Inter Press Service - October 25, 2002
Paul Weinberg

The provinces of Alberta and Newfoundland and Labrador have officially adopted this automatic, opt-out approach, ignoring the informed consent provisions of Canadian health law, says Ralf Jurgens, president of the Montreal-based Canadian HIV/AIDS Legal Network.

Under the law, patients have the right to be fully informed about medical procedures and their ability to give permission or say no when the doctor seeks to administer them.

In most cases, Canadians tend to go along with what the doctor suggests. At the same time, says Jurgens, "there is often a misunderstanding that physicians think that they don't have to tell people that they are being tested".

Now the Ontario Medical Association (OMA), representing the powerful lobby of Ontario's doctors, is pushing Canada's largest province to abandon its strict adherence to informed consent with regards to HIV/AIDS tests and adopt the automatic approach.

Canadian provinces that take that route are going against international acceptance of informed consent in HIV/AIDS, Jurgens says. "The vast majority of countries worldwide, with very few exceptions, say exactly what I am saying: all pregnant women should be offered HIV testing and counselling. At the end it should be their choice."

In practice, doctors do not always seek consent. Almost 40 percent of surveyed pregnant women in the city of Calgary in western Alberta province, for instance, recently told health officials that they were given a HIV/AIDS test without their knowledge during a prenatal examination.

Because of the social stigma and discrimination faced by people who are HIV-positive or have AIDS, pregnant women should be receiving counselling before and after the HIV/AIDS test, says Katherine Morton, director of communications and development for AIDS Calgary.

"It can be quite a shock to learn that one is positive. Now that you are positive, what can you do about it? What kinds of supports are there? Even if you are negative, you still require post-test counselling," adds Morton.

But giving Ontario women the choice to consent beforehand has led to the current situation where 70 percent of prospective mothers are taking HIV/AIDS tests, compared to almost 100 percent in Alberta under its opt-out protocol, says Ted Boadway, the OMA's public policy specialist.

With the availability of almost 100 percent reliable antiretroviral drugs that can prevent mother-to-child transfer of HIV, Ontario has to take firmer steps to increase the number of pregnant women being tested and not allow legal hurdles to get in the way, adds the OMA spokesperson.

"The more you have to do, the less likely (you are) to get everyone to participate; we are only humans," he told one local Toronto newspaper.

But Jurgens points out that most pregnant women will go along with HIV/AIDS testing to safeguard the life of the baby if a health practitioner properly counsels them.

At the same time, because of the stigma surrounding HIV/AIDS, continues Jurgens, the small number of women who will say no "often have very valid reasons".

University of Ottawa research associate Lynne Leonard found in interviews with 56 women that most of those declining tests belonged to categories of women, such as professionals and regular blood donors, less prone to behaviour that leads to HIV.

Her colleague Dale Guenter, who teaches family medicine at McMaster University in Hamilton, found in a survey of 700 doctors (general practitioners, obstetricians and midwives) that midwives (often women) are more likely to spend time providing information and counselling to pregnant women.

Guenter also encountered resistance by doctors towards treating HIV/AIDS as a "unique" condition during the prenatal examination. His respondents find the informed consent provisions "complicated and time-consuming and aren't sure why it is being handled differently from the other prenatal tests".

These surveyed doctors point to hepatitis C and syphilis, for instance, which are also targeted for routine and automatic prenatal tests, but receive less attention, continues Guenter.

The Ontario Ministry of Health survey illustrated, in Guenter's words, "a complete disconnect" between a group of aggravated doctors and a desire by surveyed mothers for more information about HIV/AIDS and treatment, not less.

Leonard in her research heard concerns by the mothers after the birth that the focus in their prenatal examinations seemed to be solely on the reduction of HIV transmission to the babies. "The women didn't figure in the picture," she says.

Jurgens echoes these comments, stating that he has noticed a trend towards "quick-fix" solutions in HIV/AIDS prevention that fail to take into account the risks faced by women from the epidemic. "Nobody seems to worry about the women."

At the same time, Jurgens recognises that doctors may not be fully compensated for the time spent in HIV/AIDS counselling. Nor are they are trained to be counsellors. "We recognise that there are systemic barriers and physicians may have reasons why they find it difficult." (END/IPS/HD/HE/PW/AN/ML/02) .

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