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Cost effectiveness analysis of antenatal HIV screening in United Kingdom

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7219.1230 (Published 06 November 1999) Cite this as: BMJ 1999;319:1230

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Cost effectiveness of antenatal HIV screening

EDITOR-Ades et. al. estimate that universal antenatal HIV screening
outside London is cost effective if the pretest counselling is 2-4
minutes, the cost of the test does not exceed £0.60 and the uptake exceeds
90%.(1) All laboratory staff we approached said a £0.60 HIV test was
impossible, and a 1993 reference in support of this is hardly reassuring.

The recent High Court case brought against an HIV-positive breastfeeding
mother has sent a clear signal that parents will not be given a choice
about whether their
children are treated or not, and the midwife has a duty to inform the
pregnant woman of this in addition to explaining the risks and benefits of
measures to reduce vertical transmission.(2) The leaflet "Better for your
Baby" issued by the Department of Health is of no help here, as it fails
to mention any possible risks of treatment. Perhaps the appropriate
information could be conveyed in a 4 minute tape played at fast speed with
no time for questions but this would hardly be the basis of informed
consent.

Without any intervention 80-85% of HIV positive women will give birth to
an HIV-negative child. All the recommended interventions- abstention from
breastfeeding, caesarean section and antiretroviral therapy- will increase
the non-HIV related morbidity and mortality of both HIV-negative and HIV-
positive children. Research by the US National Cancer Institute has
demonstrated tumorigenicity and genotoxicity in animals and genotoxicity
and mitochondrial damage in humans exposed to Zidovudine, and scientists
have warned of a possible increased risk of developing cancer.(3,4) The
mitochondrial cytopathy mentioned by Ades et al normally affects less than
one in 10,000 children but has caused the deaths of 1% of HIV-negative
infants in France who had received combination antiretroviral therapy.

Only long term studies of the morbidity and mortality of children whose
mothers
had the recommended interventions compared with those who did not will
establish whether the clinical benefits outweigh the risks.(5) The rush to
treat, enforced by law on unwilling parents if necessary, will ensure that
we will never know.
Without any screening/intervention an average health district outside
London with 3,000 deliveries a year will see an HIV positive child every
12 years. Many will argue rationally that there are far more cost
effective
ways to save children's lives. All health professionals should consider
these issues carefully before agreeing to implement a screening programme
based on the dubious evidence so far presented.

Rosalind Harrison FRCOphth, DO, DTM&H

consultant ophthalmologist

Queens Hospital,
Belvedere Road,
Burton-on-Trent,
Staffs. DE13 0RB

Kevin Corbett RGN PGCE BA MSc

reproductive/sexual health practitioner

Community Health South London NHS Trust
St Giles Hospital London SE5

We declare we have no competing interests.

REFERENCES
(1) Ades AE, Sculpher MJ, Gibb DM, Gupta R, Ratcliffe J. A cost
effectiveness analysis of anternatal HIV testing in the UK. BMJ 1999; 319:
1230-4.

(2) Rosser J. Editorial, The Practising Midwife 1999; 2 (9): 4-5.

(3) Olivero OA, Anderson LM, Diwan BA, Haines DC, Harbaugh SW,
Moskal TJ, Jones AB, Rice JM, Riggs CW, Logsdon D, Yuspa SH, Poirier MC.
Transplacental effects of 3'-azido-2'3'-dideoxythymidine (AZT):
tumorigenicity in mice and genotoxicity in mice and monkeys. Journal of
the
National Cancer Institute 1997; 89(21):1602-8.

(4) Agarwal RP, Olivero OA. Genotoxicity and mitochondrial damage
in human lymphocytic cells chronically exposed to 3'-azido-2',3'-
dideoxythymidine. Mutation Research 1997; 390(3):223-31.

(5) Harrison R, Corbett K. Screening of pregnant women for HIV:
the case against. The Practising Midwife 1999; 2 (7): 24-9.

Correspondence to:

Miss R Harrison
consultant ophthalmologist
Queens Hospital
Belvedere Road
Burton-on-Trent
Staffs. DE13 0RB

Competing interests: No competing interests

16 November 1999
Rosalind Harrison