Making it Mandatory: Should HIV Tests Be Required for Pregnant Women?

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By Tasha Yovetich

The development of antiretroviral drug therapies and the success of the drug AZT in reducing the rate of mother-to-child HIV transmission has resulted in calls for increased testing of pregnant women. While no Canadian provinces or territories demand mandatory HIV tests for any population, the climate surrounding HIV testing in general, and the testing of pregnant women in particular, has made this issue one of increased public interest.

Background



Prior to 1994, there were few, if any, interventions known to reduce the risk of HIV transmission during pregnancy. However, in 1994, the results of an American clinical trial known as ACTG 076 demonstrated that a drug known as AZT if administered to HIV-positive pregnant women and to their children directly after birth could lower the rate of transmission from 25% to approximately 8%. And, more recent studies seem to show this rate can be as low as 3-5%. These results are based on the drug being administered to the woman during pregnancy, labour and delivery and to the newborn for the first six weeks of life. All of the women involved in this trial had never taken anti- HIV drugs, had immune cell counts over 200 and received no other antiretroviral medication during the study.

After ACTG 076, the US Public Health Service recommended that AZT be offered to HIV positive pregnant women who, like the women in the initial trial, had no experience with antiretroviral drugs and had immune cell counts over 200. The Public Health Service also recommended offering HIV testing to all pregnant women who had demonstrated risk factors for HIV. In 1995, the Public Health Service changed its recommendations, suggesting that counselling on HIV testing be offered to all pregnant women to encourage them to be tested.

The Canadian Experience



After the results of ACTG 076 became known, several provinces and territories changed their policies on HIV testing and pregnancy. The Canadian Medical Association and the Society of Obstetricians and Gynaecologists of Canada both now recommend offering HIV testing and counselling to all pregnant women, with informed consent. But, the situation varies across the country. Each province falls into one of three categories:

1) Voluntarily Offering Testing to Pregnant Women with Risk Factors: Pregnant women with risk factors based on the physician's assessment are offered HIV testing. This happens now in Prince Edward Island, Saskatchewan and in Ontario.

2) Voluntarily Offering Testing to All Pregnant Women (or, "Opt-in" ): All pregnant women are counselled about the risks of HIV transmission during pregnancy and are offered HIV testing. This happens now in the Northwest Territories, Yukon and in Manitoba. Nova Scotia is revising its guidelines in this direction. In Manitoba, the Advisory Committee on Infectious Diseases recommended further that the Manitoba Prenatal Record be revised to record the HIV test being offered and accepted or refused.

3) Routinely Testing All Pregnant Women (or "Opt-out"): HIV becomes part of the routine of tests performed during a woman's prenatal exam. While in theory the test is still voluntary and women should be counselled and give their informed consent, there has been some concern that placing the HIV test on a form with other tests, such as rubella and Rh factor, may mean the patient's consent is implied rather than specifically obtained. Newfoundland, Alberta, British Columbia and Quebec all use this process, and Ontario recently passed recommendations to follow this practice. In Quebec and BC, the HIV test is not included on the general prenatal lab form, but is on a separate form, to make sure women are asked specifically about the HIV test. New Brunswick does not have a formal policy on HIV testing of pregnant women.

Key Points

While lowering the rate of mother-to-child transmission is an important and worthwhile prevention goal, the public debate on this issue has focussed almost exclusively on testing and the use of AZT. As a result, several other key points have either been underplayed or ignored.

Toxicity



There is little short term or long term evidence to indicate the impact of prenatal antiretroviral therapies on children beyond the decrease in HIV transmission. At the 12th World AIDS Conference in Geneva, there were some studies that showed children who received AZT treatment in utero were more likely to have lower birth weights. But, the sample size was too small to make the results statistically significant. As past experience with other drugs taken during pregnancy (such as DES) has demonstrated, often the effects are only evident in the long term.

Another side of the debate on drug toxicity for HIV positive women and pregnancy concerns including pregnant women in clinical drug trials. In the past, the chance of pregnancy and the unknown risks to the fetus meant that pregnant women were automatically disqualified. Women's HIV treatment advocates lobbied hard so that pregnant women would be allowed in clinical trials. Discussions about the risks of antiretroviral treatment to the fetus need to acknowledge HIV positive women's rights to make decisions about their own bodies first and foremost.

Standards of Care



An emphasis on the use of AZT to decrease transmission during pregnancy has led in some cases to HIV positive pregnant women taking only AZT during their pregnancy. Single drug therapy is universally recognized as not the best care in the treatment of HIV. Yet, a recent study of HIV women accessing prenatal care presented at the Canadian Association of HIV Researchers conference in May 1998, revealed that 20 out of 40 women taking antiretroviral therapy were taking AZT on its own.

Concerns over the standard of care for women living with HIV led the US Public Health Service to update their guidelines on the treatment of HIV positive women to indicate that the ACTG 076 regimen could be part of established combination drug therapies.

Alternatives



Discussions about the need for increased HIV testing of pregnant women rarely acknowledges the difficulties that women may face in trying to decide their treatment options for potential HIV transmission. The lack of data on the long-term impact of either AZT or combination therapies on the health of infants exposed in utero or directly after birth, make the decision to start treatment difficult. Other ways of reducing the risk of HIV transmission, such as cesarean birth, do not appear to be mentioned as much as AZT treatment, either in the scientific literature or in public debate.

Prevention



Also missing from the debate are the women themselves. Provinces and territories that work on finding HIV positive pregnant women have by and large not spent similar efforts on HIV prevention programs for women. Media accounts of transmission during pregnancy focus on the children, not on the factors leading women to become HIV positive.

This oversight guarantees that transmission during pregnancy will continue despite any testing programs and antiretroviral therapies.

































Tasha Yovetich is a National Programs Consultant at the Canadian AIDS Society.

For more information contact:
The Canadian AIDS Society
130 Albert Street, Suite 900
Ottawa, ON K1P 5G4 Canada
Tel: (613) 230-3580
Fax: (613) 563-4998









CAS Position



The Canadian AIDS Society determined its position on mandatory HIV testing of pregnant women December 1998.

"In keeping with the Canadian AIDS Society's established position that HIV testing only take place with the specific informed consent of the individual being tested," the CAS Board writes, "the Board believes that HIV testing should be offered to all pregnant women with appropriate pretest counselling and information."