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Ethics and costs of antenatal HIV screening.
- M F Brewster (24 June 1999)
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Screening for HIV in antenatal clinics fulfils criteria
- Elizabeth Foley (9 July 1999)
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Cost effectiveness of repeat offer of HIV testing to pregnant women in London
- M Postma (18 February 2000)
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M F Brewster, Retired general practitioner Wigtown, Wigtownshire.
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In the BMJ, Vol. 318, dated 19th June 1999, two papers on HIV screening in pregnancy pose some difficult questions which need urgent address. Are expectant mothers, “informed” after counselling, competent to take decisions on behalf of unborn children? Should mothers be permitted to opt out of the suggested HIV testing of blood taken routinely at antenatal clinic visits? The unborn foetus cannot express its opinion, but those born with congenital HIV will wish later that their mothers had been screened . Pasta et al. have demonstrated that universal voluntary HIV screening of pregnant women would be cost effective in high prevalence areas like London, but their paper does not debate other important financial considerations. 1. If universal routine named antenatal HIV testing were introduced, anonymous postnatal testing for statistical purposes could cease. If test costs are similar, a single named antenatal test would, without extra costs, provide the opportunity to eliminate congenital HIV-infected infants while continuing the statistical surveillance. 2. Since early HIV diagnosis and treatment postpones the onset of AIDS and can lower the annual death risk to 1.3%, (Minerva 13th March 1999, BMJ;318:688), cost savings will also accrue via newly-identified and treated infected partners who, thus remaining fit for work, may financially support mothers and children for an extended period. 3. The end of persuasive pretest counselling (on average, 7 minutes 40 seconds per patient is the time stated in the 1998 BMJ Simpson report noted below) would free large amounts of midwife time. Simpson et al. have demonstrated that, in Edinburgh, a routine voluntary approach to antenatal HIV screening improved the uptake rate from the 35% described in their previous 1996-7 survey (BMJ 1998;316:262- 7) to their 1998 figure of 88%. Why does the UK achieves such poor figures for antenatal HIV testing, when France and Sweden can achieve voluntary antenatal HIV testing rates of 99%? Several states in the USA achieve more than 90% voluntary testing rates. The UK has been said to achieve 44% voluntary screening, with the highest clinic-district figures in London, a high HIV area, being only 62%. Two further questions are posed. 1. With such low UK voluntary HIV testing figures, is there something in current UK counselling, which causes people anxiety and fear, or are the benefits of early HIV diagnosis not being properly emphasised? 2. Anonymous testing may be necessary for public health planning, but is it ethically and morally right to spend money on clinically useless postnatal testing, when routine named antenatal testing could provide the same figures and save lives? |
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Elizabeth Foley
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Dear Editor The recent papers by Postma et al and Simpson et al (1,2) highlight the difficult issues in establishing a policy to test for HIV infection in antenatal clinics. Postma et al's paper examines the cost effectiveness of universal, voluntary testing of pregnant women in England in terms of healthcare costs to the NHS. Although no cut off point at which the cost for each life year gained becomes acceptable has been defined for England, a cut off point of around $US 50 000 is suggested in the United States. They conclude that in areas of high prevalence, such as London, universal, voluntary antenatal screening of pregnant women is cost effective, however in areas of low prevalence screening may not be justified in terms of cost effectiveness. Screening for HIV infection in antenatal clinics fulfils most of Wilson and Junger's criteria as a good test(3). HIV infection can be asymptomatic, the tests are simple, relatively pain free, sensitive and specific, and there is effective treatment which can substantially reduce the risk of infection in the fetus, yet universal testing is not performed in most antenatal clinics. This contrasts with the ad hoc way in which universal screening tests for Down's syndrome have been introduced in most antenatal clinics. None of the individual tests currently available fulfil many of Wilson and Junger's criteria. Tests, which are of low risk to the fetus, are not very sensitive nor specific. In spite of their unproven record, tests are variously available, sometimes with the patient bearing the cost of testing. There is stigma surrounding HIV testing, an opt-in policy only serves to reinforce this by testing only those in obvious high risk groups. In low prevalence areas, where there are not large numbers 'high risk' women, those with HIV infection may been even harder to detect from a screening questionnaire as they mingle in with the rest of the population. In Portsmouth, a third of our HIV positive patients do not fall in to any recognised 'high risk' group. Simpson et al's paper show that for an effective screening programme to be instigated, an opt-out policy of testing is the only model which is effective in ante-natal screening; the uptake of the test increased to 88% compared with a 35% uptake with an opt-in policy. Not only should this policy be adopted for areas of high prevalence of HIV testing, but also for areas where the prevalence of HIV infection is low, so that the opportunity to reduce infection in the neonate and treat the asymptomatic mother is not missed. References 1 Universal HIV screening of pregnant women in England: cost effectiveness analysis. Postma MJ, Beck EJ, Mandalia S, Sherr L, Walters MDS, Houweling H, Jager JC. BMJ 1999; 318:1656-60. 2 Antenatal HIV testing: assessment of a routine voluntary approach. Simpson WM, Johnstone FD, Goldberg DJ, Gormley SM, Hart GJ. BMJ 1999; 318: 1660-1. 3 Wilson JMG, Junger JJ. Principles and practice of screening for disease. WHO Public Health Paper. Geneva: WHO, 1968:34. Dr Elizabeth Foley Specialist Registrar Dr V Harindra Consultant Department of Genito-urinary Medicine St Mary's Hospital Portsmouth Hampshire PO3 6AD |
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M Postma
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EDITOR - Recently the Department of Health announced the introduction of voluntary universal antenatal HIV screening in England.1 We described cost effectiveness previously, using pharmacoeconomic modeling.2 The model did not account for women becoming infected with HIV later in pregnancy after being found HIV-negative in early pregnancy. In a recent study3 28% of infants infected through mother-to-child transmission (MTCT) were born to mothers who were HIV-negative in early pregnancy. These MTCTs can be averted by repeat HIV testing in late pregnancy. Here, we report on cost effectiveness of repeat offer of HIV testing to pregnant in London. Assumptions in the model remained unchanged from our original model.2 We extended the model with universal repeat offer of testing to all pregnant women in London or selective repeat offer to pregnant women recognized to be at higher risk of HIV infection.4 The latter includes women who are injecting drug users, are from areas of the world with high HIV incidence or prevalence, have recently contracted another sexually transmitted disease or have partners with these characteristics. We expressed incremental cost effectiveness (ICE) as net costs per life-year gained. ICE was based on comparing universal HIV screening with and without repeat testing. Threshold values for counseling-and-testing costs (C&T-costs) were calculated for ICE below £10 000 and for costsaving situations. The cut-off point for ICE has not yet been defined for England, but £10 000 might be considered an acceptable cut-off point. We estimated that approximately 5 MTCTs occur in London annually in late pregnancy, with over 50% coming from mothers at higher risk for HIV infection.3,5 If at least one MTCT is averted, selective repeat testing is cost saving for C&T-costs below £10 and ICE is below £10 000 for C&T-costs below £20. Previously, we estimated C&T-costs in the range of £4-40.1 As repeat testing may not require further intensive counseling and economies-of-scale apply within the framework of universal screening, the lower part of this range is relevant. For C&T-costs of £4, universal repeat offer requires at least 2 MTCTs averted for an ICE below £10 000 and at least 3 MTCTs averted for cost saving (see Table). This pharmacoeconomic analysis indicates costsaving potentials for selective repeat offer of HIV testing to pregnant women at increased risk in London. Favorable cost-effectiveness of universal repeat offer of HIV testing depends on the exact levels of counseling-and-testing costs and mother-to-child transmissions averted. MJ Postma EJ Beck CA Hankins S Mandalia JC Jager LTW de Jong-van den Berg MDS Walters L Sherr 1. Department of Health. Reducing mother to baby transmission of HIV. London: Stationery Office 1999. (Health service circular 1999/183.) 2. Postma MJ, Beck EJ, Mandalia S et al. Universal HIV screening of pregnant women in England: cost effectiveness analysis. BMJ 1999; 318:1656 -60. 3. Duval M, Faye A, Rohrlich P et al. Failure of Pediatric AIDS Prevention Despite Maternal HIV Screening in Paris, France. J AIDS & Human Retrovirology 1999; 20:100-1. 4. Ades AE, Gupta R, Gibb DM et al. Selective versus universal antenatal HIV testing: epidemiological and implementational factors in policy choice. AIDS 1999; 13:271-8. 5. Public Health Laboratory Service. HIV infection in pregnant women giving birth in the UK - levels of infection and proportions diagnosed. Comm Dis Report 1999; 9:46-8. Table: Threshold counseling-and-testing costs (C&T-costs) for universal offer of HIV testing for different numbers of mother-to-child transmissions (MTCTs) averted per year: maximum C&T-costs for cost-saving maximum C&T-costs for ICE below £10 000 per life-year gained.
threshold C&T-costs for
MTCTs averted cost-saving ICE < £10 000
1 £1.62 £2.95
2 £3.23 £5.90
3 £4.85 £8.85
4 £6.47 £11.80
5 £8.08 £14.75
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