Eliminating Perinatal HIV Transmission in the United States: The Impact of Stigma
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COMMENTARY
Eliminating Perinatal HIV Transmission in the United States: The Impact of Stigma Kavita Shah Arora1,2 · Barbara Wilkinson2
© Springer Science+Business Media New York 2016
Keywords Perinatal HIV · Mother-to-child transmission · Stigma · HIV exceptionalism
Significance Eradication of mother-to-child transmission requires elimination of stigma towards HIV-positive pregnant women. Women represent the fastest growing subgroup of Americans with newly diagnosed HIV (Leddy et al. 2010). In the United States, despite dramatic improvements in our ability to prevent vertical transmission of HIV, mother-to-child transmission (MTCT) has remained relatively stable over the last several years with 162 infants perinatally infected in 2010, the most recent year that data is available from the Centers for Disease Control and Prevention (CDC) (Centers for Disease Control and Prevention 2012). While the absolute number of transmissions per year is small, the fact that the United States has not continued to make progress in decreasing rates of MTCT is disheartening given that the efficacy of antiretroviral therapy during labor and delivery and neonatal prophylaxis make total elimination of MTCT of HIV possible. One critical impediment to this effort is a failure of screening for and diagnosis of HIV during pregnancy. Twenty-five percent of those with HIV are unaware of their diagnosis, and up to 85% of perinatally-infected
* Kavita Shah Arora [email protected] 1
Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
2
Department of Bioethics, Case Western Reserve University, Cleveland, OH, USA
infants are born to mothers with unknown HIV status at time of delivery (ACOG 2015). The CDC and the American Congress of Obstetricians and Gynecologists (ACOG), among others, recommend universal HIV screening in pregnancy precisely because modern therapies have the ability to make such a dramatic health impact (ACOG 2015). The CDC revised its previous guidelines in 2006 in favor of universal screening, though the patient may opt out, to ensure timely diagnosis and treatment and to destigmatize the testing process. This recommendation would have been unfathomable early in the course of the HIV epidemic, when HIV’s association with stigmatized subgroups and a prognosis of certain death justified written informed consent and regulated requirements for post-test counseling (Cock and Johnson 1998). While HIV exceptionalism was thus initially ethically supportable, changes in the societal perception of HIV and advances in HIV medical care have made such exceptionalism unwarranted and unethical (Cock and Johnson 1998). MTCT prevention programs represented the first instance of transition from a paradigm of HIV exceptionalism to one of normalization (Cock and Johnson 1998; Bayer and Fairchild 2006). The 2006 CDC guidelines included HIV testing as a component of routine prenatal labs and recommended against separate, written con
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