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Does uptake of antenatal HIV testing depend on the individual midwife? Cross sectional study

^a Department of Sexual Health, King's Healthcare, London SE5 9RS, ^b Academic Unit, Department of Genitourinary Medicine, King's College School of Medicine and Dentistry, London SE5 9RS, ^c Department of Women's Health, King's Healthcare, London SE5 9RS

Correspondence to: Dr Welch

	Introduction

Top Introduction Subjects and methods Results Comment References

The risk of vertical transmission of HIV infection can be reduced by at least two thirds with perinatal interventions, including antiretroviral treatment and abstention from breastfeeding.¹ The Department of Health recommends offering HIV testing to all pregnant women in areas of high seroprevalence,² but uptake and detection rates remain low, with wide variation between centres.³ In 1994-5 only 16% (65/401) of pregnant women infected with HIV in London and south east England were recognised before the birth.⁴ As uptake varies with factors such as the ethnic group of the midwife,⁵ we examined the effect of the midwives' characteristics and site and duration of pretest discussion on uptake of testing in an area of high seroprevalence.⁴

	Subjects and methods

Top Introduction Subjects and methods Results Comment References

An antenatal HIV testing programme was introduced in June 1995. All women at their booking visit were offered an HIV test by midwives trained about HIV infection and how to discuss testing. Each midwife was allocated a number (by a senior midwife not involved in the study) and gave details of age, year of qualification, self defined ethnic group, and site of work. For each pregnant woman the midwife's number, duration of pretest discussion, decision about testing, and whether the result was to be posted or collected were recorded. Only negative results were sent by post. Uptake was calculated as the percentage of women booked who accepted an HIV test. Logistic regression models for grouped data (STATA version 4.0, Austin, TX, USA) were used to estimate odds ratios.

	Results

Top Introduction Subjects and methods Results Comment References

During the first year of the programme 3420 women were booked for antenatal care. Data from 61 forms with no midwife code were excluded, leaving 3359 women of whom 794 (24%) had an HIV test. Of women accepting a test, 739 (93%) elected to receive the result by post. Midwives booked a median of 22 women (range 1-545). Uptake of individual midwives booking more than ten women ranged from zero to 100% (median 25%).

HIV testing was twice as likely if pretest discussions lasted longer than 5 minutes (odds ratio 2.19, 95% confidence intervals 1.82 to 2.62). The table shows the effect of midwives' characteristics on uptake. After all measured characteristics were controlled for, age, experience, and ethnic group remained associated with acceptance of testing. Uptake with midwives aged over 40 and those qualified more than ten years ago was similar to uptake with the youngest and most recently qualified, but testing was significantly less likely when offered by midwives of intermediate age and experience. Tests offered by midwives describing themselves as white were about half as likely to be accepted as those offered by midwives from other ethnic groups. Overall, white women were least likely and black African women most likely to accept HIV testing, but there were no consistent trends when uptake by different ethnic groups was examined according to the ethnicity of the midwife (data not shown).

	Comment

Top Introduction Subjects and methods Results Comment References

The extremely wide variation in HIV testing rates between midwives suggests that acceptance depends greatly on how the test is offered. Uptake was higher for pretest discussions lasting longer than 5 minutes and for midwives qualified under 5 or over 10 years ago. The most experienced midwives may be more confident in their counselling abilities, or the women may be too daunted to decline any tests they offer. Recently qualified midwives may have received more up to date training about HIV infection. As reported previously, midwives from black ethnic groups had higher uptake rates.⁵

Overall uptake was low compared with countries such as France and Sweden, where most pregnant women are tested for HIV. Qualitative studies could usefully explore differences in attitudes and approaches of midwives towards antenatal HIV testing. Effective support and training for midwives will address anxieties about offering antenatal testing and update midwives about recent advances to ensure that women are not discouraged from accepting an HIV test.

	Acknowledgements

Funding: None

Conflict of interest: None

	Notes

Contributors: SJ was involved in setting up the study, including designing the data collection forms and initial data collection; TS carried out subsequent data collection and analysis; NL carried out the statistical analysis; MB and JW were primarily involved in setting up the antenatal HIV screening programme and setting up the study to monitor its progress. All authors were involved in writing the final paper.

Guarantors: MB, JW.

	References

Top Introduction Subjects and methods Results Comment References

1. Peckham C, Gibb D. Mother-to-child transmission of the human immunodeficiency virus. N Engl J Med 1995;333:298-302. [Free Full Text]
2. Department of Health. Guidelines for offering voluntary named HIV antibody testing to women receiving antenatal care. London, Department of Health, 1994.
3. Gibb D, MacDonagh S, Gupta R, Tookey P, Peckham C, Ades A. Factors affecting uptake of antenatal HIV testing in London: results of a multicentre study. BMJ 1998:316:259-61.
4. Unlinked Anonymous Surveys Steering Group, Unlinked Anonymous Prevalence Monitoring Programme England and Wales. Report. London, Department of Health, 1996.
5. Meadows J, Jenkinson S, Cataln J, Gazzard B. Voluntary HIV testing in the antenatal clinic: differing uptake rates for individual counselling midwives. AIDS Care 1990;2:229-33. [Medline]

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