Testing For Hiv For Newborn Infant

Published Date: 02 Nov 2017

Amine A. Harb

University of South Florida

Author Note

I affirm that the work on this assignment is my original work

Abstract

This paper examines the positives and negatives of a mandatory testing of every newborn for HIV in Hong Kong. Hope of early treatment to save the lives and decrease the spread of HIV is the main concern for these tests on newborns. This paper also discusses the concerns of whether parental consent needs to be required or if parents may reject such testing. Procedures and treatment types are also discussed and their effect on the healthcare economics of Hong Kong.

Testing for HIV for Newborn Infants

Mother-to-Child transmission (MTCT) of HIV is a significant route of HIV transmission around the world (Chan, 2011). In order to save the lives of newborns, it is crucial to incorporate a public health program where MTCT of HIV infection may possibly be prevented and the infected mother and/or newborn are sufficiently taken care of by presented and accessible health care organizations (Chan, 2011). Hong Kong currently has a universal antenatal (UAT) HIV testing program used to test whether a mother was infected with HIV and what steps to take in order to reduce the risks of transmitting the virus to their newborn infants (Scientific Committee on AIDS and STI, 2012). Without any intervention, approximately 15 to 30% of these infants would become positive for HIV (Lee & Wong, 2007).

Birth Rate and Statistics of HIV Positive Infants

In 2011, approximately two and a half million people around the world have been newly infected with the Human Immunodeficiency Virus (HIV) (amfAR, 2012). 330,000 of these newly infected were under the age of 15 (amfAR, 2012). In Asia and the Pacific, nearly 372,000 people were infected bringing the total number to five million (amfAR, 2012). In the East, South, and South-East Asia regions alone, there are approximately 160,000 children younger than 15 years of age who are living with HIV (World Health Organization, 2011). Of these 160,000 children, 39% are receiving antiretroviral therapy (ART), a combination of three or more antiretroviral (ARV) drugs to suppress the HIV virus and stop any further progression of the disease (World Health Organization, n.d.), leaving approximately 113,000 in need of such treatments (World Health Organization, 2011). Prevention of infecting further newborns is crucial to reducing such statistics of children with HIV. With the intention of preventing newborns from contracting HIV by means of their infected mothers, Hong Kong has adopted and began universal antenatal HIV testing (UAT) since September of 2001 (Scientific Committee on AIDS and STI, 2012).

In Hong Kong, all pregnant women who attend a public antenatal service (which accounts for approximately 70% of all deliveries) would be presented with voluntary HIV antibody testing, by means of an opt-out methodology (Lee & Wong, 2007). For the case of any HIV positive women, medical and obstetrical care would be offered (Scientific Committee on AIDS and STI, 2012). The total number of eligible woman for testing from September 2001 to December 2004 was 136,052 (Lee & Wong, 2007). The total number of HIV testing that was performed on the eligible woman was 132,333, a total of 97.3% of all woman (Lee & Wong, 2007). During this time period, a total of 160,878 deliveries were recorded in Hong Kong resulting in a total of 75% of all woman to have had HIV testing before delivery. Due to the acceptance of 97% of those woman eligible for HIV testing; the divergence of the remainder of deliveries are most likely due to late appearances of women (primarily non-residential women), resulting in an inadvertence of standard antenatal testing (Lee & Wong, 2007).

Of the 132,333 women who have accepted HIV testing from September 2001 to December 2004, a total of twenty-eight tested positive for HIV (Lee & Wong, 2007). Approximately 90% of these women received interventions through means of antiretroviral therapy or abortion to help combat mother-to-child transmission (Lee & Wong, 2007). Fifteen of the total twenty-eight HIV positive mothers gave birth, with only one of the cases to be born HIV positive (Lee & Wong, 2007). The birth of the HIV positive child is primarily due to the mother being presented late in labor, and not having tested for HIV diagnosis causing her window of opportunity to be closed for prompt intervention through ART or abortion (Lee & Wong, 2007). With assumption that natural vertical transmission rates are at 25%, an approximate six out of seven anticipated HIV infections are avoided.

Utilizing universal antenatal HIV testing has been found to not only identify whether or not the woman is infected with HIV early in their pregnancy, but may also reduce the risk of vertical transmission of HIV through use of appropriate treatment, by delivery of caesarean section and avoidance of breast feeding, to their unborn child could be reduced by approximately 67% from 26% of transmission to 8% (Lee & Wong, 2007).

Patient Consent

In order for any antiretroviral therapy or HIV testing to begin, a patient must first understand the mechanics of the trial, the potential gains from the enrollment, the possible adverse side effects, and the right to withdraw at any given moment of the trials and/or testing (Scientific Committee on AIDS and STI, 2011). Mechanisms of all the data monitored are recorded, regular view and explanation of data to the patient, thorough records of all procedures to be kept, and any newly informed consent to be properly attained (Scientific Committee on AIDS and STI, 2011). Any newly pertinent data or opinions that emerge during the testing or therapy procedures in the course of the study must be made known to the patients as rapidly as possible, even if the update provides them a new cause to withdraw from the program (Scientific Committee on AIDS and STI, 2011). Due to the complex design of the antiretroviral therapy, it is imperative that the numerous factors associated with the patient must be assessed to make sure the treatment is individualized depending on the likelihood of unfavorable drug interactions, any influences that may possibly hinder adherence such as erratic work hours, depression, gastrointestinal disturbance, etc., any pathological factors that could possibly insinuate resistance, and finally any underlying risk factors or diseases that may predispose to adverse conclusions of treatment (Scientific Committee on AIDS and STI, 2011).

Although parents are urged to begin antiretroviral therapy, there are possible outcomes that could indicate an inconsistent exacerbation and a unique presentation of disease (Scientific Committee on AIDS and STI, 2011). Extra undesirable outcomes related with extensive use of antiretroviral therapies involve heightened risk of cardiovascular disease, fat redistribution, and metabolic complications (Scientific Committee on AIDS and STI, 2011). Parents may also seek to decline testing and therapies for fear of payment, outcomes of testing and therapies, and also due to misinterpretations of the risks presumed (Scientific Committee on AIDS and STI, 2011).

Treatment Options. Prompt treatment of all newborns younger than twelve months of age who have been recently diagnosed to be HIV positive is recommended (Scientific Committee on AIDS, 2002). Each and every newborn who has presented clinical indications of HIV infection, or suggestion of immune suppression, should be treated despite his age or virus load (Scientific Committee on AIDS, 2002). All infants either born positive for HIV or born to HIV-infected mothers must obtain a six week dosage of Zidovudine (ZDV) either single-handedly or in conjunction with supplementary antiretroviral drugs such as Lamivudine (3TC) or Nevirapine (NVP) (Chiu, n.d.). Another treatment available for infants infected with HIV is to begin PCP Prophylaxis from four weeks to four months of age with CD4+ Lymphocyte Monitoring at three months of age (Scientific Committee on AIDS, 2002). After four months of age, the infant will continue to take PCP Prophylaxis from four months to twelve months of age alongside CD4+ Lymphocyte Monitoring at six, nine, and twelve months of age (Scientific Committee on AIDS, 2002). Before the administration of such antiretroviral drugs, an evaluation of the complete blood pictures and differential count should be performed on the newborn (Chiu, n.d.). Repeat measurements of hemoglobin is mandatory throughout the treatment and following the completion of the regimen (Chiu, n.d.). Breastfeeding by means of the HIV-infected mother gives the infant a 16% excess risk of transmission (Chiu, n.d.). Breastfeeding therefore must be contraindicated in order to allow the infant the safest possible food source (Chiu, n.d.).

Economic impact of HIV Treatment. In order to get an accurate impact of HIV testing and treatment a model was created using the pregnant woman associated with the time period of the beginning of September 2001 to the end of December 2004, and the anticipated incremental costs of universal screening would be estimated and evaluated against the projected incremental benefits (Lee & Wong, 2007). All expenditure values would be conveyed in Hong Kong Dollars (HKD) and displayed in their 2004/2005 prices (Lee & Wong, 2007). Establishing the universal antiretroviral therapy program entailed the development of new educational means such as videos, brochures, and advertisements and delivered through groups to all expecting mothers (Lee & Wong, 2007). All women who have been confirmed to be infected with HIV were then given more intricate post-testing treatment by means of professional counsellors (Lee & Wong, 2007). The total therapy and treatment regimen consists of three separate phases, starting with the use of Zidovudine monotherapy (Lee & Wong, 2007). Additional treatment costs for HIV infected women and her newborn based on the assumptions that without the universal antiretroviral therapy program infected women would be diagnosed within 12 to 24 months after delivery and their newborn to be diagnosed 32 to 78 months after birth were estimated to be approximately between HKD 36,180 and HKD 100,500 (Lee & Wong, 2007). With the purpose of achieving an accurate estimate, it was also anticipated that each of the infected mothers and newborns will require an out-patient visit, lymphocyte subset testing, as well as viral load determination every couple of months (Lee & Wong, 2007). Antiretroviral therapy would not begin until the child begins to carry symptoms, or if the HIV status of the child is discovered, and will continue twice a year until death (Lee & Wong, 2007). Based on these assumptions, a discounted annual cost for HIV-infected children would be estimated to be approximately HKD 758,405 (Lee & Wong, 2007). Incremental costs of the universal antiretroviral therapy program will total HKD 13,233,300 for the first three years of HIV antibody testing, a total of HKD 1,700,000 for the training of health care professionals, production of educational materials, and educational presentations (Lee & Wong, 2007). Additional costs consist of HKD 715,560 for caesarean sections, abortions, and overall medical treatment due to prior diagnosis of HIV status through the universal antiretroviral therapy program (Lee & Wong, 2007). The total of treatment and therapy costs are offset by the savings of HKD 4,550,430 from the lifetime of HIV care for the infected children that were prevented (Lee & Wong, 2007). Thus, the overall incremental costs for the universal antiretroviral therapy program for the first three years is HKD 12,227,988 (Lee & Wong, 2007).

Assuming the vertical transmission rate for HIV is 25% without the use of universal antiretroviral therapy, an estimated seven out of the twenty-eight positive pregnancies would have become HIV positive (Lee & Wong, 2007). With the use of universal antiretroviral therapy and the interventions accompanied by it, a total of only one newborn was infected out of the twenty-eight positive pregnancies (Lee & Wong, 2007). Due to these estimations, a total of six infants would have been anticipated and with the appropriate treatment savings of the six HIV-infected children would consist of a netgain of 136.32 (22.72 x 6) discounted life-years (Lee & Wong, 2007). Additionally, 18.27 ((1x17) + 1.27) discounted life years were gained due to earlier treatment of infected mothers and their newborns (Lee & Wong, 2007). A total of approximately 154.59 discounted life years yielding a calculated incremental savings of HKD 57,590,031 (Lee & Wong, 2007).

Although such a minute HIV incidence is found through the implementation of the universal antiretroviral therapy program in Hong Kong, the incremental benefit was much greater than the incremental costs (Lee & Wong, 2007). Due to such a high efficiency rate of universal antiretroviral therapies, any neglected opportunities for avoidance would be reason for distress and would present difficulties to all parties involved (Lee & Wong, 2007). However, there are still many who are ineligible to receive such testing due to not being local residents (Lee & Wong, 2007). These foreign residents primarily originate from Mainland China and other parts of Asia and have had no prior antenatal care and are presented to the hospitals near time of delivery, leaving them no time for any such HIV testing (Lee & Wong, 2007). Having the HIV test is crucial in order to prevent any mother-to-child transmissions for these patients and their newborns, it is also imperative to commence appropriate action according to the antibody outcomes if required (Lee & Wong, 2007).

Conclusion and Opinions

Mandatory testing permits a lesser likelihood of mother-to-child transmission of HIV and the universal antenatal HIV testing program will furthermore provide the patients with the appropriate actions to take in order to decrease the risks of transmission onto their newborns as a result of the contraindication of breastfeeding and by way of the use of caesarean section. Mandatory testing will also allow all pregnant women, regardless of their eligibility due to their residency status, to receive the appropriate testing in order to obtain all the benefits and aid essential to overcome what most perceive as a challenging and demanding situation to undergo. Because of fear some expecting mothers possess, these mothers would decline taking such tests because they would rather be oblivious as to whether or not they are positive for HIV and for the reason that to they believe that they are not positive since they have no symptoms shown. Provided with the additional cost efficiency of the universal antenatal therapy program, it is vital to make use of this system as extensively as feasible to increase the benefits that all individuals would receive whether it be the country of Hong Kong or the infected mother and her infant. Overall, I believe that mandatory testing on infants and their mothers has not only been proven to be efficient but also beneficial towards the mothers, the infants, and the country of Hong Kong.