HIV - PMTCT
The proposed HIV
Prevention and Control Bill is before the public for consultation. One of the contentious
issues in it is the mandatory HIV testing for pregnant women during uptake of
ante-natal care (NV July 18th). This proposal has generated genuine concerns
over ethical principles, notably; autonomy, confidentiality and informed
choices. The civil society organizations have picked on these issues well. Our
moral sense must be governed by categorical imperative not to harm the unborn
fetus and the mother.
The civil society
organizations also highlighted several social-cultural imperatives that places
the woman at a heighten risk of vices such as domestic violence, stigma,
victimization, alienation from marital home and property; and getting punished
unjustly physically and emotionally by the social system that views women as sole
gateway to HIV infection.
Arguably, there is a
moral to the perspectives of the civil society organizations, but there is also
an imperative on the side of government to take bold measures to curb down the
rising trends of HIV infections. No doubt, installation of mandatory testing
requirements creates many barriers to using healthcare services; it is
unethical and violates many international standards. But this is also the
ethical dilemma that a need for such drastic measure may generate.
The underlying reason
for the provision of mandatory testing during interface with the healthcare
system is because Uganda has enrolled in the WHO option A of the Prevention of
mother to child transmission of HIV. This option requires the measure of CD4
before a mother or anyone as such, can get enrolled for the Anti-Retroviral
Treatment (ARTs).
Recognizably, there is
pressure on most sub-Sahara Africa to put in place frameworks to reduce the
transmission of HIV from mother to Child. Significant results have been
recorded already in this area in Malawi and Botswana where there is an
increased uptake of HIV testing by over 93% of pregnant women. Malawi now boost
of 3% reduction of mother -to-child HIV infection through its bold
implementation of WHO recommended ART B/B+ option treatments, despite having
this measure in only limited number of districts.
HIV testing is a tough
personal and intrusive process that plays out on the human emotions and
generates fear. Laws requiring mandatory HIV testing become insensitive to the
autonomous nature of humankind. It deprives one of pre-testing services and violates
the principles of confidentiality.
Best practices world-over
is such that everyone is accorded a just environment to make informed decision
during such moments of vulnerability. Therefore this debate is indeed an
ethical one which must be handled rationally and with an ethical decision
making framework for its a buy-in and sustainability.
There is merit for
every pregnant woman to know her health status and this includes her HIV
status. This merit extends beyond the pregnant woman but to the general
populace. When the pregnant woman comes to know her HIV status, she begins
ante-retrovirus treatment (ART) early with a possibility of experiencing less stressful
pregnancy. This also benefits the mother-child dyad by enhancing the prevention
of transmission of the virus from mother to child.
To add value to the
proposed Bill, a national consensus has to be built around early detection of
HIV and sexually transmitted diseases to reduce the rampant maternal-child mortality
that has haunted our society. A regular, at least thrice a year complete
medical examination including HIV status must be encouraged for a population
that exists in precarious moral situations like it is in Uganda.
The Bill’s focus on
HIV prevention must be rooted in social cultural realities that focuses on four
players; the unborn fetus, the mother, the father and the community from which
the couple belong.
The intricate
complexities involving these players, ensures that HIV prevention is not merely
a medical issue, but a social one as such. To provide effective HIV testing and
prevention services, there is need to move the services to the communities
because it is within these communities that issues of stigma and victimization
takes place.
Further, reports show
that men tend to resist HIV screening, as a result, statistics show disproportional
numbers of women to men, as living with HIV and yet it is more likely that a
man uses multiple partners than a woman. There must be HIV family centre
testing requirements that compels every couple to pre-test counseling and HIV testing
irrespective of pregnancy. This approach may lessen the blame burden on the
woman and provides her with the confidence to enjoy her reproductive rights
without fear.
Case studies
Lessons from Malawi,
Ghana, Kenya, Tanzania, Rwanda and Botswana can attest to these. In Malawi the
controversy over mandatory testing was resolved by creating an alternative
pathway service delivery in their PMTCT national guidelines. Each pathway is
provided with pre-test counseling services for individual and family to attend
clinics with their sexual partners. A pregnant mother is offered counseling
before testing, if they consented to testing and found to have positive HIV
results; they were put on WHO option B+ ART therapy and provided support by
trained community agents through the pregnancy. The mother remained on ART for
life.
The Option B+ does not
require CD4 count like it is for Option A that Kenya, Uganda, Tanzania and
South Africa are adopting, and it is cheaper to administer. In the second
pathway option, pre-counseling was provided to the pregnant women and family
irrespective of level of literacy. If she or her family declines, she is
processed through the system and provided counseling at every point of contact
with the healthcare system while being reminded that they can decline to HIV
tests. These services extend to the community.
According to UNICEF
and UNAIDS 2013 reports, Malawi’s approach initially reduced the uptake of antenatal
services, but after a short period, a surge was registered because of the
benefits that some of these communities started seeing – that children are
being born without HIV while the mothers on ART remained healthy to nurse and
nurture their children. Over 90% of women are using HIV testing services and
are getting enrolled and the Maternal-Child transmission has reduced to <5%
in both Malawi and Botswana.
While there is a focus
on ensuring that pregnant mother's get the treatment that they need, and that
HIV transmission to the child is prevented, the law must propose a
comprehensive family oriented approach. To ensure that women do not become
victims of HIV testing, the law must encourage couples to undergo tests during visits
to ante-natal clinics following counseling.
In places like Canada,
once found to have any sexually transmitted disease, one is required to disclose
recent sexual partners for follow-up by public health. This is largely because
it is against the law to knowingly infect another person and is punishable by
jail if found to have been negligent.
Uganda may not be bold
enough to enact such a law, but under the current situations, there must be an
integrated approach to HIV care which combines a number of fronts and yet very
rational and ethical in all its vestiges.
END
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