Mandatory HIV Testing


Boston. -- It's almost nine months now, nearly a full gestation period. Time to come to term, or at least to terms, with a new point of view.

In November, there was something akin to good news in the often gloomy world of AIDS research. A federal study found that HIV- infected women who took the drug AZT during their pregnancy could reduce the risk of transmitting the virus to their babies by as much as two-thirds.

This not only changed the odds of having a healthy baby, it added weight to the importance of HIV testing. Until last fall, the message a pregnant woman got from testing positive sounded like a death knell. Now, she had the chance at least to protect her fetus.

In little more than a trimester, the study changed the public argument about HIV testing. For a long time, the endless debate about mandatory testing was cast as a struggle between civil rights and public health. But if two-thirds of the 2,000 babies born HIV-positive every year could be saved from infection, the sides had to be weighed all over again.

So, during the months of this "gestation period," new legislation has cropped up to enforce testing of pregnant women or at least newborns. It appeared in state legislatures from Florida to New York. It was proposed most recently as an amendment to an AIDS funding bill before Congress -- the Ryan White Reauthorization Act.

At the same time, the Centers for Disease Control has just recommended for the first time that all pregnant women be tested routinely. But voluntarily.

So the argument goes on. There is a special moral obligation now on the part of a pregnant woman to be tested for HIV. But there remains an ethical dilemma in forcing her to do so. After all, if we can mandate HIV testing -- for the sake of the fetus -- surely we can mandate all sorts of other tests, even genetic tests.

More important, as Dr. Martha Rogers of the CDC says, mandating tests only guarantees test results. It doesn't guarantee treatment. The next step, mandating treatment for pregnant women, heads down the slipperiest of slopes.

Even AZT, the drug in this study, has its problems. We don't yet know the long-term side effects of giving AZT to a fetus, especially a healthy fetus. Without any treatment, only a third of the babies born to infected women will be infected. It's not an uncomplicated decision.

As the treatment of choice moreover, AZT must be taken five times a day for five and a half months of pregnancy and then given to a newborn five times a day for six more weeks. There is simply no way to mandate that short of imprisoning and strapping a woman down.

As for mandatory testing of newborns, even Rep. Tom Coburn, the Oklahoma Republican and M.D. who wants this condition attached to the AIDS funding bill, acknowledges that he really wants to reach the pregnant women in their first trimester. There is value in testing newborns, but, again, testing isn't treatment and treatment against a mother's will would entail, what? Taking the baby away? That's hardly an idea that you want to consider as a first resort.

The first, second and third resorts ought to be better counseling, reaching out to women, getting them into a trusting relationship with medical care. A relationship that will help them through the unimaginable crisis of facing their own illness and even mortality, while bringing another life into the world. This is not a relationship that can built by adversaries or by force.

When women are counseled thoroughly, as many as 95 percent choose to be tested. When women know about the benefits, well, there is already evidence that, in just the first months after the study about AZT was released, as many as half the HIV-positive pregnant women were on the drug.

There has always been a segment of the political population more interested in mandating testing than providing care. There's always a segment that believes women have to be coerced into providing their children with a potentially life-saving treatment.

It's time to move from a heated debate about civil rights and moral wrongs to a discussion about what works. As Dr. Rogers says, "We need to get off the debate about voluntary or mandatory testing. We need to reach women who don't seek prenatal care. We need to think about how we get them services, how we pay for them, how we handle patients when they're identified as HIV. That's where our energies should be focused."

Almost nine months after the good news, we're reaching the due date for a change of attitude.

Ellen Goodman is a syndicated columnist.

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