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Prevention of HIV Transmittance to BabiesLast year, it was cause for celebration. The cause of celebration was for theresults that several clinical trials of zidovudine cut the risk for mother tochild transmission of human immune deficiency virus (HIV) by two thirds.Although, this year, it is the basis for new federal recommendations that allpregnant women should receive HIV testing and counseling. But, these findingshave been cause of protests by several activist groups. Activists fear thatconservative legislators and policy makers will use the clinical data to justifymandatory testing and treatment for pregnant women.During the latter part of February, the United States Public Health Servicespublished guidelines for HIV pregnant women in the Federal Register. Whichcoincidentally was published on the same day as the National Conference inWashington, DC for 'HIV infection in women: Setting a New Agenda.' Theconference included activists, physicians and HIV positive women who used themeeting as a forum to voice their concerns about how best to balance women's ownmedical needs with those of their infants. Other concerns of activists thatwere voiced were that they don't want laws, policies or medical care imposed onwomen merely as 'vectors' who may transmit HIV to their infants.The new guidelines recommend that all pregnant women should receive HIVcounseling and testing.
These guidelines are aimed at helping pregnant womenknow their HIV status early so that medical care, including zidovudine (Retrovir,known as AZT, Burroughs Welcome Co., Research Triangle Park, NC), can be madeavailable. The new guidelines also reiterate previous federal health advisoriesthat say counseling should precede HIV testing. Physicians and other healthprofessionals who counsel women should be well informed about the complex issuesthat face HIV infected pregnant women, according to the guidelines. Thisinformation should include about all of their reproductive options. Womenshould also be advised that in order to help reduce prenatal HIV transmissionsHIV infected women in the United States should not breast feed their infants.The guidelines further states that all HIV testing should be voluntary for womenand their infants.
Also, all decisions about AZT use should be made by the HIVinfected pregnant woman in a non coercive atmosphere and based on a balance ofthe benefits an potential risks of the regimen to herself and her child. Theguidelines also state that women who are infected or refuse testing must not bedenied medical care, reported to child protective agencies, or discriminatedagainst in any way.The center for Disease control and Prevention (CDC), Atlanta, GA. reports thatas 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 thefourth leading cause of death in US women ages 25 to 44 and in 15 major UnitedStates cities.In 1993, the CDC estimated that 7,000 HIV infected women gave birth in thiscountry, in other words, about one in every 625 women who gave birth that yearwas 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 infantsborn in the United States in 1993. Much of the controversy centers on AIDSClinical Trials Group (ACTG) protocol 076.
In the 2 year study, 239 of the 477HIV infected women enrolled received AZT during pregnancy and delivery. Theirinfants received the drug for six weeks. At 18 months, 8.3% of the infants inthe treatment group vs. 25.5 % of the controls were infected. 'Evidence basedon every analysis that has been done of the outcomes to date shows that this isa prevention breakthrough,' said Wanda Jones, DrPH, acting associate director ofCDC's office of Women's Health.Activists believe that the data is incomplete and should not be used as thebasis for federal guidelines.
They wanted to know the effects AZT might have onthe estimated 75% of infants who are born to HIV positive mothers but don'tseroconvert, and whether a pregnant woman who takes AZT early in the course ofinfection will still benefit from the drug later, when she is sicker. They alsowanted to know what the long term effects may be if women take AZT duringmultiple pregnancies, and whether ACTG 076 showed a correlation between highmaternal viral load and the likelihood of transmission. A few small studies,including one from New York State Health Department, are beginning to point inthat direction. Jones of the CDC conceded that the study leaves many questionunanswered. However, it is the only one ever to have demonstrated any effectivemethod of preventing maternal fetal HIV transmission.
'It would beirresponsible 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 wepublished these guidelines is that we believe they represent the very best inpublic health practice.'Besides their scientific concerns, activists also believe that the guidelinescome at a politically tenuous time. Two years ago, before the ACTG 076 resultswere announced and before Congress took a conservative turn, New York lawmakersconsidered legislation to unbind mandatory testing of newborns so thatseropositive infants could be identified. The law failed. But now, since theclinical results have been widely publicized, a similar bill is pending inCongress. For example, in Illinois, lawmakers are considering a bill that wouldmandate HIV testing and counseling for all pregnant women. And in New York, theyhave proposed legislation would mandate testing of pregnant women withoutrequiring counseling.
Experts say that initiative like those in Illinois and NewYork are likely to crop up in more states. To counter pro-mandatory testingmovements, activists have urged federal health officials to strengthen languagein the guidelines before they are finalized so that the document won't beconstrued 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 andmay drive some people away from receiving the medical care they need. Therefore,without a stronger message in support of voluntary testing the guidelines maybecome a way to discriminate against pregnant women who are HIV positive.BibliographyRogers, Martha, Simonds, R.J.; March 15, 1996; Preventing Prenatal HIVInfection 'How Far Have We Come?'; Journal of the American Medical AssociationVolume 19; Page 1514Voelker, Rebecca; April 5, 1996; US Public Health Service Recommends Counselingand HIV Testing For All Pregnant Women; Journal of the American MedicalAssociation; Volume 19; page 977Wolfe, Maxine Ph.D.; October 1, 1996; Mothers To Infant HIV Transmission 076Update; Women Alive; page 6.
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