Hiv testing and arv prophylaxis for newborns without their mothers consent

A paediatrician is called to the nursery ward of a government hospital to see a male infant born 8 hours previously. The infant's mother is 33 years old, wasted and has oral thrush. This is her second child, the first having died in infancy after a short illness with a history typical of pneumonia. The mother was not offered an HIV test during pregnancy as the clinic she attended did not have such services. A nurse calls the paediatrician as her offer of HIV testing to the mother has been declined. She requests the paediatrician to convince the woman to test, given the benefits that such knowledge gives the woman, as well as to enable the provision of postexposure prophylaxis for the newborn and of infant feeding counselling. The paediatrician examines the newborn, who is vigorous, fully grown for age and has no signs of HIV infection. She then carefully counsels the patient, explaining the potential harm of testing, and the benefits of HIV testing, for the woman and her infant. The woman still declines. The paediatrician is aware of the efficacy of antiretroviral (ARV) prophylaxis given to HIV-exposed newborns whose mothers did not receive ARVs.(1-3) The former's conscience and medical duty to act in the best interests of her patient (the child) have to be balanced against hospital and international policies which state that newborns cannot be tested for HIV exposure and be given prophylaxis without their mothers' consent. She thinks of many other colleagues-such as the previous medical superintendent of the East London Hospital Complex(4) who in similar situations acted from their conscience, even if such actions were contrary to prevailing policies and protocol. The paediatrician then tests the infant, whose antibody rapid tests show he is HIV-exposed. The doctor provides ARV prophylaxis to the infant, counsels the woman about her own HIV status and enrols her in an HIV clinic which provides antiretroviral treatment (ART). Questions for discussion 1. Was the paediatrician correct to test the infant without the mother's consent? What is the optimal balance between a woman's right to autonomy and choice, and her infant's access to health care services? 2. Was the paediatrician correct to provide ARV prophylaxis to the infant without consulting the mother? Should the paediatrician have informed her that she had given the infant ARV prophylaxis?