Pregnant women should routinely be offered HIV testsBMJ 1998; 316 doi: http://dx.doi.org/10.1136/bmj.316.7141.1333 (Published 02 May 1998) Cite this as: BMJ 1998;316:1333
All pregnant women in the United Kingdom should have access to testing for HIV infection as part of routine antenatal care in a major effort to reduce the risk of vertical transmission.
This recommendation, from an intercollegiate working party, is based on the growing recognition that many women do not realise that they are HIV positive until their babies are diagnosed with AIDS related illnesses. The working party was set up last year after research showed that more than seven in 10 pregnant women who were HIV positive did not know they were infected with the virus. The chairman, Dr Graham Davies, consultant paediatric immunologist at Great Ormond Street Hospital, said, “This means that babies are born with vertically acquired HIV infection, which may be preventable if mothers are tested early in pregnancy and steps taken to reduce the risk of infection being passed on to their babies.”
The problem is growing, and now one in 520 babies in London are born to women who are infected with HIV. The Department of Health recommended in 1992 that HIV testing should be offered to pregnant women in areas of high seroprevalence. The working party investigated why current testing is inadequate and why measures are needed to reduce the maternal transmission of HIV. “We concluded that the case for HIV testing early in pregnancy is now so strong that it should be made obligatory for all pregnant women to be given information about HIV transmission and offered testing if they wish,” Dr Davies said.
Anonymous testing currently monitors levels of HIV infection in pregnant women, but this does not allow identification of women for treatment during pregnancy. Dr Danielle Mercey, fellow member of the working party and senior lecturer at University College London Medical School, wrote in a recent editorial in the BMJ (1998;316:241-2): “It is shameful and negligent that we have counted the numbers of babies at risk of infection since 1990 without acting to reduce their risk.” Research published in the same issue showed that antenatal detection rates are currently only 7% and are showing no improvements.
Part of standard care
The working party recommends that HIV testing—carried out with a woman's fully informed consent—should be offered at the same time as other tests carried out routinely in antenatal care. Dr Davies explained: “We hope it will become an ordinary part of standard antenatal care, just as women are currently tested for hepatitis B, syphilis, and rubella.” This would mean performing tests at antenatal booking clinics, usually at around eight to 14 weeks of pregnancy in most cases. Blood for HIV testing would be taken at the same time as checking for other conditions. Many centres may have to change their arrangements for HIV testing if they currently require patients to attend genitourinary departments for the tests. The report recommends that appropriate counselling should be offered to women who test positive for HIV but considers it impractical to offer full pretest counselling to all women.
Detecting HIV early in pregnancy should achieve a major reduction in maternal transmission of the virus. Research has shown that it is possible to reduce transmission by about two thirds with new drug combinations if these are given throughout pregnancy. Delivery by caesarean section and advising mothers who are HIV positive not to breast feed further reduces transmission. It has been estimated that optimal management could reduce the number of infected babies in London each year from 40 to 13. Dr Davies considers that this level of benefit justifies allocating resources to giving women access to HIV testing as part of routine antenatal care. “The cost effectiveness of greater HIV testing in pregnancy will depend on the seroprevalence in different areas. But from a human point of view, efforts to save any baby from developing HIV infection are worth while,” he concluded.
Reducing Mother to Child Transmission of HIV Infection in the United Kingdom. Recommendations of an Intercollegiate Working Party for Enhancing Voluntary Confidential HIV Testing in Pregnancy is available from the Royal College of Paediatrics and Child Health, 50 Hallam Street, London W1N 6DE.
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