General Practice

General practitioners' attitudes and beliefs on antenatal testing for HIV: postal questionnaire survey

Sally Whittet, general practitioner ^a, Peter Trail, HIV surveillance officer ^b, Annemiek de Ruiter, consultant ^d, Donal O'Sullivan, consultant ^c, Roger Jones, professor ^e. 

^a The Surgery, London SW4 6TB, ^b Lambeth, Southwark, and Lewisham Health Authority, London SE1 7NT, ^c Communicable Disease Control, Lambeth, Southwark, and Lewisham Health Authority, ^d Department of Genitourinary Medicine, Guy's and St Thomas's Hospital Trust, London SE1 7EH, ^e Department of General Practice and Primary Care, Guy's, King's and St Thomas's School of Medicine, London SE11 5SP

Correspondence to: S Whittet binfieldrd.surgery{at}ob.lslha.sthames.nhs.uk

The London boroughs of Lambeth, Southwark, and Lewisham have a population of 737 000, which is served by 427 general practitioners. Data from the unlinked anonymous monitoring programme coordinated by the Public Health Laboratory Service's communicable disease surveillance centre show that in 1998 the prevalence of HIV infection in women attending antenatal clinics in this health authority had risen to 1 in 155.

Transmission from mother to child can be reduced from about 30% to less than 5% through use of antiretroviral therapy, elective caesarean section, and avoiding breast feeding; avoiding breast feeding alone reduces transmission by half.¹ HIV antenatal testing should be recommended routinely in the United Kingdom.² Screening is cost effective and acceptable to women. ^{3 4} Women act on a positive test result and take measures to reduce transmission.⁵

Lambeth, Southwark, and Lewisham health authority promotes testing for HIV infection by midwives as part of routine antenatal testing. General practitioners are involved in antenatal care, and we felt that it was important to assess their beliefs and attitudes towards the test before encouraging their increased involvement.

	Subjects, methods, and results

Top Subjects, methods, and results Comments References

In January 1999 questionnaires were posted to all general practitioners in Lambeth, Southwark, and Lewisham. Questions assessed the subjects' attitudes, knowledge, beliefs, and practice regarding antenatal HIV testing. Non-responders were sent a repeat questionnaire after two weeks. Non-responders were significantly more likely to be older, with a median age of 50 years (interquartile range 40-56), and male (87; 77%). Responders had a median age of 43 (interquartile range 38-51) and 133 (45%) were women.

A total of 303 (71%) responses were received by April 1999. Most respondents (251; 83%) had knowingly cared for patients who were HIV positive. Most (240; 79%) believed that all pregnant women should be offered antenatal HIV tests. Although 256 (84%) believed that general practitioners should discuss the test, both before conception and during pregnancy, only 38 (13%) believed that they always discussed the test antenatally.

A total of 266 (88%) knew that vertical transmission can be reduced. There was confusion about the role of breast feeding: 27 (9%) thought breast feeding should be actively encouraged in women who were HIV positive and 50 (17%) did not know what advice to give about breast feeding. Nearly half (146; 48%) believed that a negative HIV test would adversely affect life insurance.

	Comments

Top Subjects, methods, and results Comments References

Most of these general practitioners recognise the importance of routine antenatal HIV testing and believe they should discuss the test with their patients. However, this is routine clinical practice for only a small minority. An encouraging majority are aware that vertical transmission can be reduced. Of concern is that a considerable proportion seem unaware that HIV positive women who avoid breast feeding help prevent transmission of the virus.

Four months before the distribution of our questionnaire, the directorate of health policy and public health at the health authority had written to all general practitioners emphasising the need for a high uptake of HIV antenatal testing enclosing the joint statement from the Association of British Insurers and the Department of Health, which states that "a negative and routine antenatal HIV test will not affect applications for life insurance." Despite this, almost half the respondents wrongly believed that a negative test will adversely affect insurance, a belief that might discourage uptake if it is conveyed to the patient.

Increased participation by general practitioners is needed, but it must be based on accurate knowledge of means of preventing HIV transmission, such as avoiding breast feeding, and an awareness that a negative HIV test result has no effect on life insurance. Well informed general practitioners can and should play a part in preventing vertical transmission of HIV.

	Acknowledgments

We thank Tim Clayton of the London School of Hygiene and Tropical Medicine, who coded and entered the data.

Contributors: RJ participated in the design of the questionnaire and provided comments on drafts of the paper. AdeR initiated the research project, discussed core ideas, participated in the design of the questionnaires and the interpretation of the results, and contributed to the paper. DO'S initiated the research project, discussed core ideas, participated in the design of the questionnaire, the distribution of the questionnaire, data collection, interpretation of the results, and contributed to the paper. PT discussed core ideas, participated in the design and execution of the study, particularly data collection, data documentation, statistical analysis and interpretation, and contributed to the paper. SW (the guarantor) initiated and coordinated the study, discussed core ideas, participated in the design of the questionnaire and the interpretation of results, and contributed to the paper.

	Footnotes

Competing interests: None declared.

	References

Top Subjects, methods, and results Comments References

1.	Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of human immunodeficiency type 1 virus transmission through breast feeding. Lancet 1992; 340: 385-388.
2.	Department of Health. Reducing mother to baby transmission of HIV. London: NHS Executive, 1999 (HSC 1999/183).
3.	Postma MJ, Beck EJ, Mandalia S, Sherr L, Walters MDS, Houweling H, et al. Universal HIV screening of pregnant women in England: cost effectiveness analysis. BMJ 1999; 318: 1656-1660[Abstract/Free Full Text].
4.	Simpson WM, Johnstone FD, Goldberg DJ, Gormley SM, Hart GJ. Antenatal HIV testing: assessment of a routine voluntary approach. BMJ 1999; 318: 1660-1661[Free Full Text].
5.	Duong T, Ades AE, Gibb DM, Tookey PA, Masters J. Vertical transmission rates for HIV in the British Isles: estimates based on surveillance data. BMJ 1999; 319: 1227-1229[Abstract/Free Full Text].

(Accepted 25 May 2000)