For a variety of reasons, HIV antenatal testing has been a political issue which has divided professionals. One reason that feelings have run high on this issue has been that for many people, the urge to target pregnant women has been seen as a tool to prevent babies becoming infected. There has been little attempt to prevent transmission of HIV to women. In addition there have been few initiatives to target heterosexual men.

Research suggests that where women know their HIV status during pregnancy, counselling about the risks of vertical transmission results in a high uptake of antiretroviral therapy. 81% of mothers were of African origin. 69% of mothers took antiretroviral therapy, with a transmission rate of 8% amongst this group, compared to a transmission rate of 22% amongst mothers who did not take antiretroviral drugs (Lyall).

Debate about how the test should be offered has been influenced by a randomised study in Edinburgh, where four different methods were compared. 3,024 pregnant women attending Edinburgh maternity clinics during 1996 were randomised either to:

• No pro–active offer of testing; the only information provided was a poster in clinic waiting areas.
• Provision of an HIV–specific leaflet describing the potential benefits of detection and treatment during pregnancy followed by an explicit offer of the test from a midwife.
• Provision of a blood tests leaflet which included a discussion of HIV testing followed by the explicit offer of a test from a midwife.

The two active intervention groups were further randomised to one of two forms of discussion:

• Detailed discussion with a midwife which recapped the information in the HIV specific leaflet.
• Minimal discussion to check that the leaflet had been understood.

There was a significant difference between the control group and the intervention groups in terms of uptake. However, other factors not directly connected with the study design were also significant. The uptake rates for testing varied between midwives irrespective of the intervention to which the patient had been assigned, suggesting that midwives' own attitudes towards offering the test affected the response of patients. It was also found that routine testing did not provoke any more anxiety amongst pregnant women than other routine blood tests offered during pregnancy. The authors of this study recommended that routine testing should be normalised (Simpson).

In 1998, the Department of Health endorsed an Intercollegiate Working Party Document which urged that pregnant women in areas of high HIV prevalence be offered and recommended to have an HIV test. This is part of an initiative to normalise the HIV test as one of many tests women are routinely offered antenatally. Whilst it will still be important for a woman to consent specifically to the test, it will be recommended in the same way as routine syphilis, rubella and hepatitis B tests.

This practice was extended to the whole of the UK by the Department of Health in August 1999.

It remains the case that some HIV infected pregnant women do not know, or do not disclose, their HIV status. One problem in offering this test is that many women feel HIV is not an issue for them. They believe HIV to be a gay issue despite the fact that the figures for heterosexual women continue to rise, particularly in the sub–Saharan African population who are mainly living in London.

On the other hand some women accept all antenatal tests believing they are of benefit to their baby and are totally unprepared for the impact of a positive result. It is vitally important that where HIV testing is to be routinely offered and recommended that midwives and other health care workers are prepared and adequately trained. Acceptability of the test depends on the manner in which it is offered. The follow-up care of women found to be HIV–positive, and their families, must also be adequately funded both from treatment and psychosocial points of view.

Whilst HIV continues to incur stigma and discrimination, there will be a disincentive to HIV testing. Any attempts to normalise HIV antenatal testing must recognise this and strong measures to combat prejudice must accompany such efforts. Whilst testing is always a diagnostic tool, individual rights to treatment and risk reduction strategies may be compromised if we do not constantly reassess the value of HIV testing.

References

D Gibb et al. Factors affecting uptake of antenatal HIV testing in London: results of a multicentre study. BMJ 316: 259–261, 1998.

EGH Lyall et al. Review of an uptake of interventions to reduce mother to child transmission of HIV by women aware of their HIV status. BMJ 316: 268–270, 1998.

W Simpson et al. Uptake and acceptability of antenatal HIV testing: randomised controlled trial of different methods of offering the test. BMJ 316: 262–267, 1998.