Mandatory newborn HIV testing a contentious call

There are no easy answers when it comes to mandatory testing of newborns for HIV. In a year when about 250 US infants are expected to be born HIV positive with no advance warning or maternal testing, ethics, politics, and costs are colliding in an explosion of argument, opinion, and data.

"We all agree that it is appropriate to screen all newborns for HIV," said Ellen Wright Clayton, MD, JD, Vanderbilt University at a noontime panel discussion on Monday. "What is not clear is that it is appropriate to test against the mother's wishes. We need to focus on areas where resources can be used most effectively."

Or maybe not.

"If 98% voluntary testing is okay, then we are not saving 125 HIV positive kids who we could treat if we had caught them at birth," said Ram Yogev, MD, Children's Memorial Hospital, Northwestern University, Chicago. "To wait for a child to be infected when we could have saved him, that is something that my ethics tell me is wrong."

A majority of pediatricians support Dr. Yogev's contention that while prenatal HIV testing is the preferred practice, mandatory newborn testing is a necessary backup measure. A 2005 random survey of 300 pediatricians from the American Academy of Pediatrics found that 96% of respondents support mandatory newborn testing for HIV. Support fell to 88% for toxoplasmosis and 68% for cytomegalovirus.

"I believe that the majority of my colleagues are wrong on this issue," said Lainie Friedman Ross, MD, University of Chicago MacLean Center for Clinical Medical Ethics.

There are two problems with mandatory testing, she explained. Mandatory screening implies that the results will be translated into action, Dr. Ross said. The current HIV screening infrastructure reports results in three to five days. In order to effectively treat HIV neonates, test results must be available within 12 hours after birth.

"If you want to prevent vertical transmission, you have to test the moms. We would get more bang for our buck with screening of moms, not newborns," she explained.

There is also a small percentage of mothers who refuse prenatal HIV screening for a variety of reasons, Dr. Ross noted. Requiring HIV screening whether the mother assents or not will encourage some mothers to avoid prenatal care altogether.

"We may do more harm than good in this population," she warned. "A mandatory screening program of either moms or newborns is not an effective strategy."

Dr. Yogev countered that to not require screening is an ineffective strategy. A rapid HIV screen costs about $10 per patient, he noted. On the other side of the equation is the cost of treating an HIV positive infant. Current estimates are about $10,000 per year and children now born with HIV have an expected life span of about 25 years, for a total lifetime cost of treatment of about $250,000.

"If you look at the costs of screening versus the costs of lifetime treatment, you are saving money with universal HIV testing, not losing it," he said. "We should be testing both mothers and newborns."