QUESTIONING MANDATORY HIV TESTING DURING PREGNANCY

Schuklenk and Kleinsmidt’s recent proposal1 to pilot mandatory HIV testing of pregnant women during antenatal care in areas with high HIV prevalence rates provides a plausible ethical justification for compulsory testing and treatment—if such a program were likely to succeed. The authors fail, however, to provide evidence that their program would be successful. In addition, they overlook several basic implementation problems likely to accompany a compulsory program.

Three omissions are particularly striking. First, the authors fail to consider the possibility that a compulsory program could deter women from seeking any antenatal care. Presumably, the goal of implementing a mandatory program would be to reach those women who would have opted out of testing if given a choice. Might not these women forgo antenatal care altogether under a mandatory testing approach?

“Kids IV,” an oil painting by Marcia Pinho, created in 2005.

Printed with permission of Absolute Arts, World Wide Arts Resources, Granville, Ohio. Available at: http://www.absoluteartist.com.

Second, there is no discussion of how to enforce mandatory testing and treatment, or of the resources needed for this endeavor. Although voluntary counseling and testing (VCT) has helped reduce risk of HIV infection,2 the authors suggest that VCT programs “divert resources away from testing and [treatment],” concluding that “preserving lives must take priority over counseling.”1^(p1182) However, forcing reluctant women to submit to testing and treatment would also consume considerable resources, as the authors acknowledge: “continuing mandatory HAART treatment (after pregnancy) would not be feasible in a coercive regulatory environment.”1^(p1182)

Finally, there is no discussion of how a compulsory program could affect behavior after pregnancy. Knowing one’s HIV status does not necessarily lead women to engage in treatment, nor does it necessarily lead to change in risk behaviors. Each of these actions or behaviors is guided by complex decisionmaking processes and influenced by social and cultural factors. Even if a successful mandatory program could be imposed during pregnancy, diverting resources away from VCT programs may increase risky behavior after pregnancy.

When choosing between a compulsory and a voluntary program, policymakers should heavily favor the program that provides the most personal choice and bodily integrity for women. Those who advocate forced testing and treatment have the burden of proving why the benefits of their proposals will outweigh the inevitable costs. They cannot simply assert that their proposal will save lives; they must provide details of how a compulsory program would be structured and address the very real implementation problems that such a program is likely to face. In short, a much fuller discussion is still needed.