A Gain Against AIDS That Carries Ethical Questions : Should HIV-positive pregnant women face mandatory AZT therapy?
A rare piece of good news from the AIDS front poses difficult ethical questions: Should pregnant women be compelled to take the test for the virus that causes AIDS and then, if they test positive, be required to undergo AZT drug therapy to help save their unborn children from the disease? After all, pregnant women must be tested for syphilis; why not for the far deadlier AIDS?
Until now, there was no reliable means of preventing the transmission of the virus to the child. But a new study, cited by President Clinton Thursday in naming Patricia S. Fleming as the new AIDS czar, has shown that aggressive intervention to treat both the pregnant woman and the newborn with antiviral AZT can dramatically reduce the infant’s chances of acquiring the virus.
The lesson is clear: Doctors should urge all pregnant women to take the HIV test and then draw into treatment those who carry the virus. However, any attempt to make either the test or treatment mandatory at this time would be counterproductive, probably deterring poor women from seeking perinatal care.
The new study found that maternal transmission to newborns can be cut by two-thirds if infected women are given AZT during pregnancy and delivery and the infants themselves are continued on AZT for six weeks. The researchers took the unusual step of ending the experiment early to publish the findings.
While encouraging, the findings have caused unease. The prevailing law and ethics of medicine today dictate that no one can be subjected to tests or therapy without informed consent. In California, even rapists cannot be forced to take AIDS tests; how could pregnant women be?
The new study shakes those principles of privacy and confidentiality, for the treatment benefits not the mother but her child, who to avoid AIDS surely would consent if he or she could. Last year in New York, an uproar ensued over demands for mandatory HIV testing of newborns because that would violate the privacy of the mother. The new study sharpens the issue in that it offers not just treatment but a means of preventing the disease altogether.
The study--which involved 44 research hospitals in the United States and France, including those of UCLA and USC--does have limits. It says nothing about the possible long-term negative side effects of AZT or whether the method is effective when mothers have full-blown AIDS. Nonetheless, the U.S. Public Health Service is expected soon to urge doctors to offer HIV tests to all pregnant women and then counsel AZT therapy for those who test positive. Only 1,000 to 2,000 babies are born with HIV yearly in the United States, or less than .05% of all births. But the number is growing, and in Los Angeles one of every 1,000 pregnant women has HIV, one in 160 among African Americans.
For now we agree that mandatory testing is not needed. But it may be, should the numbers multiply. The tougher question is whether infected women should be compelled to take therapy to save their children. After all, it is estimated that it costs from $35,000 to $75,000 a year in hospital fees to treat a child with AIDS but only about $3,000 to apply the AZT therapy likely to prevent the disease.
It would not be legal to compel treatment now, nor advisable. We have come a long way since the Supreme Court authorized states to sterilize retarded people involuntarily. How could a woman be made to take five doses of AZT a day unless she were jailed or forcibly hospitalized? The larger public benefits if authorities ensure privacy and confidentiality, rather than drive people out of the health system with coercion.
Most HIV-infected women are poor, women who normally get little or no perinatal care. The challenge here is to reach out to them and present them with the best alternatives. Doctors at UCLA say such women mostly are quite willing to undergo AZT therapy for their infants when informed of the potential benefits.
A breakthrough has been achieved, one that promises to interrupt the spread of AIDS. With 1 million children infected worldwide, no speedy progress will be made in underdeveloped countries. But a good start has been made.
New Hope on AIDS
Probability of HIV infected women transmitting to their infants.
With AZT Treatment: 8.3%
With Placebo: 25.5%
Source: New England Journal of Medicine
