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LETTERS: Babatunde A Gbolade, K H Tan, K P Teo, Ben Essex, Mary A Waldron, Elizabeth Foley, V Harindra, Meg Goodman, Adeola Olaitan, Sara Madge, Melvyn Jones, Margaret Johnson, Fabio Parazzini, Elena Ricci, Paola Grasso, Matteo Surace, Guido Benzi, and Paquita de Zulueta Reducing the vertical transmission of HIV BMJ 1998; 316: 1899 [Full text]

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Doubtful logic

Andrew Dunford   (29 June 1998)

But primary care staff are apathetic..

Andrew Dunford   (29 June 1998)

Doubtful logic 29 June 1998
Andrew Dunford, Lecturer in HIV Liaison Medicine Queen Mary & Westfield College, London Send response to journal: Re: Doubtful logic	I find this article rather patronising, and reminding me of discussions in the '80s about Depo-Provera for retarded girls. While absolutely on the side of increasing levels of HIV-testing across the board, and 'normalising'it during antenatal booking, I think the logic of this argument from Leeds somewhat poorly thought through. First, picking up the diagnosis in the antenatal clinic during a subsequent pregnancy would almost certainly happen well before the third trimester. It is now policy in most areas not to start therapeutic intervention with - say - AZT until this time anyway. This is for reasons of safety to the foetus, increased drug-resistance with longer courses of medication (1), and the time of most likely vertical transmission (2). So it would not be 'too late to begin measures to prevent vertical transmission'. Second, the idea that 'a young woman who tests positive for HIV for at the time of requesting an abortion will be more likely to choose not to get pregnant again...'all sounds rather triumphalist - yet another risky woman prevented from getting pregnant again! Yet do we still really hope that diabetic women will decide against pregnancy? Or women with a family history of twins? Rather, we explain the options to the woman, and if she wishes to conceive, plan for the best outcome. Please let us remember that, with appropriate risk-reduction, the likelihood of her transmitting her HIV is considerably less than 5%, reducing all the time, and lower if she becomes pregnant earlier rather than later in the course of her HIV disease. Third, there has been a lot of debate about whether normalising antenatal HIV testing is yet one more burden for a woman to bear during an emotionally traumatic time: that this is a form of discriminatory 'targetting'. How much more traumatic for a 'young woman...requesting an abortion' then to be told that 'apart from losing your baby, we also have to say that you are HIV positive'. And then to add 'and we hope that this would make you consider whether you really want to get pregnant again'? Refs: 1. McIntosh K. Antiretroviral resistance and HIV vertical transmission. Acta Paediatr. Suppl.1997;421:29-32 2. Fowler MG. Update: transmission of HIV-1 from mother to child. [Review] [33refs]. Curr Opin Obstet Gynecol 1997; 9(6):343-8
But primary care staff are apathetic.. 29 June 1998
Andrew Dunford, Lecturer in HIV Liaison Medicine Queen Mary & Westfield College, London Send response to journal: Re: But primary care staff are apathetic..	I applaud Mary Waldron's exhortation for 'more HIV training...for primary care staff' but suspect that this is more complex than simply increasing appropriate training provision. For those of us charged with this responsibility, the apathy with which primary care staff greet such provision is heart-rending. And yet 'apathy' is perhaps not the right word. Lamentable short-sightedness on the part of GPs in not allowing their precious practice nurses to attend further professional training is well known, and doesn't seem to be amenable to the provision of financial incentives or locum cover. Most GPs asked about HIV will reply that they 'don't have any patients with HIV on their lists' and consequently don't attach much priority to further training in it, especially with competition from training in much more prevalent conditions that GPs do have to deal with. The patients then vote with their feet by attending their all-singing, all-dancing hospital HIV clinics, where their HIV physicians continue - with the best philanthropy available - to cater for all their health care needs, primary and secondary. In fact, with around 15,000 patients registered with HIV living in the North Thames Region, which in turn employs around 3,500 GP principals (not to mention the non-principals who make up a fifth of the GP workforce), we should expect each GP to have four such patients. When you then take into consideration the likely concentration of patients into apparently less-discriminatory or more modern practices, this number will rise again. Then again, there are the estimated 30 - 50% of patients with HIV who don't yet know it, waiting to develop potentially preventable AIDS-defining conditions because they and their GPs don't know how to - or don't want to - talk about their risk behaviour... By all means let's ensure appropriate and accessible HIV training for all primary care staff, but let's also be aware that there are plenty of other and apparently more important calls on their time. Until the general climate in the Health Service changes to one of wanting and needing them to be more involved, they won't be.