AIDS AND SOCIETY
Aids and Society The number of newborns infected by vertical transmission of the human immunodeficiency virus is increasing as the prevalence of HIV-positive women increase within India. It is estimated that while seven thousand HIV-positive women become pregnant each year, between one thousand and two thousand of their newborns will be HIV-positive. This research paper will concentrate on the transmission of the human immunodeficiency virus from mother to child, the benefits of drugs intervention, and whether or not the HIV-screening process of pregnant women should remain voluntary or become mandatory.
The HIV-virus has proven that it is not a disease to be taken lightly or ignored. I chose this topic because I want to be informed about the virus and its rate of vertical transmission so that I will be able to inform others about such ethical topics: Does the baby have rights and should pregnant women be denied her right to privacy with respect to HIV?
Data shows that AIDS is now increasing faster among females than males, with women accounting for seven percent of cases in 1985 and nineteen percent in 1995. The incidences of HIV-positive heterosexual women have risen dramatically over the past decade, and AIDS is now the third leading cause of death among women ages twenty-five to forty-four. The one thing that all of these women have in common is that they all are of child bearing age. Consequently, the incidences of HIV-positive newborns have also increased. As mentioned previously, about seven thousand HIV-infected women give birth each year, and about twenty-five percent of their babies are HIV-positive. “Maternal transmission accounted for ninety-two percent of all new AIDS cases reported in children in 1994″(Davis).
A major breakthrough in drug intervention began in February 1993. The AIDS Clinical Trials Group administered a double-blinded, randomized, placebo-controlled study of zidovudine, also known as AST. Four hundred seventy-five women were enrolled in the study. These women were randomly assigned to one of two groups. One group received zidovudine while the other, the control group, received a placebo. The administration of either zidovudine or placebo began in the second trimester of pregnancy and continued through labor. For six weeks after birth, the babies received the same treatment as the mothers in a syrup form. Because it was a double-blinded study, neither the researchers nor the patients knew who was actually receiving the zidovudine. Only three hundred sixty-four babies of the four hundred twenty-one born were available for testing. Results showed that, “of the three hundred sixty-four available for testing, fifty-three were infected with HIV; thirteen were born to mothers receiving zidovudine and forty to mothers on placebo” (FDA Consumer). According to this data, when both mothers and babies received zidovudine, there was a transmission rate of 8.3 percent.
This was a dramatic decrease in the rate of transmission when compared to the control group who had a transmission rate of 25.5 percent. With results such as these, drug intervention with respect to both pregnant women and newborns should become more commonplace with each day. For example, if the decrease in maternal transmission rate is duplicated from the AIDS Clinical Trials Group study, and the estimated seven thousand HIV-infected women deliver infants while accepting treatment with zidovudine, one will conclude that “under these hypothetical conditions, as many as two-thirds, or twelve hundred, of all vertically acquired HIV-infections could be prevented annually”(Davis).
This decrease in maternal transmission would be ideal if all conditions were met, but there seems to be one major flaw. Many pregnant women do not know they are infected with HIV. The problem now is how to identify HIV-infected pregnant women at an early enough stage, so that the use of AZT could drastically reduce the chances of the baby being born with HIV.
It is critical that the physician know of a women’s HIV-infection prior to or early in her pregnancy. Because many women who are at risk are completely unaware of it, a growing national debate has centered on mandatory HIV testing of all pregnant women. This notion of mandatory screening has raised many ethical issues. It is certain that those who test positive and accept treatment with AZT would have a decreased transmission rate, but according to some, this notion takes into account only the child and not the mother. Opponents on the other hand want to consider the woman’s right to privacy. A Center for Disease Control spokesman says, “Mandatory testing destroys the relationship of trust between the women and her health care provider”(Kent).
Many feel that because of the stigmatization associated with the HIV-virus/AIDS, pregnant women should not be singled out. As of August 1994, voluntary testing of pregnant women seems to be the most viable way to get the cooperation for both testing and treatment. Medical groups say, “mandatory testing simply does not work for the populations most at risk (for the HIV-virus), and could undermine physicians’ effort to build collaborative, trusting relationships with patients” (Shelton).
Mandatory testing could also be viewed as a deterrent to obtaining prenatal care. Those who would find it as a disincentive would most likely be those individuals most in need of education, counseling and treatment. The result would be the loss of opportunity to provide both counseling and treatment. Because of these findings, voluntary testing seems to be the most effective.
On July 1, 1995, the Center for Disease Control released guidelines specific for HIV-screening. The guidelines, “recommend that physicians counsel all pregnant women about HIV and that they are to offer them the chance to be voluntarily tested” (Kent).
According to the Center for Disease Control guidelines, those found to be HIV-positive are then offered zidovudine which has been found to reduce prenatal HIV transmission by as much as two-thirds. These guidelines were established because it is believed that pregnant women who are given information about HIV are more eager to comply than those who feel as though they are being coerced.
Aggressive voluntary strategies have been shown to work. One study showed ninety-six percent of almost thirty-six hundred women at Grady Hospital in Atlanta, Georgia, chose to be tested after being counseled. Along with the voluntary testing offered to pregnant women, there is a mandate testing of all babies born to women who do not receive a prenatal test for the HIV-virus. The combination of the two testing procedures works well by accounting for the rights of the newborn child. Even if the mother refuses testing and is HIV-positive, there is about a seventy-five percent chance the baby would not acquire the virus during pregnancy and labor. However, the HIV-infection can be transmitted to the infant from the mother even after birth. Breast-feeding has been shown as a way of contracting the human immunodeficiency virus. Therefore, breast-feeding should not be an option for those infants whose mother is HIV-positive. Because of the mandatory testing of the newborn, one who tests positive for the HIV-virus can be given treatment for AIDS related diseases.
The infant may test false positive due to the fact that
maternal antibodies can cross the placenta and enter the baby’s bloodstream. The ELISA test may record a positive test
because of the presence of maternal antibodies to the HIV-
virus. Testing of the baby periodically will determine whether
or not the HIV antibodies present are actually produced by
the baby’s own immune system, or whether they were passed
across the placenta from the mother’s antibodies. This combination of the two tests, “encourages women to have the test, but for women who do not, who fall through the cracks, this
protects their babies” (Kent).
One question remains about the Center for Disease Control’s guidelines, “Who will pay to screen the women who give birth each year in the United States?” (Kent).
While many are concerned about the costs associated with HIV testing and treatment of HIV-positive pregnant women, they fail to look at the entire picture. One would have to ask them in return, “Who is paying for the extensive treatment required by those HIV-infected children.” It seems as though there would be economic benefits to the screening process. The expected total drug costs for zidovudine per case under the AIDS Control Trials Group 076 regimen including all phases of treatment was estimated at eight hundred ninety-five dollars. On the contrary, “estimated lifetime cost of pediatric HIV-infection has previously been reported to be one hundred thousand dollars” (Mauskopf et al).
Voluntary screening programs can enhance cost savings and health benefits for pregnant women. Cost savings will occur for a wide range of zidovudine efficacy rates and lifetime treatment costs for pediatric HIV-infection. It should also be noted that reducing the number of HIV-positive infants has more effects than simply the potential savings in cost. There are also important issues related to avoiding grief as well as the increased life expectancy for the infant.
This paper demonstrates both the health and the economic benefits associated with treating HIV-positive pregnant women and their newborns with the drug, zidovudine. I feel that voluntary screening programs offered to all pregnant women would help to avoid the problems associated with discriminations, whether it is a demographic location or an individual’s background. The high-risk pregnant women may be more likely to participate in the human immunodeficiency virus screening because every pregnant woman would be offered the same regimen. Therefore, there would be fewer stigmas associated with the screening process. One would not be as likely to shy away from prenatal care because it would be understood that all pregnant women receive the same opportunity for testing and treatment.
Although there are still ethical question about whether the mother’s right to privacy or the baby’s rights are more important, there has been some agreement. As the incidence of HIV infection among women of childbearing age continues to increase, programs of voluntary screening and AZT treatment, along with continued educational efforts, should be considered integral components of HIV prevention programs.