A movement to mandate HIV testing for all pregnant women is rippling across the nation because of research about preventing mother-to-child transmission of the AIDS virus. But some Minnesotans feel there is no need for such an aggressive measure here.
The debate includes a number of unresolved issues: the costs of testing vs. treatment, the rights of mothers and the lives of children.
The American Medical Association passed a resolution supporting mandatory testing in June. Congress also passed a law this summer requiring states to test all pregnant women by the year 2000, if the national level of mother-to-child HIV transmission is not cut in half.
However, Minnesota officials have been slow to jump on the mandatory-testing bandwagon because the number of pregnant women at risk for transmitting HIV to their children is so low here.
University doctors are struggling with the issue, including epidemiologist James Rothenberger, who said the federal law treats all states equally, as if they each have the same rates for HIV transmission. Rothenberger said that because less than 1 percent of children born in Minnesota receive HIV from their mothers, it would be hard to cut that number in half.
Officials are still debating whether mandatory testing is necessary for Minnesota. The Centers for Disease Control, Minnesota Department of Health and Minnesota Medical Association all advocate counseling and voluntary testing as more responsible methods to control HIV transmission.
Minnesota health officials suggest that pregnant women should be tested because of potential risks to themselves and their children — not because they have to.
U.S. Public Health officials estimate that between 15 percent and 30 percent of the 7,000 children born to HIV-positive women in the country will contract the virus. Not only do HIV-positive women risk transmitting the virus to children during vaginal birth, women can also transmit the virus through breastfeeding.
However, a study conducted by the AIDS Clinical Trial Group in 1994 showed that treating HIV-positive women with AZT, an HIV virus inhibitor, reduced the transmission rate from mother to child by two-thirds.
Researchers treated HIV-positive women with AZT before the 14th week of their pregnancies and during childbirth. Then they gave AZT to the child for six weeks after birth. The results showed how the treatment reduced the likelihood of the mother transmitting the virus.
Although the nationwide statistics regarding mother-to-child HIV transmission have compelled some to suggest mandatory testing, statistics in Minnesota show a considerably lower rate of transmission.
Only three cases of mother-to-child HIV transmission were recorded in Minnesota last year.
Rothenberger said it would not be cost effective, with 70,000 births in the state each year, to test every pregnant woman to prevent the few HIV-positive babies born.
“I don’t know if I want to legislate and mandate a test for all these women when the payoff is going to be so slight anyway,” Rothenberger said.
HIV tests cost approximately $40 per person. 1995 statistics indicate that mandating every pregnant woman in the state be tested for HIV would cost approximately $2.8 million.
The costs of treating HIV
The U.S. Department of Health and Human Services is weighing the costs of testing against the costs of living with HIV and, eventually, AIDS.
The estimated annual cost for an HIV-infected adult is $5,000 for those without AIDS, and $35,000 for those with AIDS. For an HIV-infected child, costs are $9,400 before developing AIDS and $38,000 afterwards.
How long children can live with HIV and AIDS depends upon how old they are when they contract the disease. Generally, the older the child is, the longer the child can live with the disease.
Furthermore, experts are trying to reduce the costs of treating HIV-positive children during the last few weeks of pregnancy and vaginal birth, as suggested in the AIDS studies.
U.S. Department of Health analysis suggests that this perinatal treatment can save as much as $235 million in treatment costs nationwide.
An issue of choice
The Centers for Disease Control strongly advises against forcing women to be tested because doctors cannot force women to get the treatments necessary to thwart the effects of HIV.
“There is a concern that women will not come in for prenatal care,” said Elaine Collison from the Minnesota Department of Health. “There is also an issue if you force them to be tested. How far do you take it? Do you force them to take treatment, too?”
Physicians in Minnesota agree that when a pregnant woman finds out she is HIV positive, the treatments require a great deal of compliance on the part of the patient. “Treatment requires a very trusting relationship with her health care provider,” said Dr. Richard Danila, Minnesota Department of Health supervisor of HIV and infectious diseases. “When you set up an adversarial relationship, then you have a problem.”
Testing positive for HIV while being pregnant forces women into difficult decisions regarding the welfare of unborn children. They can choose to have the AZT treatments during pregnancy, or deal with the risk of passing HIV on to the baby.
Some experts say that abortion may also be an option for women who fear transmitting the virus to the child. Others, including Raymond Christensen, president of the Minnesota Medical Association, said the effectiveness of HIV and AIDS treatments are improving and people are better able to live with the disease.
“There are different medications that are working,” Christensen said. “People are getting better.”
Doctors in the state are concerned about giving women the proper care they need regardless of the HIV status. They are advocating an aggressive campaign that counsels pregnant women regarding HIV and AIDS, and allows them to choose to be tested.
Collison said the goal is to make HIV testing a regular part of prenatal care.
“We support a standard of medical care that would approach HIV like other infectious diseases,” Collison said.
“All women should be tested,” Danila said, “but ultimately they would have the option that they not be tested.”
Danila said that HIV counseling is an important link in the chain of preventing transmission of the disease. “If you don’t provide it, then you’re providing substandard care,” he said.
“What’s really important is that there has been a change in the way AIDS is treated,” said Christensen. He said the MMA and department of health initiatives raise public awareness regarding AIDS.
Danila said that when women are told about the test and a doctor explains the importance, close to 95 percent agree to be tested. U.S. statistics show that when that many women receive counseling and testing during pregnancy, those women save a collective $68.5 million nationwide on the cost of intervention in pregnancies.
Also, counseling results in a reduction of lifetime treatment costs for HIV-infected children by $14.4 million in cases that require less treatment and $80 million in more serious cases.
Protecting the child
In the midst of the debate are bio-ethicists who question when a disease poses enough of a public health risk to justify abridging an individual’s rights.
Jeffrey Kahn, director of the University’s Center for Biomedical Ethics, said that in the past, public health problems resulted in drastic measures. He said that in a public health crisis, the community’s needs often supersede that of the individual.
“Do we trump women’s individual rights for the protection of their fetus?” Kahn asked. “I think that we do trump individual rights for public health in other places, but it’s a very difficult case when it’s a woman and her pregnancy. That’s a very particular kind of relationship, one that we have to be very careful about treading upon.”
What mothers think
Pregnant women have mixed opinions on whether or not their consent should be obtained for testing.
Jessica Davis, a woman who is eight months pregnant, said she feels every test should be voluntary. She said tests regarding birth defects and retardation are completely up to the mother. “They’re voluntary because you have to live with the consequences,” Davis said.
Davis said if she had reason to think that her child would have serious birth defects, she would want to know, but would still want to be asked before getting tested. She said performing an HIV test without the person’s consent is never justified.
Billie O’Brien, a nurse at Mercy Hospital in Coon Rapids, recently found out she was pregnant with her second child. She said she personally does not care if the test is mandated because there are already a number of tests performed without the patient knowing.
“The general public really doesn’t know what they’re being tested for,” O’Brien said.
University epidemiologist James Rothenberger said he himself has twice been tested for HIV without prior consent. He said some experts estimate up to one-third of all HIV tests are performed without initial consent from the tested party. He said the vast majority come up negative, so no harm is done.
Is the treatment safe?
Many doctors question the safety of administering AZT to unborn and newborn children. Rothenberger said that experts still have no long-term studies regarding the safety of the drug on the children.
“The assumption is that it’s more risky for a child to have AIDS,” he said. “It’s a very powerful drug to give during pregnancy.”
Kahn said he would wait to mandate testing until the effects of the treatment were better understood. “When it becomes compelling that we can really make the offspring better off, so we can prevent infection from occurring, then we go to mandatory testing.”