Last year, it was cause for celebration. The cause of celebration was for the results that
several clinical trials of zidovudine cut the risk for mother to child transmission of
human immune deficiency virus (HIV) by two thirds. Although, this year, it is the basis
for new federal recommendations that all pregnant women should receive HIV testing and
counseling. But, these findings have been cause of protests by several activist groups.
Activists fear that conservative legislators and policy makers will use the clinical data
to justify mandatory testing and treatment for pregnant women.
During the latter part of February, the United States Public Health Services published
guidelines for HIV pregnant women in the Federal Register. Which coincidentally was
published on the same day as the National Conference in Washington, DC for "HIV infection
in women: Setting a New Agenda." The conference included activists, physicians and HIV
positive women who used the meeting as a forum to voice their concerns about how best to
balance women's own medical needs with those of their infants. Other concerns of
activists that were voiced were that they don't want laws, policies or medical care
imposed on women merely as "vectors" who may transmit HIV to their infants.
The new guidelines recommend that all pregnant women should receive HIV counseling and
testing. These guidelines are aimed at helping pregnant women know their HIV status
early so that medical care, including zidovudine (Retrovir, known as AZT, Burroughs
Welcome Co., Research Triangle Park, NC), can be made available. The new guidelines also
reiterate previous federal health advisories that say counseling should precede HIV
testing.
Physicians and other health professionals who counsel women should be well informed about
the complex issues that face HIV infected pregnant women, according to the guidelines.
This information should include about all of their reproductive options. Women should
also be advised that in order to help reduce prenatal HIV transmissions HIV infected
women in the United States should not breast feed their infants.
The guidelines further states that all HIV testing should be voluntary for women and
their infants. Also, all decisions about AZT use should be made by the HIV infected
pregnant woman in a non coercive atmosphere and based on a balance of the benefits an
potential risks of the regimen to herself and her child. The guidelines also state that
women who are infected or refuse testing must not be denied medical care, reported to
child protective agencies, or discriminated against in any way.
The center for Disease control and Prevention (CDC), Atlanta, GA. reports that as of
December 31, 1994, there were 58,448 women with AIDS in the United States. Nearly one
fourth of the total were reported in 1994 alone. AIDS is now the fourth leading cause of
death in US women ages 25 to 44 and in 15 major United States cities.
In 1993, the CDC estimated that 7,000 HIV infected women gave birth in this country, in
other words, about one in every 625 women who gave birth that year was HIV positive. The
rate of mother to child transmission rate ranged from 15% to 30%, which is estimated that
there were as many as 2,000 HIV infected infants born in the United States in 1993.
Much of the controversy centers on AIDS Clinical Trials Group (ACTG) protocol 076. In
the 2 year study, 239 of the 477 HIV infected women enrolled received AZT during
pregnancy and delivery. Their infants received the drug for six weeks. At 18 months,
8.3% of the infants in the treatment group vs. 25.5 % of the controls were infected.
"Evidence based on every analysis that has been done of the outcomes to date shows that
this is a prevention breakthrough," said Wanda Jones, DrPH, acting associate director of
CDC's office of Women's Health.
Activists believe that the data is incomplete and should not be used as the basis for
federal guidelines. They wanted to know the effects AZT might have on the estimated 75%
of infants who are born to HIV positive mothers but don't seroconvert, and whether a
pregnant woman who takes AZT early in the course of infection will still benefit from the
drug later, when she is sicker. They also wanted to know what the long term effects may
be if women take AZT during multiple pregnancies, and whether ACTG 076 showed a
correlation between high maternal viral load and the likelihood of transmission. A few
small studies, including one from New York State Health Department, are beginning to
point in that direction. Jones of the CDC conceded that the study leaves many question
unanswered. However, it is the only one ever to have demonstrated any effective method
of preventing maternal fetal HIV transmission. "It would be irresponsible for us not to
be out front on this," she said. James W. Curran, MD MPH, associate director for
HIV/AIDS at the CDC added that, "The reason we published these guidelines is that we
believe they represent the very best in public health practice."
Besides their scientific concerns, activists also believe that the guidelines come at a
politically tenuous time. Two years ago, before the ACTG 076 results were announced and
before Congress took a conservative turn, New York lawmakers considered legislation to
unbind mandatory testing of newborns so that seropositive infants could be identified.
The law failed. But now, since the clinical results have been widely publicized, a
similar bill is pending in Congress. For example, in Illinois, lawmakers are considering
a bill that would mandate HIV testing and counseling for all pregnant women. And in New
York, they have proposed legislation would mandate testing of pregnant women without
requiring counseling. Experts say that initiative like those in Illinois and New York are
likely to crop up in more states. To counter pro-mandatory testing movements, activists
have urged federal health officials to strengthen language in the guidelines before they
are finalized so that the document won't be construed as supportive of mandatory
testing.
Mandatory testing has been controversial since the AIDS epidemic began. Opponents
contend that is violates civil rights, results in discrimination and may drive some
people away from receiving the medical care they need. Therefore, without a stronger
message in support of voluntary testing the guidelines may become a way to discriminate
against pregnant women who are HIV positive.
BIBLIOGRAPHY
Rogers, Martha, Simonds, R.J.; March 15, 1996; Preventing Prenatal HIV Infection "How
Far Have We Come?"; Journal of the American Medical Association Volume 19; Page 1514
Voelker, Rebecca; April 5, 1996; US Public Health Service Recommends Counseling and HIV
Testing For All Pregnant Women; Journal of the American Medical Association; Volume 19;
page 977
Wolfe, Maxine Ph.D.; October 1, 1996; Mothers To Infant HIV Transmission 076 Update;
Women Alive; page 6
|