Changing the Face of an Epidemic: Screening Pregnant Women for HIV
by Jeffrey P. Kahn, Ph.D., M.P.H.
Director, Center for Bioethics
University of Minnesota
Last week a panel appointed by the influential Institute of Medicine issued a report recommending that all pregnant women be tested for the AIDS virus as part of routine prenatal care. There are important reasons to undertake the first widespread HIV screening of a part of the population. Most important, testing during pregnancy allows for early drug treatment that can substantially reduce the risk of passing the infection from mother to child, and offers women the best chance to fight their own infection.
But the panel also came to more worrisome conclusions in order to implement across-the-board testing of all pregnant women -- two recommendations with ethical implications. First: members suggested that pre-test counseling requirements could and should be relaxed, and second: that unless women specifically objected they should be tested for HIV.
These recommendations are based on the practical realities of implementing such a large screening program. Testimony from health care providers argued that the current requirement for pre-HIV test counseling for pregnant women would create unacceptable burdens for doctors if all pregnant women were counseled. Even now, the prospect of spending up to 30 minutes satisfying the pre-test counseling requirement discourages some physicians from offering testing at all.
The panel concluded that the very large benefits of universal screening will outweigh whatever harms will result from reduced counseling and presumed consent for testing.The costs of silence
But there are serious costs that will come with less counseling and less rigorous requirements for consent. In addition to less understanding for women about what HIV testing means and the risks of HIV-related disease, trust may well be undermined: in physicians, in the medical system, and in the social system that we expect to protect our health. We must ask whether an additional half-hour per patient is too high a price to pay for improved understanding and preserving trust by patients and society.Protecting children and protecting rights
The risks of a positive HIV test are still not confined to the impact on health. Discrimination in insurance and employment are still real concerns that any woman needs to understand and consider when agreeing to an HIV test and those concerns should be part of counseling and consent. Along with widespread screening programs, we must also develop policies that will protect individuals and potentially sensitive information about them.
The benefits of universal testing can be achieved while respecting the rights of the women and children who will be affected by the results of HIV tests.
As we propose to undertake the testing of a large part of our population, we must be prepared to address not only the medical but also the social needs such testing will create. History and experience with discrimination and inadequate social services should have taught us that we canŐt be satisfied with medical success at the price of social failure.
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