The Drum Beat 406 - HIV Testing and Pregnant Women: How Do We Best Prevent Vertical Transmission?

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This Drum Beat is one of a series of commentary and analysis pieces. In this issue, the HIV/AIDS Programme of UNICEF TACRO (the United Nations Children's Fund Regional Office for the Americas and the Caribbean Regional Office) shares its perspectives on both the prevention of mother-to-child transmission (MTCT) of HIV, and access to HIV testing among pregnant women. Drawing on some case studies from the region, UNICEF TACRO presents strategies that have been developed to overcome the social, economic, and health obstacles that prevent pregnant women from having wide access to HIV testing.

The Drum Beat continues to feature a range of critical analysis commentaries of the communication for change field. These appear regularly on the first Monday of most months and are meant to inspire dialogue throughout the month. Though we cannot guarantee to feature your commentary, as we have a limited number of issues to be published each year, if you wish to contribute please contact Deborah Heimann dheimann@comminit.com Many thanks!

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HIV Testing and Pregnant Women: How Do We Best Prevent Vertical Transmission?

If an HIV-positive pregnant woman receives no preventative therapies, her child has a 30% chance of becoming infected with the virus. If she follows a full course of prophylaxis and precautions during pregnancy, birth, and breastfeeding, the risk can be reduced to less than 2%. Considering how effective these methods can be, it is essential that a woman know her HIV status in order to ensure the health of her child, as well as her own health. In the Latin American region, rates of vertical transmission remain quite low, and many governments have set the ambitious goal of eradicating the problem entirely. Achieving this goal requires primary prevention of HIV infection among all women, a reduction in the number of unwanted pregnancies, and efforts to ensure that all women are aware of their serological status.

For women who do become pregnant but who do not know their HIV status, the next important step in preventing vertical transmission is HIV testing. Countries have adopted a range of policies in the attempt to achieve universal testing. Some, like the Dominican Republic, have made the HIV test legally mandatory for all pregnant women. Others, like Panama, offer it within the routine prenatal package, but also provide the option to decline the test. These different approaches all have their own benefits and drawbacks.

Originally, the international protocol for HIV testing strongly recommended the opt-in policy, under which women are informed that the test is available, but must sign a consent form before it is administered. An opt-in policy is seen as more effective in protecting a woman's rights, preventing invasions of privacy, and ensuring that she understands the implications of a possible positive diagnosis. Due to the stigmatisation and discrimination associated with HIV/AIDS, an HIV test has been considered to be different from other routine tests for sexually transmitted infections (STIs). The reason many are now pushing for a shift away from opt-in testing strategy is the fear that the extra steps involved in the decision making process deter women from getting tested or from being offered a test.

Mandatory testing policies are one way to avoid this problem of self-selection. The argument for the mandatory strategy seems simple - every woman who receives prenatal care knows her serological status and (if treatment is available in her country) her child has a great chance of being HIV-negative. The drawbacks to mandatory testing policies are on the human rights front. In many medical facilities, there are problems with maintaining confidentiality. That is, if a woman is required to be tested, and those results become public knowledge, the test can be a violation of her privacy. In addition, it is feared that if a mandatory HIV test is included in prenatal care, a woman may be discouraged from seeking medical attention during her pregnancy, impeding the woman and her child from claiming their right to healthcare. In fact, there are already a significant proportion of women who are not receiving any prenatal care, which puts them and their children at higher risk.

The current Centers for Disease Control & Prevention (CDC) guidelines seem to present a viable compromise: routine opt-out testing. Under this policy, the test is included in prenatal care for all pregnant women, but the woman has the option to decline testing. This approach appears to avoid the problems associated with opt-in testing because a woman would have to take the initiative to refuse. In addition, under this opt-out policy, there may be a smaller risk that women are deterred from seeking prenatal care due to fear of obligatory testing, which might be the case under a mandatory programme.

At first glance, it may seem surprising that pregnant women would ever decline an HIV test. After all, the future health of their child is at stake. However, the public sentiment surrounding the HIV/AIDS epidemic in Latin America is still charged with misconceptions and stigmatisation. For many women, these prospects are understandably frightening, to the point that the consequences of knowing one's status seem worse than the benefits. In addition, because in much of Latin America the epidemic is still concentrated, people associate the infection with vulnerable populations that are often characterised by high risk and stigmatised behaviours. Advocacy campaigns and education programmes have yet to convince the general population that HIV/AIDS can - and does - affect anyone. This misunderstanding of the potential for infection often leads to denial of personal risk.

Regardless of which testing policy is chosen, the problems of stigmatisation and discrimination are real, and new strategies are needed to address them. If women felt that they could continue with their lives and jobs and still be welcomed in their communities, even with an HIV positive diagnosis, it would remove a major deterrent to their seeking out and accepting testing. Decreasing the stigma of HIV/AIDS requires that people better understand the nature of the infection and the epidemic.

Women themselves need to truly understand the importance and implications of testing. They need to learn about the risks of transmitting HIV to their child if they do not receive treatment, and they need to know how successful treatment can be. The statistics themselves are strong enough to convince most women. Ideally, with sufficient information and easily accessible health facilities with trustworthy staff, universal testing can be achieved voluntarily. It is important to remember, however, that even if 100% of pregnant women are tested for HIV, this is only one step in the process of complete prevention. If vertical transmission is to be eradicated, each woman still needs access to appropriate drugs, attentive medical care to ensure compliance with the regimen of anti-retrovirals (ARVs), a caesarean birth (ideally), and, if feasible, safe options for replacement feeding. The barriers to achieving universal HIV testing among pregnant women are certainly more easily surmountable than the difficulties associated with providing the necessary treatments for life for an HIV-positive child. In the fight against vertical transmission, testing should not stand in the way.

The HIV/AIDS Programme of UNICEF TACRO
Vivian Lopez - vlopez@unicef.org
Anna Berardi - aberardi@unicef.org

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Please participate in an Opinion Poll related to the above commentary.

Do you agree or disagree?

HIV/AIDS advocacy campaigns and education programmes for pregnant women in Latin America should include an HIV testing component in order to reduce stigma and discrimination.

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This issue of The Drum Beat is meant to inspire dialogue and conversation among the Drum Beat network.

Please engage in dialogue, beginning August 6th, through the DrumBeatChat forum.

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RESULTS of past Pulse Poll

It's time we stopped dividing the world into North and South.

[For context, please see The Drum Beat #401.]

Agree: 72.06%

Disagree: 11.76%

Unsure: 16.18%

Total number of participants = 68

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This issue of The Drum Beat is an opinion piece and has been written and signed by the individual writer. The views expressed herein are the perspective of the writer and are not necessarily reflective of the views or opinions of The Communication Initiative or any of The Communication Initiative Partners.

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