PROVIDER‐INITIATED HIV TESTING AND COUNSELING IN HEALTH FACILITIES – WHAT DOES THIS MEAN FOR THE HEALTH AND HUMAN RIGHTS OF PREGNANT WOMEN?

Since the introduction of drugs to prevent vertical transmission of HIV, the purpose of and approach to HIV testing of pregnant women has increasingly become an area of major controversy. In recent years, many strategies to increase the uptake of HIV testing have focused on offering HIV tests to women in pregnancy-related services. New global guidance issued by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) specifically notes these services as an entry point for provider-initiated HIV testing and counseling (PITC). The guidance constitutes a useful first step towards a framework within which PITC sensitive to health, human rights and ethical concerns can be provided to pregnant women in health facilities. However, a number of issues will require further attention as implementation moves forward. It is incumbent on all those involved in the scale up of PITC to ensure that it promotes long-term connection with relevant health services and does not result simply in increased testing with no concrete benefits being accrued by the women being tested. Within health services, this will require significant attention to informed consent, pre- and post-test counseling, patient confidentiality, referrals and access to appropriate services, as well as reduction of stigma and discrimination. Beyond health services, efforts will be needed to address larger societal, legal, policy and contextual issues. The health and human rights of pregnant women must be a primary consideration in how HIV testing is implemented; they can benefit greatly from PITC but only if it is carried out appropriately.     

Is the Social–Ecological Framework Useful in Understanding Infectious Diseases? The Case of HIV/AIDS

The extraordinary complexity of emerging infectious diseases calls for new paradigms and approaches to understand the casual mechanisms underlying pathogen emergence and to improve disease prevention. An attempt was made to foster interdisciplinary collaboration and stimulate transdisciplinary approaches to improve emerging infectious disease research during and subsequent to a meeting held in March 2005 as part of the US NIH Roadmap initiative “Research Teams of the Future.” The meeting drew on models and theories associated with the idea of humans and nature as interactive, complex systems. Of the three diseases chosen as case studies to represent the wide range of social and ecological emergence factors involved (dengue, leptospirosis, and HIV/AIDS), HIV/AIDS proved especially difficult. This Profile examines the meeting themes with a particular focus on the deliberations of a working group focused on HIV/AIDS. Attention is given to the challenges of bridging different disciplines and perspectives in applying a social-ecological framework to analyze HIV/AIDS and the benefits of reductionistic vs. holistic strategies in responding to the global HIV/AIDS pandemic. The issues raised point to opportunities to significantly deepen understanding of HIV/AIDS as a transdisciplinary problem. Disclaimer: The author is Director of the Research Program at the East–West Center and was chair of the HIV/AIDS mini-symposium. This Profile is based on the important contributions and efforts of all the members of the HIV/AIDS working group. All omissions or misrepresentations are the author’s.     

抗病毒治疗艾滋病48例临床研究

目的探讨艾滋病抗病毒治疗的效果,为进一步开展有效的抗病毒治疗提供依据。方法应用抗病毒治疗药物对符合治疗条件的艾滋病患者进行规范的抗病毒治疗,并进行病毒载量检测。结果对接受抗病毒治疗的48例患者进行病毒载量测定,平均病毒载量为2.0log拷贝/ml,其中16例血浆中未检测到艾滋病病毒,占57.14%。30例患者的CD4细胞均有不同程度升高,从26个/μl升高至517个/μl,平均升高(193.27±51.91)个/μl;治疗2年以上者CD4细胞平均升高(221.08±87.65)个/μl。病人机会性感染得到明显控制,发病率和死亡率显著降低(死亡率从44.44%下降至2.50%)。病人能从事中、重度体力劳动的比例由治疗前的13.33%上升到治疗后的30.0%。结论艾滋病患者抗病毒治疗效果显著,病人生活质量得到明显改善,符合治疗条件的病人应及早进行规范抗病毒治疗。     

IS IT ETHICAL TO STUDY WHAT OUGHT NOT TO HAPPEN?1

In the Democratic Republic of Congo, only an estimated 2% of all AIDS patients have access to treatment. As AIDS treatment access is scaled-up in the coming years, difficult rationing decisions will have to be made concerning who will come to gain access to this scarce medical resource. This article focuses on the position, expressed by representatives of Médecins sans Frontières (MSF), that the practice of AIDS treatment access rationing is fundamentally unethical because it conflicts with the ideal of universal treatment access and the human right to health. The conclusion is that MSF's position lacks coherence, has negative practical implications, and is unfair to governments struggling to increase patient's access to AIDS treatment in unfavorable circumstances.     

Governmental policies on HIV infection in China

This article is a general review of the evolvement of HIV/AIDS-related public policies in China since 1980＇s. It tracks the important laws, regulations and other governmental documents in regard to HIV/AIDS prevention mainly at central level.     

SHOULD RAPID TESTS FOR HIV INFECTION NOW BE MANDATORY DURING PREGNANCY? GLOBAL DIFFERENCES IN SCARCITY AND A DILEMMA OF TECHNOLOGICAL ADVANCE

Since testing for HIV infection became possible in 1985, testing of pregnant women has been conducted primarily on a voluntary, 'opt-in' basis. Faden, Geller and Powers, Bayer, Wilfert, and McKenna, among others, have suggested that with the development of more reliable testing and more effective therapy to reduce maternal-fetal transmission, testing should become either routine with 'opt-out' provisions or mandatory. We ask, in the light of the new rapid tests for HIV, such as OraQuick, and the development of antiretroviral treatment that can reduce maternal-fetal transmission rates to <2%, whether that time is now. Illustrating our argument with cases from the United States (US), Kenya, Peru, and an undocumented Mexican worker in the US, we show that when testing is accompanied by assured multi-drug therapy for the mother, the argument for opt-out or mandatory testing for HIV in pregnancy is strong, but that it is problematic where testing is accompanied by adverse events such as spousal abuse or by inadequate intrapartum or follow-up treatment. The difference is not a 'double standard', but reflects the presence of conflicts between the health interests of the mother and the fetus--conflicts that would be abrogated by the assurance of adequate, continuing multi-drug therapy. In light of these conflicts, where they still occur, careful processes of informed consent are appropriate, rather than opt-out or mandatory testing.     

MANDATORY HIV TESTING IN PREGNANCY: IS THERE EVER A TIME?

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, particularly in southern Africa where HIV prevalence is the highest in the world. In this region, emphasis has shifted from voluntary HIV counselling and testing to routine testing of women during pregnancy. There have also been proposals for mandatory testing. Could mandatory testing ever be an option, even in high‐prevalence settings? Many previous examinations of mandatory testing have dealt with it in the context of low HIV prevalence and a well‐resourced health care system. In this discussion, different assumptions are made. Within this context, where mandatory testing may be a strategy of last resort, the objections to it are reviewed. Special attention is paid in the discussion to the entrenched vulnerability of women in much of southern Africa and how this contributes to both HIV prevalence and ongoing challenges for preventing HIV transmission during pregnancy. While mandatory testing is ethically plausible, particularly when coupled with guaranteed access to treatment and care, the discussion argues that the moment to employ this strategy has not yet come. Many barriers remain for pregnant women in terms of access to testing, treatment and care, most acutely in the southern African setting, despite the presence of national and international human rights instruments aimed at empowering women and removing such barriers. While this situation persists, mandatory HIV testing during pregnancy cannot be justified.     

Governmental policies on HIV infection in China

This article is a general review of the evolvement of HIV/AIDS-related public policies in China since 1980‘s. It tracks the important laws, regulations and other governmental documents in regard to HIV/AIDS prevention mainly at central level.