AIDS Organizations Express Concerns with Revised Recommendations for HIV Screening of Pregnant Women
In a Nov. 30 letter to the CDC, several organizations expressed their concerns with the draft U.S. Public Health Service Revised Recommendations for HIV Screening of Pregnant Women, saying that the absence of an HIV counseling requirement following HIV testing "undermine[s] earlier CDC messages about the importance of HIV counseling," and noting that "HIV testing, in and of itself, is a very poor substitute for prevention education, counseling, and accessible medical care." Calling counseling a "cornerstone of our HIV prevention efforts in the United States," the letter, signed by the AIDS Foundation of Chicago, AIDS Legal Council of Chicago, Gay and Lesbian Medical Association, HIV Law Project, Howard Brown Health Center, Lambda Legal Defense and Education Fund, and Project Inform, noted concerns with the CDC's proposal that would "'simplify' the testing process and make the process of informed consent more 'flexible.'" They also objected to guideline modifications that "accept the provision of education materials as sufficient substitutes for face-to-face HIV counseling," and "allow the provider to determine whether written informed consent is a barrier to HIV testing." According to the organizations, the suggestion that "testing itself is more important than a fully informed, written consent and effective HIV counseling, increase[s] the likelihood that providers will postpone any substantive HIV counseling efforts until they have obtained a positive HIV test result for their patient." If this occurs, "women may agree to an HIV test without a full understanding of the implications to their own health and pregnancy," and HIV-negative women "will obtain no meaningful HIV prevention information during their prenatal care." The groups also wrote of their concerns about the encouraged use of rapid HIV testing during labor and delivery, as the guidelines "do little to address clinical practice or offer best practice guidance." Guidance is important when determining how to "approach" antiretroviral treatment "in the context of labor and delivery," and how to inform women of the risks and benefits of such therapy. The organizations concluded that the CDC should withdraw its draft recommendations and "maintain and actively promote" the existing U.S. Public Health Service Recommendations for HIV Counseling and Voluntary Testing for Pregnant Women, as well as lead an "exploratory process" to improve HIV testing with pre- and post-test counseling and informed written consent among medical providers to improve prenatal care access for all pregnant women, particularly those infected with HIV (Coalition letter, 11/30).
Lambda Weighs In
The Lambda Legal Defense and Education Fund, Inc. scripted a second letter to the CDC's National Center for HIV, STD and TB Prevention reemphasizing the need for counseling and informed, written consent. The organization pointed out that the panel of "experts" that recommended "a reduced standard of care for pregnant women that undervalues women's participation in their health care included twice as many men as women," and "did not appear to include any of the real 'experts' in barriers to HIV-related care and testing: women living with HIV and in poverty, particularly those who have experienced pregnancy or childbirth." The letter also called for withdrawal of the draft guidelines and added that resources should be devoted toward strategies to "overcome physicians' lack of training, knowledge, or acceptance of appropriate HIV counseling, testing and treatment, and acceptable ways to 'streamline' the counseling process." In addition, the USPHS should "convene a group" with a "significant number of women, particularly those of childbearing years and who are at risk for or living with HIV," to implement strategies for "overcoming real obstacles to care, including poverty, lack of insurance, lack of child care, lack of transportation and other barriers preventing disadvantaged and underserved populations" from receiving care (Lambda Legal Defense and Education Fund letter, 11/30).
Chicago Public Health Emphasizes Concerns
The Chicago Department of Public Health also issued a statement commenting on the guidelines and noted similar concerns with the separation of HIV testing from counseling, and the consideration of the rights of pregnant women to be separate from other populations. In its statement, the public health department recommended an emphasis on the importance of pre and post-test counseling; the removal of negative comments on pre-test counseling and written, informed consent to stress their importance; and requested the assurance that the document refers its readers to the "more comprehensive Guidelines for HIV Counseling, Testing and Referral" (Chicago Department of Public Health letter, 11/30).