Editorials

Reducing vertical transmission of HIV in the UK

At last the UK is getting serious about reducing mother to child transmission

Papers pp 1227 , 1230

For five years we have known that administering zidovudine to HIV infected women during pregnancy and in labour, and to the neonate for the first 6 weeks of life, greatly reduces mother to child transmission of HIV.¹ This intervention, together with delivery by caesarean section and avoiding breast feeding, has reduced the risk of transmission from over 20% to well under 5%.² In the United States, where antiretroviral therapy is widely used to reduce perinatal transmission, the incidence of AIDS in infants, a sensitive indicator of mother to child transmission, has fallen by 80%.³ In the United Kingdom, although routine antenatal testing for HIV infection has officially been recommended for high prevalence areas since 1994, most maternal HIV infections remain undetected.⁴ Thus the number of infants presenting with AIDS in the UK has not declined, as it has in other European countries, and in 1997 was higher than in France, Italy, or Spain. Yet these countries have adult HIV burdens four or more times greater than that of the UK.⁵

In 1997 the unlinked anonymous programmes of HIV testing found evidence of 265 births to HIV infected women, 195 in London, 14 in Scotland, and 56 elsewhere in the UK. Allowing for areas outside the programmes, this amounts to an estimated 300 births to HIV infected women each year in the UKover 70% of whom would be unaware of their infection.⁴ What underlies this failure? Until recently, and despite the official guidelines, few hospitals offered HIV testing as part of routine screening. Some offered it in addition to routine tests; in others mothers would be referred to a sexually transmitted disease clinic or not offered the test at all.⁶ Furthermore, while one professional might commend the test another would remain diffident.⁷ Consequently whether or not a woman was offered an HIV test, and how she was offered it, depended on where she received her antenatal care and the attitude of individual health professionals. This is scarcely a fair and acceptable situation considering that failure to offer the test seems to be a much greater barrier to preventing mother to child transmission than any reluctance of mothers to accept effective interventions when indicated. ^{2 6 7}

This August the government made a commitment to change this situation, setting a national objective of reducing the numbers of children acquiring HIV infection from their mothers by 80% by the end of 2002. The key policy change was to make the offer of an antenatal HIV test a routine and integral part of antenatal care across England. Wales will follow suit while decisions are awaited from Scotland and Northern Ireland.⁸ Targets for achieving this were outlined in an accompanying circular and expert group report (see box and fuller details on www.bmj.com).⁹

The National Screening Committee had already sought assurance that the universal offer of an HIV test met the cost effectiveness criteria applied to other screening programmes, and this was shown to be the case for the United Kingdom as a whole and in most health authorities (not only in high prevalence areas). ^{8 10} Previous work which supports this programme was published last year as recommendations from the royal colleges in medicine, nursing, and midwifery and the Public Health Laboratory Service.¹¹ These emphasised that testing of mothers had to be with verbal consent; arrangements had to be in place to manage promptly and advise women found to be HIV infected; expert advice should be available to those providing care; and ethnic minority groups particularly affected needed to be involved in this process.¹¹ As for all diagnostic HIV testing, clinical and laboratory procedures need to be adhered to, ensuring that when initial tests give positive results they are repeated on a second specimen and that repeat positive results are confirmed by a specialist laboratory.¹²

An intermediate objective for reducing mother to child transmission is that 80% of HIV positive women giving birth should have their infection diagnosed. This target is already monitored through the unlinked anonymous programmes and national surveillance of pregnant women and children,⁴ but a study by the group implementing antenatal HIV testing in London has already made it clear that many hospitals' information systems cannot provide data on the proportion of women screened, let alone the proportion offered the test.¹³

Therefore information systems will urgently need to be developed so that the uptake of HIV tests and other antenatal tests such as those for hepatitis B, syphilis, and rubella can be recorded and performance monitored.⁸ This is in accordance with other initiatives to improve quality in screening programmes by the National Screening Committee.¹⁴

The government's year targets for the year 2000 are entirely achievable. Some hospitals in London and Edinburgh have shown that when an offer and recommendation of voluntary HIV testing is made routine as part of standard antenatal care uptake exceeds 80%. ^{13 15} Some London hospitals have already seen an increase in the proportion of HIV infected women detected.⁴ The challenge that remains is to extend this to the rest of the UK, to sustain improvements and to use the lessons learnt to benefit all aspects of screening and care in pregnancy.

Angus Nicoll, consultant epidemiologist. 

HIV and STD Division, PHLS Communicable Disease Surveillance Centre, London NW9 5EQ

Catherine Peckham, professor. 

Department of Epidemiology and Public Health, Institute of Child Health, London WC1N 1EH

Footnotes

website extra: A fuller version of the government targets appears on the BMJ's website www.bmj.com

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2.	Duong T, Ades AE, Gibb DM, Tookey PA, Masters J. Verical transmission rates for HIV in the British Isles: estimates based on surveillance data. BMJ 1999; 319: 1227-1229[Abstract/Free Full Text].
3.	Lindegren M, Byers RH, Thomas P, Davis SF, Caldwell B, Rogers R, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999; 282: 531-538[Abstract/Free Full Text].
4.	Communicable Disease Surveillance Centre, Scottish Centre for Infection and Environmental Health, Institute of Child Health (London), Oxford Haemophilia Centre. AIDS and HIV-1 Infection in the United Kingdom: monthly report (HIV infection in pregnant women giving birth in the UKlevels of infection and proportions diagnosed). Comm Dis Report 1999; 9: 45-48.
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8.	Department of Health. Reducing mother to baby transmission of HIV. London: NHS Executive, 1999 (HSC 1999/183).
9.	UK Health Departments. Targets aimed at reducing the number of children born with HIV: report from an expert group. London: Department of Health, 1999.
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11.	Intercollegiate Working Party for Enhancing Voluntary Confidential HIV Testing in Pregnancy. Reducing mother to child transmission of HIV infection in the UK. London: Royal College of Paediatrics and Child Health, 1998.
12.	PHLS HIV Diagnosis Working Group. Towards error free HIV diagnosis: notes on laboratory practice. PHLS Microbiology Digest 1992; 9: 61-64.
13.	Pan-London antenatal HIV testing implementation group. Review of antenatal HIV testing services in London. London: NHS Regional Office, 1999.
14.	Quality management for screening. London: National Screening Committee, 1999.
15.	Simpson WM, Johnstone FF, Goldberg DJ, Gormley SM, Hart GJ. Antenatal HIV testing: assessment of a routine voluntary approach. BMJ 1999; 318: 1660-1661[Free Full Text].