By Todd J. Ochs, M.D., and Deborah Borchers, M.D.
HIV testing of international adoptees is a controversial topic in the field of international adoption. Debate regarding this topic has been fueled by reports in the press about the increasing incidence of HIV in China. As a result, many adoptive families traveling to China (as well as to other countries) have requested more information about the HIV status of the child they are seeking to adopt. This has resulted in families seeking HIV testing before or during the adoption process, as well as adoption agencies offering this test to families, often while they are in China completing the adoption process.
In many cases, the foreign governmental adoption authorities (e.g., China Center for Adoption Affairs in China) have responded to the requests by doing the basic HIV ELISA screening test.
Screening tests for HIV are designed to yield some false positive results, but not false negative results. This means that the initial test done (usually the ELISA, which identifies antibodies for HIV) will show positive results in some people who do not have HIV. Once the initial test is positive, then more specific tests are routinely done. Frequently individuals with a positive ELISA test will not actually have HIV. With HIV, the ELISA is backed-up frequently by one of two tests, the Western Blot or the PCR. Both of these tests are is more specific than the ELISA in identifying antibodies to HIV. The PCR, or Polymerase Chain Reaction is designed to identify the viral genetic footprint. Unfortunately, the PCR is a very expensive and complex laboratory test to perform, and results from the PCR are dependent upon the quality of the laboratory doing the test. Regulation of laboratories in adoptees' countries of origin is often problematic.
In addition to problems performing the HIV ELISA test, is that performing the test itself may increase the child's risk of actually acquiring HIV. For this (and other reasons), most adoption physicians recommend that testing for HIV (as well as Hepatitis B and Hepatitis C) be performed after a child arrives in their home (adopted) country, and then again six months later.
The real problem with HIV testing is that the antibody tests do not discern between maternal and child antibodies. HIV antibodies can cross the placenta. Maternal antibody may persist in the child's blood stream for two years, or more. So, it is not hard to imagine what happens to children who test positive for HIV antibodies, without the benefit of back-up tests. The Russian experience has been tragic for infants, who were warehoused until their ELISA's turned negative. Two and three year-olds have been so damaged by neglect, by the time they converted to negative, that they suffered from the effects of prolonged institutionalization. Undoubtedly, some antibody-only children became infected during that time, and children who needed anti-HIV medication were not identified early enough to treat them.
A final dilemma is what to do about children who are adopted in their native province, and then are tested (as per parent or agency request) for HIV and have a positive ELISA test. The majority of these children will not have HIV, but it is doubtful that a safe, timely and accurate PCR test will be able to be done for those children. Unfortunately, their adoptive parents may be confronted with a decision that will undoubtedly be very difficult. Do they turn down their adopted child, not knowing whether or not she/he has HIV or not? And, if they do disrupt their adoption, do they get another referral, and, if so, when? Do they bond with their adopted daughters and sons, or should they wait until the HIV ELISA is negative?
In short, many physicians experienced in international adoption medicine do not recommend routine testing of HIV in China for the following reasons:
Undoubtedly, it would be tragic for a family to adopt a child in China and find out, upon arrival testing in the home country, that the child has HIV. But if we remind ourselves that adoption is all about finding homes for children who are in need of permanent families, then it is easy to see that this child will have a much better prognosis in a family than continuing to live in an orphanage, where it is unlikely that aggressive treatment for this devastating disease will be available.
The decision for HIV testing in a child to be adopted is one that needs to be made by each family, in conjunction with the adoption agency, after careful consideration of the risks to the child and benefits for the family. Again, focusing on the overall purpose of adoption as being for children may help families to better accept the risk that comes with NOT having testing done in China. Until HIV testing can be done reliably, safely, timely, and with no risk of false positives (or negatives), it cannot be recommended as being in the best interest of children or adoptive families.
Todd J.Ochs, MD, FAAP Adoption Pediatrics, S.C. 841 West Bradley Place Chicago, Illinois 60613 773-975-8560 Fax: 773-975-5989 Deborah Borchers,M.D., FAAP Eastgate Pediatric Center 4357 Ferguson Drive, Suite 150 Cincinnati,OH 45245 513-753-2820 Fax: 513-753-2824
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