----- Original Message -----
From: "Sarah Davies" <[log in to unmask]>
To: <[log in to unmask]>
Sent: 24 November 2000 10:21
Subject: HIV statement


Dear Ishbel
Here is a statement that came out of a midwives' conference we held here at
Salford. Please feel free to circulate it among as many midwives as
possible; we would value any comments/thoughts.

Final statement on the implementation of routine voluntary antenatal
screening for HIV in the UK from HIV Antenatal Screening: Examining the
Evidence Conference held at University of Salford, UK, 12th October 2000.

The statement will be distributed to: DoH Expert Advisory Group on AIDS;
RCM; Association of Radical Midwives; AIMS; NCT; other maternity consumer
organisations; RCN Midwifery Society; Breastfeeding organisations; Child and
Maternal Health Section of DoH; Unison; PHLS; North West Local Supervising
Authority; Heads of Midwifery; Midwifery Educationalists; RCOG;
Parliamentary working group on HIV and AIDS; Appropriate Journals including
BMJ; Relevant Voluntary Sector HIV and Reproductive Health Agencies;
A range of internet based information networks; Press Release

Background
This statement was compiled following the conference HIV antenatal
screening: examining the evidence which took place at the University of
Salford on 12.10.00. The conference was attended by approximately 100
people; the majority being practising midwives from different areas within
the North West Region. They were joined by statutory health policy
personnel, academically based researchers and representatives of the
voluntary sector. The conference was convened in response to the groundswell
of concern amongst midwives about their roles in the implementation of
current government directives that relate to routine antenatal screening for
HIV antibodies. In its final session, the conference produced a set of
priority areas that require further exploration and/or action. This was
written up as a draft conference statement and sent to all attendees for
comments, which were then incorporated into this final statement.

The Statement

1. Targets. In areas of low uptake, the DoH has stated that midwives should
be aiming for the target of 50% uptake of HIV antenatal screening by
December 2000. This is to be increased to 90% by December 2002. The
conference does not accept that it is possible to achieve either of these
targets within a framework of routine voluntary testing for HIV. Within the
North West region, a large number of practising midwives have yet to begin
to offer the test. Thus, the meeting of a 50% target within two months and a
90% uptake rate within 2 years would preclude women from making fully
informed decisions and in practice might indeed amount to coercion. This
applies particularly to women for whom English is not the first language, as
relevant information in many areas is not yet available in any other
language than English. This is likely to exclude a number of women from
equal access to the information that is available.

2. Quality of care. On the basis of the current evidence, screening in low
prevalence areas is not cost effective. Targets for uptake have been
introduced in an effort to maximise cost effectiveness. Within the policy
framework of clinical governance, Trusts are using targets as a marker to
demonstrate their quality of care achievement levels. However, this
imperative results, in practice, in midwives experiencing pressure to
achieve the targets.

3. The HIV antibody test. Various aspects of the technology of HIV testing
and their current application to blood samples derived from those who are
perceived to be at risk give cause for concern. Several test manufacturers
state that the enzyme linked immunosorbent assay (ELISA) has limitations and
may give false positive results for a variety of reasons e.g. prior
pregnancy. In the case of the polymerase chain reaction (PCR), manufacturers
warn that their test package should not be used to diagnose HIV infection,
yet this is the test most commonly used to detect HIV in neonates.
Furthermore, several test manufacturers state that there is no "gold
standard" for the isolation of HIV. Therefore this may indicate that
false-positive and false-negative results are inevitable. The conference
calls for an open dialogue with the UK Public Health Laboratory Service in
order to raise these issues and to seek further clarification.

4. Interventions
4.1. Clinical
In the light of contradictory evidence about the risks and benefits
associated with elective caesarean section, breastfeeding and antiretroviral
therapies, the conference calls upon the RCM to:
Review their advice to midwives and also clarify what support is available
from the RCM for any midwife supporting a woman who has chosen not to accept
one or more of the three proposed interventions (antiretroviral therapies,
caesarean section delivery, cessation of breastfeeding)
Re-emphasise the importance of professionals respecting women's cultural
background and personal beliefs when discussing decisions around the three
treatment interventions
Reconsider how the cascade of interventions (which may follow a positive
test result) could undermine the ethos of choice and control established
through Changing Childbirth.
Withdraw their support for the DOH targets that are inappropriate at this
time and potentially damaging to the relationship between mother and midwife
Oppose all attempts to legitimise state intervention between women and their
new-born babies on the basis of perception of HIV risk

4.2. Social
The conference was informed of the confusion that exists at the highest of
levels within the social service system about how midwives should respond in
the situation where one of their mothers has an HIV positive diagnosis and
is breastfeeding. It was advised that a court order has been applied to
prohibit a Somali woman living in this country from breastfeeding; this
raises the issue of confidentiality between midwife and mother. The
conference calls upon the RCM and the Local Supervising Authorities to take
up this issue directly with the Department of Social Security.

4.3. Criminalisation of wilful transmission
The conference rejects all attempts to make it possible for any mothers or
their babies to be prosecuted for having transmitted HIV. Were this to
become law, the women and babies found to have an HIV positive diagnosis
through this screening would become vulnerable to miscarriages of justice.


5. Professional Issues
In many instances midwives are being expected to implement HIV antibody
screening without having undertaken adequate training/preparation and,
thereafter, having severe time constraints imposed upon the pre-test
discussion. This results in midwives not having enough time to ensure fully
informed decision making on the part of their clients. In the areas where
this is happening, midwives' experience is that they are not able to fulfil
their professional obligations as laid out in the Midwife's Code of
Practice. Furthermore, the government directive that midwives should
recommend the test violates a fundamental tenet of the midwife-mother
relationship; the mother should be free to make an informed choice following
a neutrally framed opportunity to appraise herself of all relevant
information.


Conference Organisers: Sarah Davies & Rhetta Moran, University of Salford,
Nov 2000
Contacts: [log in to unmask]; [log in to unmask]





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