly damaging to the adult's autonomy.
Civil liberties aside, where I think this plan would fail is in
effectivity. The people at greatest risk for HIV infection during pregnancy (intravenous drug users, prostitutes) are also among the people least likely to seek pre-natal care. There will be no
governmental opportunity to extract a mandatory test from many of these
women or to provide any HIV treatment at all, because they will not be seen by any doctor prior to giving birth. You will catch a few people who come in for care, but I think the vast majority of those who would benefit from this testing and care will never enter the healthcare system and thus the government will never be able to enact this proposal.
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