Reply turned post, HIV testing for neonates style

This is one of those three way mirror type reply turned posts. If you want to follow the background, the comment thread appears on this post, but it is actually referring to an older post I wrote about mandatory HIV screening in pregnancy. This reply is in regards to the common practice of testing the newborn when the mother refuses.

I am really conflicted about this. Because, in essence, it is testing the mother. It is not the baby’s antibodies being tested, it is the mother’s that she transferred to the baby. A baby won’t have a valid HIV test until it is 12 months old or more, generally.

So, if it is to decide whether to administer AZT to the baby, which would be what it would be for, I would assume, I would also assume the same woman would probably refuse to have the baby treated. So, where are we then?

I am definitely speaking hypothetically, of course. If I get the local residency I want, I will be in a hospital system where I face the reality of caring for women with HIV and unknown HIV status.

If her child is going to be removed and become a ward of the state, then testing may be ethical once she has relinquished parental rights. Is it ethical to give AZT to a baby against the mother’s wishes? Will the state get a court order to take custody just to administer the medications? How soon until we get to imprisoning women with HIV? Oh, wait we already are.

That being said, I agree it is obviously better for the health of the baby and the mother if they know their HIV status and are medicated. And, both may be lost to the system if not screened and treated at this point. Pregnancy, especially labor and delivery, is a unique time in which women have more access to care due to increased Medicaid coverage and women seek out more care in the peripartum period than when they are not pregnant. But there are lots of ticking time bombs out there that don’t get the government in their lives like women do at the point of delivery. I think she should have a psych consult, possibly, and/or a social worker and a compassionate practitioner who can find out what is going on in her life and why she is refusing. Maybe she will agree at a follow up appointment. Maybe she will sign a release for the baby 12 hours or 18 hours after the delivery. How often does this even come up, and when it does, is it worth it to override her autonomy and remove the child from custody?

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5 responses to “Reply turned post, HIV testing for neonates style

  1. Oops, it looks like one of my comments elicited an entire post! I do find this a fascinating subject, and I love medical ethics. Here is my comment to your current post. It is a very loooong comment, sorry :(

    ” Because, in essence, it is testing the mother. It is not the baby’s antibodies being tested, it is the mother’s that she transferred to the baby. A baby won’t have a valid HIV test until it is 12 months old or more, generally.”

    You are correct that the rapid HIV test on the newborn is essentially testing for maternal HIV antibodies in the infant’s bloodstream.
    Two negative DNA PCR test results are needed to confirm a baby as non-infected with HIV (one before and one after 4 months). Antibody testing is conducted on infants between 12 and 18 months to document the clearance of maternal antibodies.

    “So, if it is to decide whether to administer AZT to the baby, which would be what it would be for, I would assume, I would also assume the same woman would probably refuse to have the baby treated. So, where are we then?”

    You are correct to assume this. If the mom refuses to be tested herself, we will do a rapid HIV on the infant, almost immediately after birth. If it comes back preliminary positive, we will start AZT on the infant STAT, until a confirmatory Western Blot can be obtained. We do not do this lightly. If an HIV positive mom gets treated while pregnant, it decreases the HIV transmission rate to the infant from 25% to 2%. If the HIV positive mom refuses treatment, starting the baby on AZT IMMEDIATELY after birth can reduce the transmission rate to the baby by 50%. Every second delay in treatment can increase the chance of HIV transmission to the newborn.

    “Is it ethical to give AZT to a baby against the mother’s wishes? Will the state get a court order to take custody just to administer the medications? How soon until we get to imprisoning women with HIV? Oh, wait we already are.”

    I would say it is unethical NOT to give AZT to the newborn, even if it is against the mom’s wishes. Let’s say hypothetically, that HIV did not have such a stigma related to it. Would it be such a big issue to test the baby? We test pregnant mom’s all the time for conditions that only have an effect on the newborn. Should we stop testing for GBBS? What if a GBBS positive mom refuses antibiotic treatment for herself, and then refuses treatment for her newborn? Should the mom’s autonomy over rule the baby’s health and lack of autonomy? As far as imprisoning women with HIV, this is outrageous and completely ignorant. I am embarrassed that things like this can still happen in today’s world.

    ” I think she should have a psych consult, possibly, and/or a social worker and a compassionate practitioner who can find out what is going on in her life and why she is refusing. Maybe she will agree at a follow up appointment. Maybe she will sign a release for the baby 12 hours or 18 hours after the delivery. How often does this even come up, and when it does, is it worth it to override her autonomy and remove the child from custody?”

    We actually have a very compassionate HIV policy in my state. We council every woman on testing, offer free follow-up care and a 24 hour hot line. We have had mom’s refuse testing for herself, but never for her baby. When this happens (because I am sure it will), I can only assume we would take temporary custody of the baby, as we would if a parent refused a life-saving blood transfusion, for example. It would be a temporary removal of custody. Is it pleasant, no. Am I fine with it, yes. As far as the mom mulling it over for 12-18 hours to decide on testing or treating her newborn, this is not an option. As I mentioned earlier, prophylactic AZT treatment needs to be started STAT in order to get that 50% reduction in HIV transmission to the infant.

    • MomTFH

      It is fascinating. I totally agree with the 50% reduction in transmission being a worthy and important outcome. I just don’t know if it warrants saying childbirth is a special time where women do not get to make decisions about their own family and their own health. I am not sure if a woman has ever attempted to refuse the screening or care of the newborn for HIV. I am not sure what other diseases guardians have refused to have babies or children screened or treated for, and what the outcomes of those refusals were, other than isolated stories. I know there have been decisions going either way. Maybe this is more of a philosophical point than anything.

  2. Pingback: Get Ye to the Stockades, Ye Pregnant, HIV Positive Wench! « Reality Rounds

  3. Evie

    This is a one sided street. Mandatory HIV testing for pregnant women? And babies? Women do not have the right to know the HIV status of their health consultant and practitioner, in order to protect the worker from discrimination. It is arguable that testing pregnant women en masse is discriminatory and based on a guilty until proven innocent theme.

    Lets open up this road and let women have access to the screening results for HIV and hep.B&C of private and corporate carers so we can choose our birth workers more selectively. IF those carers choose not to test and report their results, we should pull their licenses. Testing should occur every year in order to maintain current results. This should be on top of mandatory compliance with recommended adult vaccinations. Healthcare workers with positive HIV and hep.B&C status have no business working with patients, and should be restricted to clerical duties, with deviations resulting in jail time for endangering lives.

  4. Evie,
    I am not quite sure where you are coming from. Health care professionals have to be privy to the health information of our patients we are caring for. Otherwise, we can not competently care for them. We have developed very cumbersome HIPAA laws to protect the privacy of these patients. Is it fail safe? No, nothing is. It is not just HIV we are testing the mom for in regards to the health of her fetus. We test blood type and coombs to see if the infant is at risk for hyperbilirubinemia, GBBS to test if the baby is at risk for serious infections, etc. The mom can certainly refuse all these test. But, once that baby is born and becomes an autonomous member of society, we will test and treat him/her to maintain his health and well being.
    I am not getting how this relates to health care workers disclosing their health information to people who are not actively caring for them in a medical way? Please enlighten me.

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