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HIV Testing in Pregnant Women
- Inaam A. Nakchbandi, MD;
- J. Craig Longenecker, MD, MPH; and
- David Gary Smith, MD
- Yale University School of Medicine; New Haven, CT 06520 Johns Hopkins University; Baltimore, MD 21205 Abington Memorial Hospital; Abington, PA 19001
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IN RESPONSE
Dr. Wong suggests that we did not model the impact of false-positive HIV test results in our analysis. He also suggests that the principle of patient autonomy effectively argues against the implementation of any mandatory screening program.
Testing for HIV is a two-step process, so that one must apply the operating characteristics sequentially. The combined specificity is on the order of 0.9999926 [1, 2]. Thus, the number of possible false-positive results out of 1.6 million screened women is approximately 11, not 16 000 as suggested by Dr. Wong. Second, and probably more important, any patient with positive results on Western blot should have HIV RNA levels measured to determine the viral burden or to confirm HIV infection in someone with a suspected false-positive result. The HIV RNA or other available tests would probably identify any false-positive results. Therefore, the theoretical problem of a false-positive result should not affect our analysis.
Although the principle of patient autonomy is of great importance in most ethical dilemmas, it may not be decisive in any ethical conflict involving two parties. This is especially true when one of the parties cannot speak (that is, the fetus) and the best way of preventing HIV infection of the newborn is therapy during pregnancy. However, what often gets lost in the debate about mandatory testing is that although testing is a critical first step, it is not the only consideration. The most important part of the process is the counseling and subsequent care, which will maximize the likelihood of a woman getting and taking treatment and completing the entire course.
We agree with Dr. Wong's conclusions that mandatory screening should not be public policy, although we disagree with some of his reasons. The focus should move from discussion of mandatory testing to the greater need for excellent counseling and care for all pregnant women, HIV infected or not.
Inaam A. Nakchbandi, MD
Yale University School of Medicine; New Haven, CT 06520
J. Craig Longenecker, MD, MPH
Johns Hopkins University; Baltimore, MD 21205
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
