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Stupid question
Mar 19, 2004

I am amazed by your answer about HIV testing for pregnant women.When you apply for life insurance they test for HIV. They test for STD's when you apply for a marriage licence. I am a mother (and I am also strongly PRO-CHOICE in all reproductive areas!) and I would have no problem with being tested for HIV, because my primary concern is the well being of my baby. We now perform pre-natal testing for a wide variety of things, what is one more. I don't think any pregnant women would object to being tested if it was in the best interest of not only herself but also her unborn child. I'd rather be safe than sorry! Is it the Manditory testing that is the concern?

Response from Dr. Lee

Yes.

My concern is with the use of the word MANDATORY. Most people agree that testing of mothers is important to help prevent transmission. The difference of opinion is related to the whether this testing ought to be voluntary or mandated. Testing is a good idea, but mandatory (ie compulsory, involuntary) is, reprehensible to me. I believe strongly that pregnant women should not be forced (ie mandated) to test for HIV.

I agree that most women, when given the option for testing, will do so because their primary concern is the well being of their baby. However, because HIV disease has such a significant impact on the mother, I believe it should remain voluntary.

I believe that we should be encouraging all women to consider voluntarily HIV testing prior to becoming pregnant.

Consider:

Who to test? There is evidence that there are higher testing rates (and yes, higher rates of treatment and ultimately increased prevention of transmission) when the opportunity to be tested during pregnancy is "routine" rather than targeted only to women perceived to be at high risk.

How to test? Testing may be routinely recommended in an "opt out" approach in which notification that an HIV test is included in a standard battery of prenatal tests with the option of refusal. In other words, the woman has the option to say no, but otherwise testing proceeds. The "opt-in" approach requires specific consent after pre-HIV testing. This requires the woman to answer yes for the test to be done.

This may seem like much ado about nothing, but there is evidence of higher testing rates with the opt out rather than the opt in approach. I believe that globally the implementation of routine "opt out" rather than "opt in" consent for testing is preferable.

I am concerned that the follow-up (for those testing positive) could lead to coercion or intervention to compel treatment of the mother during pregnancy or of the infant after delivery. (In the US, the state does at times force these types of issues. In fact, currently a mother is being charged with murder because she declined a doctor's recommendation that she have a cesarean section and her infant died.)

Having said all of this, I should clarify that in my practice, I have offered routine (not targeted) testing of all pregnant women with informed consent since 1986 when testing became available. In addition, due to the presentation of the test as a normal part of prenatal care (although requiring specific consent or "opt in" for testing), 100% of the prenatal patients in my practice have been tested. I have also offered treatment during pregnancy since 1986 and the majority of mothers have accepted treatment.

There is further information on this topic at the following sites:

http://www.aidslaw.ca/Maincontent/issues/testing/07mandate1.html http://www.findarticles.com/cf_dls/m0838/120/107894045/p1/article.jhtml http://www.thebody.com/gmhc/issues/julaug97/testing.html http://www.sumeria.net/aids/icmjmsg.html

The person who claims to have originated this topic through his question describes a situation (below) which is tragic and quite understandably upsetting. I feel sympathy for the loss of his wife and I understand his anger and frustration. However, I do not believe that mandatory (ie involuntary)testing is the best answer to the problem he presents.

With this conversation we have gone beyond the usual parameters of this forum. Therefore this is the last note on this subject.

Now I am going to give the following letter the (mostly unedited) last word.

Good Day Ms Lee

I, as the author of the question of the above subject, on The Body.com feel the need to reply to what in my mind is an ignorant and biased answer from you. I have always had the belief the no question asked is a "stupid question" I hope you take the time to read this email as the many, that will read your "expert opinion" on the Body .com.

I found your answer to be ill-advised and I will "forgive" but I only forgive your ignorance which led me to a quote from William Ellery Channing "....Every mind was made for growth, for knowledge, and its nature is sinned against when it is doomed to ignorance....."

I found your answer akin to the ignorance of the naysayers in the 1980's when they balked at the very thought of testing every blood donation for HIV. Yet through progress and necessity it did come about. I have a question for you, do you deem all your fellow medical practitioners in the States of New York and Connecticut as "stupid" for implementing such a test?.

In this day and age when we test a pregnant woman for RH type anenmia and Hepatitis or Syphallis and all the other mandated tests my question was why with the medicines of today do we not test for HIV. I also stressed that a womans rights would be the answer, but never did I "dictate" or imply that a woman be forced to do anything! That is where your answer became uneduacated as you may have, as an, "expert", misread the question. I believe by counseling any pregnant woman is aiding in the prevention of the spread of this disease. If her unborn child is born free of HIV with the medicines of today then we have surpressed the continuation and the freedom of this disease to live, and deserts cannot be formed without the first grain of sand.

Education about this disease is the best form of prevention and you have truly educated the masses when they read your answer to my question. I, unlike you, am no expert in this field and I credit you for your accomplishments written in your bio, so you ask "who are you?"

I am the father of a six yr old girl living with HIV and the widower of her mother. She entered that hospital with a CD4 count of 1 never to walk out of that same hospital. Had she not seen some narrow-minded professionals in the medical field much like yourself then she may be alive today and had an HIV test been mandated at her time of pregnancy then she may have been told and my daughter, an American Citizen may have been given the freedom of this country that the outdated laws have denied her. these are the issues I try to prevent by asking about mandatory testing.

I, by asking that question to the body.com was also thinking of a woman and "HER DECISION" however, as it is wrong for a man or woman to go out and willingly infect someone with the knowledge that they are HIV positive and go to to jail for such acts why is it that a woman can decline a test when pregnant and pass it on to their child with no repercussions.

I try to reach the powers that be in order to prevent this from happening again and I thought that asking the "experts" I might have some feedback. But people in power can not, or will not, open their mind to change, and as Robert Kennedy once said "....the problem of power is how to achieve its responsible use rather than its irresponsible and indulgent use- of how to get men of power to live for the public rather than off the public.."

If I have offended you by replying to what I thought was an intelligent question seeking an intelligent answer then forgive me and now I will quote you "I am aware that even clever people come up with some real doozies!" and you now have a "doozie" .


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