Abstract
Infants are increasingly being infected with HIV virus every year due to mother to child transmission. Funding and advances in antiretroviral therapy have generally made the reduction and prevention of mother to child transmission (PMTCT) of HIV accessible and affordable but infants are still being born and infected with HIV. There is a 15-50% chance of HIV transmission from the mother to the newborn in the time of breastfeeding, pregnancy, labor and delivery, if appropriate measures are not undertaken. In interpretation of parental requisite role of protecting the infant, there has been a heated debate on whether mandatory HIV testing for infants should be endorsed. The aim of this essay is to present reasons, policy and ethical issues for mandatory testing of HIV for pregnant women and opinions on whether Liberia needs to embrace mandatory HIV testing with respect to prevention of mother to child transmission (PMTCT).
Human Immunodeficiency Virus (HIV) is usually fatal. It causes Acquired Immune Deficiency Syndrome (AIDS).This virus may display no symptom of its prevalence for years, and, still further, neither a vaccine nor a cure exists. Infection of HIV is one of the leading causes of death among children aged below four years in Liberia and the World Health Organization (WHO) approximates that over two million children are HIV infected globally. These grim figures and their public reaction have resulted in statutory attempts to make screening of newborns for HIV mandatory. This would require all hospitals to test and disclose every newborn’s HIV test results to the child’s guardian or parent. The pregnant mother must also be tested to prevent or reduce the rate of mother-to-infant transmission either before, during or immediately after birth.
The HIV transmission rate from infected mothers to their newborns has been estimated to range from 13% to 39% in various studies (UNICEF, 2013). This perinatal transmission presently accounts for more than eighty percent of all pediatric AIDS conditions. More than a fifth of all perinatal infected infants globally, die by nineteen months of age. According to a UNICEF report of 2012, more than three thousand children were living with HIV in Liberia. Even though HIV tests results that are definitive permit for immediate medical care and treatment of the infected infants, the challenge is whether the HIV status of the mother should be exposed without her assent. Proposals for mandatory HIV testing of infants have continually met tough resistance from privacy defenders. Testing infants and parents for HIV against their will, and then informing them of their HIV status is barely the effective way to offer effective treatment but to persuade individuals to take decisions to lower the risks of transmission of the virus to others especially mother to child. But improvements in science have led a number of people to reassess their stand. Do the possible benefits of HIV testing in some situations outweigh the confidentiality interests? This argument is nowhere more intense than in the setting of newborns and pregnant women. It is currently proven that with the appropriate treatment, starting from the third pregnancy trimester; the probabilities of infants contracting the mothers' HIV can be intensely reduced - from about one in every four case that the infant will be infected, to as low as about one in fifty. These auspicious discoveries have resulted to a brash of proposals for compulsory testing for HIV in newborns and pregnant women so that treatment and care can start immediately (American Civil Liberties Union, 2001). The question that is thus posed is whether HIV testing of newborns should be made mandatory (Malloy, 2010).
Children and infants bear a substantial part of the global burden of HIV. In the year 2008, four hundred and thirty thousand of the estimated 2.5 million global infections were children. Furthermore, of the two million deaths globally, 14% occurred in children (World Health Organization, 2006).Liberia is not an exceptional in these statistics. Testing and identifying the exposed infant at an earlier stage is crucial since timely HIV diagnosis allows timely lifesaving care access, including antiretroviral therapy to the infected. Without this therapy, most of the HIV infected infants will die even before reaching the second year of age (REPUBLIC OF LIBERIA, 2008-2011).
The benefits of acquiring HIV testing and counseling for these infants are numerous. Early identification of these infants is the first step to care and treatment. It also facilitates follow-up prevention measures that will keep the infants healthy and uninfected. This early testing will also ensure life planning for both children and parents who are infected with HIV. Parents will also have increased access to antiretroviral therapy and care.
The most effective and efficient way to deal with pediatrics worldwide is to reduce mother to child transmission. This has been a challenge, however since the infants infected with HIV show the symptoms in the first year of age. Many of the infants will have died at this age. There has thus been a need in Liberia to provide antiretroviral therapy for children and infants, despite the many efforts that are being put to prevent these infections. In Liberia, ART has significantly reduced the rate of HIV infections. The infected infants can now survive to adulthood the (REPUBLIC OF LIBERIA, 2008-2011). However, this pediatric care has been scaled down by obstacles such as lack of human capacity, insufficient advocacy, limited HIV testing, lack of simple screening technologies, limited experience and lack of affordable pediatric antiretroviral formulations. This need to care and treat a growing number of infected infants, details the importance of preventing virus transmission from mother to child early enough. Treatment in Liberia has been elongated by the fact that antibody testing methods available have to take up to eighteen months before results. This is unlike high income countries which have polymerase chain reaction tests (PCR) which are faster and can detect the HIV genetic material. This technology is however unaffordable in Liberia (aidsmap, 2013). A number of factors may also prevent the infant from being tested. These include poor systems for analysis in the laboratory, problems arising from transportation and handling of specimen and results, low confidence in caring for the infant among health care providers and lack of heath authorities’ technical ability. In Liberia, antiretroviral treatment is the most common. Initiation of treatment to these HIV diagnosed infants depend on the level of their CD4 cells. To guide decisions about infant treatment, viral load testing which measures the amount of HIV in the infant’s blood is also used. This therapy is initiated immediately to infants under eighteen months of age whose viral test is positive. Antiretroviral (ART) therapy with at least three drugs is endorsed for infants. These are the treatment methods in this country (World Health Organization, 2006).
The treatment of HIV has adverse effects on the economic growth in Liberia. Societies and economies in countries with high birth rate of infants affected with HIV tend to collapse. This is mostly by reducing human capital availability. Infants born with HIV and are not treated and taken care offend up dying at an early age. This increased death rate has reduced the number of young people who are energetic enough to work and improve economic growth. This rising mortality has also resulted into poor skilled labor force. This has reduced productivity. Parents and relatives to the infants who are infected waste a lot of time and resources paying special attention and care to them. This also has lowered productivity. Since infants show a growing population, their deaths from HIV will affect population growth negatively. Sectors such as education where these infants are part of are also affected. Huge amounts of money and labor have also been spent by the Liberian government to test, treat and take care of these children. The treatment itself is expensive considering the large number of infected infants. These treatment expenses could be used for economic growth in other sectors. The young people also form the taxable population of Liberia and thus the death of the young people reduces the resources available for expenditures. This causes pressure in the state’s finances and thus slow the growth of the economy. The affordability of the antiretroviral treatment is also low in Liberia due to the declined household incomes. This has necessitated high dependence on external funding, further affecting the economy. Testing newborns would therefore reduce mortality rate only if there is available and affordable treatment. This would improve the economic growth in the long run although the health care and economic burden will be high. However, if testing is done and no treatment is available and affordable, then the country’s economic growth will decline and even continue deteriorating even in the long run since mortality rate will increase among infected infants.
Another cultural principle that must be considered towards adoption of the recommendation is social relations. This refers to the importance of smooth social relations in the culture. This will mandate respect and politeness while shunning criticism, direct negative responses and assertiveness to the victims. Respect and maintaining of personal integrity in one’s interaction with others are critical. Victims should therefore be assured of treatment with value and respect. Many citizens will not adopt the recommendation due to the fear of social criticism. This necessitates the need to assure parents and families whose infants are to be tested that the results will be private and confidential. This will ensure that there is smooth social relation with the affected families and, therefore, encourage more parents to adopt this recommendation of mandatory HIV testing for their infants.
“Personalism” is another factor that should be taken into consideration for this recommendation to be adopted by citizens. This means that people to be tested more likely to cooperate and trust with someone whom they have had a pleasant conversation with. This conversation would include caring questions about the individual’s family. The delivery of HIV testing information and results, services and treatment will be effective and trustworthy when victims, health providers and educators establish a relationship that nurture personalism.This will encourage families affected to confidently take an HIV test for their infants.
HIV-related discrimination and stigma remain extensive in Liberia. Despite having, a high number of HIV cases and deaths related to AIDS among infants, families whose children are identified as living with HIV are still facing serious discrimination together with and from their families. Discrimination related to HIV can be evident in different ways – from refusal and delay of treatment, social isolation, inappropriatecomments and breaches of victims’ confidentiality. Discrimination and stigmahinder the uptake of HIV testing recommendations among citizens. A study conducted in Liberia, Zambia and Botswana found that humiliation against HIV-positive families and the fear of being discriminated were the key causes of the low acceptance of voluntary counseling and testing services to avert transmission of the virus from mother to child. It has been claimed that testing for HIV routinely, as part of delivering health services, would make HIV testing normal and make it less stigmatizing. However, it is difficult to imagine how this would happen given the confidentiality issues surrounding the HIV testing process both in infants and adults and the reduced rate of acceptance and disclosure by victims who test positive. Unless the existing discrimination and stigma associated with HIV is addressed seriously in Liberia, any policy of mandatory HIV testing could be counter-productive by keeping citizens away from health amenities if they discern that they will be tested for HIV (UNESCO/UNAIDS, 1999).
Religious and ethical factors should also be considered if the recommendations are to be adopted by the citizens of Liberia. Some of religions belief that an infant gets health care from God and thus keep them away from heath facilities. Both political and social leaders should therefore be educated on the need to carry out HIV tests to infants so that the practice can be ethically and religiously adopted.
The overall impact of the recommendation to have a mandatory HIV testing for infants is a society that is healthy and productive. Many parents will be forced to accept testing for their infants and, therefore, protecting the minors who have no contribution in decision making but yet are directly affected by the decision of their parents not to agree with their HIV testing. This will be a means for the government of Liberia to reduce mortality rate among infants and, therefore, save the future generation which would be economically productive. However, for the overall impact to be positive, those tested and diagnosed with HIV should be able to access affordable treatment. Although the economic burden will be high, every person has a right to health and life which should not be suppressed. It is, therefore, recommended to adopt mandatory HIV testing for infants while taking into consideration the privacy and rights of the parents, infants and their families.
References
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