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Case Study: Mandatory premarital HIV screening

To help students understand how public health policy, as well as other types of public policy, is developed
To help students understand that public health policy should be based on valid statistics and sound scientific research; however, political, economic, social and cultural factors also play a very important role in shaping these policies    To teach students to analyze a policy to determine if it is actually effective in improving and promoting the health of a population

You will review documents and research additional websites to develop a better understanding of the issue of public health policy development. You will then use this information to argue for or against the policy.

Theoretically, public health policy should be based on valid and reliable research. This includes, but is not limited to, statistics that show how much of a problem a particular health issue actually is, the population that is affected the most by this health issue, and research that has already been done to show that this particular intervention would be effective in decreasing the number of deaths or disease related to this particular health issue. However, research is not the only factor that shapes policy. Political, economic, social and cultural factors also affect how health policy is shaped. Although a large percentage of human immunodeficiency virus (HIV) transmission in this country is through intravenous drug use, most state and local governments in the United States do not support clean needle exchange programs. They believe that by doing so they are condoning the use of drugs.

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Case Study: Mandatory premarital HIV screening
Factors Influencing the Policy

• Potential dangers of HIV screening: Dangers false positives both psychological and social
• Mayor pushed it as a policy to support the health and well-being of citizens.
• Is HIV a serious public health hazard?
• How will the local public be affected by the policy?
• Will mandatory screenings reduce the risk of HIV transmission?
• Is it enforceable?
• Personal choice and civil liberties issues
• Does this policy seem feasible with regard to the financial responsible of the people involved?
• Unintended effects:
• Encourages people to practice safer sex
• Increased screenings may result in fewer marriages in the state or increase in number of couples going out of state to marry
• Reduced societal and health care cost

Student Handout

People often wonder about the logic behind certain public health policies and why they were passed. Many everyday citizens and health professionals have questioned the effectiveness of school drug education programs, such as D.A.R.E., in preventing young adults and adolescents from trying and using illegal drugs. Some question whether these drug education programs might even have a reverse effect by encouraging school-aged children to try drugs, because adolescents may often do the opposite of what they are told to do, especially if they think they are being lied to. Many school-aged children question the information that is given to them in these drug education programs. Theoretically, public health policy should be based on sound scientific research, which includes epidemiologic research. A health policy is developed because extensive research supports that this health issue is a serious problem and that the government can play a role in either intervening to improve one’s health or creating an environment that promotes health. Research should also show that the actions involved in the policy will be very effective in decreasing the incidence of a particular disease or the number of premature deaths or both. Illness and death among a population contribute to increased costs to society, such as health care expenditure, loss of productivity and increased social services for either patients with chronic diseases or those who have relied on someone who has become ill or has died prematurely. The seat belt laws that have been passed in many states exemplify a public health policy that has been very effective in decreasing the number of deaths and serious injuries caused by automobile accidents.

However, the development of policy is not always based on statistics and sound scientific research. As with any other situation, political, economic, social and cultural factors also play a very important role in why local, state and federal governments pass certain policies related to health. It is because of these factors that many question whether a certain health policy being passed will play a significant role in preventing the number of cases of a particular disease or the number of premature deaths due to this health issue. Then there is the age-old debate between public protection and personal liberty. Just as there is currently a tobacco tax imposed by many state and local governments, some governments are considering passing a tax on foods high in fat and cholesterol content to pay for the health care costs of eating these foods. Those who are opposed to these laws argue that it is one’s personal choice to eat whatever is desired, as long as one is willing to deal with the consequences.

In this assignment, you will be asked to analyze a public health policy that is being considered by the Mayor of your town. You will question for yourself whether this policy will be effective in saving the lives of many, as well as preventing the onset of disease
for many, or whether this policy was economically or politically motivated, as health policies often are. As mentioned previously, a policy that is related to a particular health issue should be supported by research proving this issue to be a public health problem. Research should also demonstrate that the intervention strategy being developed for this policy should be effective as well in meeting the goals and objectives of the policy.

Mandatory Premarital HIV Screening

In December 1982, a report in the MMWR described three persons who had developed acquired immunodeficiency syndrome (AIDS) but who had neither of the previously known risk factors for the disease. These three persons had previously received whole-blood transfusions. By 1983, widespread recognition of the problem of transfusion-related AIDS led to controversial recommendations that persons in known high-risk groups voluntarily defer from donating blood.
In June 1984, after the discovery of the human immunodeficiency virus (HIV), five companies were licensed to produce enzyme-linked immunosorbent assay (EIA, then called ELISA) test kits for detecting HIV antibody. A Food and Drug Administration (FDA) spokesman stated that, “…getting this test out to the blood banks is our No. 1 priority….”
Blood bank directors were anxiously waiting to start screening blood with the new test until March 2, 1985, the date the first test kit was approved by the FDA.
In the pre-licensure evaluation, sensitivity and specificity of the test kits were estimated using blood samples from four groups: those with AIDS by CDC criteria, those with other symptoms and signs of HIV infection, those with various autoimmune disorders and neoplastic diseases that could give a false-positive test result, and those presumed to be healthy blood and plasma donors.
Numerous complex issues were discussed even before licensure. Among them were understanding the magnitude of the problem of false-positive test results, and determining whether test-positive blood donors should be notified.
The sensitivity of test kit A is 95.0% (0.95) and the specificity is 98.0% (0.98). These and related measures are reviewed below.
Sensitivity – the probability that the test result will be positive when administered to persons who actually have the antibody.
= true positives / all with antibody
Algebraically, sensitivity = A / (A+C)

Specificity – the probability that the test result will be negative when administered to persons who are actually without the antibody.
= true negatives / all without antibody
Algebraically, specificity = D / (B+D).

Predictive-value positive (PVP) – the probability that a person with a positive screening test result actually has the antibody.
= true positives / all with positive test
Algebraically, PVP = A / (A+B).

Predictive-value negative (PVN) – the probability that a person with a negative screening test result actually does not have the antibody.
= true negatives / all with negative test
Algebraically, PVN = D / (C+D).

Establishing the cutoff value to define a positive test result from a negative one is somewhat arbitrary. Suppose that the test manufacturer initially considered that optical density ratios greater than “A” on the above figure would be called positive.

The Western blot test identifies antibodies to specific proteins associated with the human immunodeficiency virus. The Western blot is the most widely used secondary test to detect HIV antibody because its specificity exceeds 99.99%; however, it is not used as a primary screening test because it is expensive and technically difficult to perform. Its sensitivity is thought to be lower than that of the EIA. Another option to the Western blot test to confirm positive results is to conduct the test a second time on persons that have EIA-positive results and by considering persons to have the antibody only if results of both tests are positive.

The Policy
A policy to establish a premarital HIV screening program is being considered by the Mayor in your home town. An estimated 60,000 people will get married in the town in the next year. If passed, the policy requires that each prospective bride and groom submit a blood sample for EIA testing. Samples that test positive by EIA will undergo confirmatory second EIA or Western blot testing. The cost of screening will be the responsibility of the couples and will be added on the cost of a marriage license. So no one not having the screening will be able to get a marriage license in your town. The legislation describes the goal of the screening program to be to decrease inadvertent perinatal or sexual HIV transmission by determining who among those to be married are probably infected with the virus. Thus, the incidence of HIV will decrease as well as the health cost associated with the infection and with the disease AIDS.
Critics of this new policy argue that this law would hurt the businesses that provide goods and services for weddings, such as photographers, wedding planners, reception halls, caterers, florist, and bridal and men’s clothing stores by forcing many to seek marriage outside the county or state. The new policy may even cause many employees of these businesses to lose their jobs. Supporters of the policy countered that the new policy would have little effect on where couples chose to marry. Supporters also argue that the revenue generated from the cost of screening justifies any personal business loss which is believed by this group to be minimal.

Residents of your home town tend to value personal freedom. The debate between personal liberty and protection of the public also applies to this policy. Although HIV screening may protect the health of others who are not infected or not yet born, others argue that it is their personal liberty to decide when and if they will be tested for HIV, even if not knowing puts their spouse or offspring at risk. Furthermore, many question whether screening everyone that plans to marry when the individuals have not engaged in any known risk behaviors for HIV transmission. Is it justified to develop a policy that will require premarital HIV screening, especially when it might result in the amount of lost revenue for many businesses not to mention the social stigma of a (+) result, false or true? Simply, will this policy have an impact on decreasing the number of health problems related to HIV, and is it worth the amount of cost for screening or the amount of lost revenue that may result from this policy?

Another question to ask about this policy is whether this law is even enforceable and how will it be enforced.

Your Assignment

Your assignment is to analyze the policy for yourself and decide if such a policy is justified. Your decisions will be based on a series of government documents and articles that are related to this topic.
You will also look at the current research literature on HIV as a public health problem to determine if this policy is justified. This page includes some questions you should be asking yourself when you are looking over these documents.

Questions to Ask When Reviewing the Documents

1. What does the current research say about HIV?

2. Is HIV truly a public health hazard? If so, what does the current research say about control?

3. The mayor of your town, argued that this law will protect the health of citizens and unborn children. How much of a threat is HIV, compared with other public health concerns these citizens may face? Is this policy economically or politically motivated?

8. Does this law justify the loss of personal liberties in order to protect the health of the public?

9. Is this law enforceable?

10. What are some negative and positive unintended effects of this policy?

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