Antenatal HIV testing: current problems, future solutions. survey of uptake in one London hospitalBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7127.270 (Published 24 January 1998) Cite this as: BMJ 1998;316:270
- Teresa A Duffy, research midwifea,
- Charles D A Wolfe, senior lecturerb,
- Claire Varden, assistant statisticianb,
- Jane Kennedy, midwife counsellorb,
- Jane Kennedy, midwife counsellora,
- Ian L Chrystie, lecturerc,
- Jangu E Banatvala, professor of clinical virologyc
- a Department of Midwifery, Guy's and St Thomas's NHS Trust, St Thomas's Hospital, London SE1 7EH
- b Public Health Medicine, United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SE1 7EH
- Department of Virology, United Medical and Dental Schools of Guy's and St Thomas's Hospitals, London SE1 7EH
- Correspondence to: Professor Banatvala
- Accepted 10 December 1997
Pregnant women attending Guy's and St Thomas's Hospitals Trust have one of the highest prevalence rates for HIV-1 in inner London (0.53% in 1996).1 In 1992 we showed that this was associated with African ethnic origin.2 However, despite the Department of Health's recommendations that named HIV testing be made available to all pregnant women in areas of relatively high prevalence, uptake in our trust is disappointingly low—about 30%—as elsewhere in inner London. In 1995, throughout London, only 26 of 205 (13%) HIV positive pregnant women had been identified antenatally.3 Most were therefore almost certainly unable to benefit from recent advances in treatment and in the prevention of mother to child transmission of HIV.
Subjects, methods, and results
This paper describes uptake of HIV testing among pregnant women between 1991 and 1996 and includes a detailed survey of 789 women, of whom 428 attended antenatal clinics at Guy's Hospital, 310 attended six community clinics, and 51 attended a midwifery group practice between 5 March and 20 December 1996. Of the antenatal population, 50% were white, 24% were black African, and 13% were black Caribbean. Before booking, women were sent a locally produced leaflet about HIV. At booking, midwives—49 of 51 (96%) of whom had had specific training about HIV—initiated a pretest discussion, and before and after booking women were invited to complete questionnaires relating to attitudes towards HIV testing.
Although 35% of 789 women accepted the offer of an HIV test, over a third of those who had intended to be tested changed their mind during the booking interview; only a few of those not intending to be tested did so (1). Multivariate analysis showed that being non-white was a significant predictor of uptake (P=0.044) and that uptake was higher in the hospital based clinic (41%) than in the community clinic (30%) or midwifery group practice (10%) (P=0.0001).
Since the start of antenatal HIV testing in 1985, uptake at St Thomas's Hospital has risen from 5% to about 30%. In 1992-4, of those identified on a named basis, 14/18 (78%) were identified via the genitourinary medicine clinic; in 1995-6, 19 of 32 (65%) were identified in antenatal clinics.
Although our results may seem disappointing in terms of uptake, the value of midwifery staff trained in HIV is emphasised by differences in HIV detection rates between Guy's and St Thomas's Hospitals before their unification in 1995. Between 1991 and 1995, Guy's, which had no midwifery staff trained in HIV, failed to identify any of the HIV positive pregnant women identified by the Public Health Laboratory Service's unlinked anonymous survey; at St Thomas's, however, which had an HIV specialist midwife counsellor and trained staff, 39 of 105 (37%) were identified.
Merely achieving higher uptake rates may not increase the proportion of women positive for HIV-1 identified, as many may decline testing. Indeed, in the past 8 months, we know of three pregnant women who knew they were HIV positive at booking but declined testing without divulging their serostatus.
Britain is lagging behind other European countries and some American states in detecting HIV positive pregnant women.4 Furthermore, even in locations such as ours, where current Department of Health recommendations are being implemented, uptake is disappointingly low. As a matter of urgency, multidisciplinary research needs to be directed towards discovering why pregnant women seem to feel that the social consequences of being identified as HIV positive outweigh the advantages of high quality management for mother and baby. In the meantime the Department of Health should strongly support the recommendations of the Intercollegiate Working Party for Enhancing Voluntary Confidential HIV Testing in Pregnancy, and consideration should be given to implementing an opt-out approach to HIV testing, as approved by the working party of the Institute of Medical Ethics in 1990.5
We thank colleagues involved in the European study on antenatal HIV testing—policies and procedures (EU grant SOC 95200587 05F202) for their help.
Funding: Lambeth, Southwark, and Lewisham Health Authority.
Conflict of interest: None.
Contributors: Each of the authors has been involved in the ongoing investigations of antenatal HIV testing at Guy's and St Thomas' Trust and participated in the design of the 1996 uptake study. TAD with the assistance of JK carried out that study, with statistical analysis being coordinated by CV and CDAW. ILC and JEB collated and analysed the 1991–6 uptake data. The paper was written jointly by ILC and JEB with input from the other authors.