Am J Obstet Gynecol. 2014 Apr 11. pii: S0002-9378(14)00364-0. doi: 10.1016/j.ajog.2014.04.014. [Epub ahead of print]

When courts intervene: public health, legal and ethical issues surrounding HIV, pregnant women and newborns.

Tessmer-Tuck JA1, Poku JK2, Burkle CM3.

Author information

• 1Department of Obstetrics and Gynecology, North Memorial Medical Center, 3300 Oakdale Avenue North, Robbinsdale, Minnesota 55422. Electronic address: jennifer.tessmertuck@gmail.com.
• 2Mayo Medical School, Mayo Clinic, Rochester, Minnesota.
• 3Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota.

Abstract

Ninety-three percent of pediatric AIDS cases are secondary to perinatal HIV transmission, a disease that is almost entirely preventable with early intervention, which reduces the risk of perinatal HIV infection from 25% to less than 2%. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) both recommend routine HIV testing of all pregnant women and at-risk newborns. When pregnant women decline HIV testing and/or treatment, public health, legal and ethical dilemmas can result. Federal courts consistently uphold a woman's right to refuse medical testing and treatment, even though it may benefit her fetus/newborn. Federal courts also reliably respect the rights of parents to make health care decisions for their newborns, which may include declining medical testing and treatment. Confusing the issue of HIV testing and treatment, however, is the fact that there is no definitive United States (U.S.) Supreme Court ruling on the issue. State laws and standards vary widely and serve as guiding principles for practicing clinicians, who must be vigilant of ongoing legal challenges and changes in the states in which they practice. We present a case of an HIV-positive pregnant woman who declined treatment and then testing or treatment of her newborn. Ultimately, the legal system intervened. Given the rarity of such cases, we use this as a primer for the practicing clinician to highlight the public health, legal, and ethical issues surrounding prenatal and newborn HIV testing and treatment in the United States, including summarizing key state-to-state regulatory differences.