Mandatory HIV Testing Among Pregnant Women in Cameroon: Where is the Place of Ethics?

Abstract

Background: Prevention of mother to child transmission of HIV remains a key public health priority in Cameroon. The provider Initiated Opt-Out Prenatal HIV Screening Approach, recommended by the World Health Organization (WHO) lately has been adopted and translated into policy in this country. Despite recent advances in ways to prevent transmission of HIV from a mother to her child during pregnancy, infants continue to be born and become infected with HIV in Cameroon. Many pregnant women, both in urban and rural areas today are still received in labor rooms with unknown or doubtful HIV status. In this region, emphasis has shifted from voluntary HIV counselling and testing to routine testing of women during pregnancy. Ethical tensions arising from compulsory or consenting strategies regarding the labor room HIV testing remain unresolved. We therefore come forth with this write up to be sure of the ethical arguments for or against the provider initiated opt – out approach in prenatal HIV screening within the Cameroonian context.

Discussion: Over the past years, there has been a considerable evolution in prenatal HIV screening in Cameroon. The different approaches constitute a spectrum where at one end there is voluntary counseling and testing, and at the other end there is mandatory (compulsory) testing. In between these two extremes, we have routine counseling and testing. In an effort to increase coverage, the global strategy has shifted from voluntary to routine counseling and testing. Mandatory testing is yet to receive widespread acceptance, if ever.

Conclusion: The Provider Initiated Opt-Out Prenatal HIV Screening option remains ethically acceptable, but deserves caution, active monitoring and evaluation within the translation of this approach into to practice. Pressure with regards to the rights of an expectant mother to determine what is done to her body (autonomy) and obligations to the well-being of an unborn child (beneficence) remain unresolved.

Keywords: Pregnant Women; HIV Screening and Testing; Prenatal; Cameroon

Background

Significant progress has been made in curbing HIV-AIDS prevalence, incidence and burden in the past two decades [1]. However, over 36 million people still live with the disease worldwide especially in Sub – Saharan Africa [1-3]. Nowadays, most infected persons live a normal life due to the improved access, availability and effectiveness of Anti –Retroviral Therapy [2]. Testing pregnant women for HIV at the time of labor and delivery is the last opportunity for Prevention of Mother-To-Child HIV Transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care [3-5]. About 60 % of the general population globally remains untested, or is unaware of their HIV status [2]. Despite the availability and effectiveness of new rapid HIV tests and prevention strategies, many women are still seen in labor rooms with uncertain HIV serology status [6-8]. Tudor Car and colleagues reported in a recent systematic review that over 70% of women admitted to the labor rooms did not know their HIV status [7,9]. More than 90 % of the new infections occur during the prenatal period [10,11]. Over 75 % of perinatal HIV transmission occurs during labor and delivery [11]. If the HIV status of the mother is known especially during the prenatal or intrapartum period, affordable and effective interventions (specific medical staff practices and anti-retroviral therapy) for immediate protection of the neonate and treatment for the mother can be readily provided [8,10-12].

Transmission rates from infected mothers to their children could be reduced to 2 % or less with the current Prevention of Mother to Child Transmission of HIV prevention package [9]. Prenatal and labor room HIV screening could be a starting point to get to the sexual partners of infected mothers since some of these mothers and their husbands or sexual partners are generally unaware of their HIV status [5].

Recent global advances in available technology to prevent motherto- child HIV transmission necessitate a rethinking of contemporary and previous ethical debates on HIV testing as a means to preventing vertical transmission. HIV testing models, policies and protocols rooted in human rights principles are in the best interest of individual and collective public health goals; human rights are an integral subset of public health. Worldwide, the main approaches that have been used in the prenatal HIV testing services are the Opt-In (compulsory) and Opt-Out (consented) approaches [7,8,12]. In the Opt-In approach, the pregnant women are given pre-HIV test counselling, and they actively choose to receive the test usually in writing (written informed consent) [3,12]. With the Opt-Out approach, pregnant women are informed that an HIV test will be included in the standard group of prenatal tests (that is to say, tests given to all pregnant women), and that they may decline the test. A written document is often not required and the HIV test is incorporated into the usual package of routine care tests [6,7]. Unless they decline, they will receive an HIV test [6]. The other-side of an opt-out strategy is that it may end up as involuntary testing in a clinical setting [3]. There are two main reasons for HIV testing during pregnancy: to prevent Mother to Child Transmission (MTCT) of HIV and to provide treatment to women with indications for antiretroviral therapy. However, there is evidence that HIV testing can lead to violence against women, stigmatization of women within their community and by health workers, and emotional and psychological sequelae [3,4]. Debates surrounding the testing of HIV during pregnancy have been based on the ethical principles of beneficence and autonomy. In Cameroon and most African countries, culture dictates that people do not question medical advice from providers [3,4,6,7]. In addition, there is often an imbalance in the power relationship between the provider and clients especially women, which makes rational decision making almost impossible [6]. The reason why women may fail to oppose medical recommendations include the high social status of the health professionals, gender inequality and the fear that providers might negatively impact on healthcare provision [4]. Women from this region of the world undertake the HIV test under some degree of implicit or “involuntary” coercion, and that the consequences when these women would realize that they actually had a choice either to turn down or to comply with the test could be counterproductive [6,7]. These consequences could range from lack of trust in the health care providers to refusal to take part in future research activities [6].

Our aim is to introduce a novel perspective from which to analyze testing strategies, and to explore the implications and possible benefits, to better appreciate whether this prenatal HIV screening approach is appropriate or not from an ethical perspective. The main objective here is to ascertain the ethical arguments for or against the provider initiated opt-out approach in prenatal HIV screening within the Cameroonian context.

Discussion

There are two main reasons for HIV testing during pregnancy: to prevent mother to child transmission of HIV and to provide treatment to women with indications for antiretroviral therapy [6,13,14]. However, there is evidence that HIV testing can lead to violence against women, stigmatization of women within their community and by health workers, and emotional and psychological sequelae [6,13]. Debates surrounding the testing of HIV during pregnancy have been based on the ethical principles of beneficence and autonomy. If the individual’s autonomy is respected, then a woman should have the right to refuse an HIV test. In practice, women are frequently unaware of this right. Studies carried out in certain countries in South and sub Saharan Africa where HIV testing is routinely offered to pregnant women, 68% of participants believed that they could not refuse the test [6,14,15]. The right to refuse an HIV test can only be guaranteed if women are aware that they could refuse and are empowered to do so [6]. In sub-Saharan Africa, culture dictates that people do not question medical advice from providers. In addition, there is often an imbalance in the power relationship between the provider and clients, especially women, which makes rational decision- making almost impossible [6]. The reasons why women may fail to oppose medical recommendations include the high social status of the health professionals, gender inequality and the fear that providers might negatively impact on healthcare provision [6,16].

The World Health Organization (WHO) has specified the minimum package of information to be given to clients during the informed consent process including the tests clinical and prevention benefits, the right to refuse the test, the follow – up services that will be offered and the need to anticipate informing any contacts at risk in case the test turns out positive [7,17]. These conditions are rarely met in most health care settings [7]. Even in developed countries, many women are still seen in labor rooms with unknown HIV serostatus [7]. For instance, Siemieniuk et al. reported cases from Alberta in Canada who were diagnosed either in the labor room or postpartum [7,18]. About 32 % of women who give birth in Sub-Saharan Africa do so without ever receiving any prenatal care [7,19,20].

The post-test counseling is generally time-consuming as it has to be conducted at individual level and information tailored according to the individual HIV serostatus. Routine HIV testing is currently used in many sub-Saharan African countries, including Cameroon [6,21]. The details of how routine HIV testing is conducted and the degree to which emphasis is given on consent, counseling and confidentiality vary from country to country. This approach has been shown to increase coverage and decrease stigma associated with HIV testing in many countries in sub-Saharan Africa [6]. However, it has been criticized for lack of emphasis on informed consent, as the concept of ‘routine’ testing sometimes misleads providers to believe that there is no need for consent [6]. Lack of informed consent has been associated with fear, disbelief, shock and embarrassment on an individual learning their HIV status [6,22,23]. Without written consent, the likelihood that the test becomes compulsory increases [4,24]. However, Bayer has argued that making it more difficult to say no with regards to taking an HIV test within the opt-out approach can be justified from a public health perspective. He is particularly concerned with the opportunities accrued to treating the infected on time, avoiding treatable and preventable opportunistic infections and reducing transmission to their partners [4,7,24]. Empirical research in bioethics has been embraced and its importance has generally been well recognized [7,25,26]. Despite concerns raised by empirical research about the disregard or inappropriate practice of the informed consent procedure, coercion or compulsory testing with this testing approach, it might be of interest for public health actors to embrace these claims with caution [7].

Conclusion

Faced with the devastating epidemic of HIV/AIDS that has already infected more than 3% of its adult population, the government of Cameroon has taken strong steps to improve access to testing and to ensure the right to life-sustaining treatment for all of its citizens. General efforts to scale up HIV/AIDS testing, however, must also be accompanied by appropriate monitoring of testing practices to ensure that they are implemented in accordance with international guidelines on human rights and HIV/AIDS [15,27,28].

Policies that recommend provider-initiated opt-out HIV testing of pregnant mothers, with a risk of becoming involuntary testing in a clinical setting, are acceptable. The rationale behind this is that the increased availability of very effective and inexpensive life-saving drugs makes the ethical problems raised by the possible intrusiveness of HIV testing less important than the child’s hypothetical preferences to be born healthy. Health care providers, therefore, have a duty to offer both opt-out HIV testing and available PMTCT (preventing mother-to-child transmission) interventions. Routine testing appears to be widely supported and may reduce barriers to testing in Cameroon. As routine testing is adopted in Cameroon, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

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