Dear Kevin and others,

I am interested in your reference to the 'huge dilemma' that you say
the policy of offering antenatal HIV testing has given rise to.  I think
it is really important for you to be explicit about what you perceive
the dilemma to be.

It is worth acknowledging the background to the policy.

It needs to be recognised that HIV has a particular significance for
women during pregnancy.  This is because of the risk of mother to
child transmission.  Interventions are available which can
dramatically reduce this risk.  These include at the current time -
and it must always be recognised that this can change over time
with the accumulation of information and knowledge - avoidance of
invasive procedures during pregnancy and labour; caesarean
section; AZT and/or other antiretrovirals during pregnancy, labour
and to the baby after delivery; avoidance of breastfeeding in parts
of the world where there are safe alternatives,  prophylactically
treating potentially infected babies to protect from pnuemocystis
carinii pneumonia.

The fact that some of these are interventions that are counter to
what women and midwives aspire to achieve during childbirth is
regrettable and problematic.  But what makes it problematic is not
testing for HIV, but the fact that this serious infection is liable to be
transmitted to about 20-40% of babies of infected women without
them. (The large range reflects the varying impact of the infection in
relation to women's health conditions, social conditions etc globally).

 The earlier policy in this country was for midwives to offer of HIV
testing to women receiving antenatal care in high prevalence areas
in England - e.g. London.  This policy was not working in the
interests of women with HIV.  About 70% pregnant women who
were infected with HIV  were not able to become aware of their
infection prior to their baby's birth.  Thus, they were denied the
possibility of considering the options currently available to them,
including antiretroviral treatment during pregnancy, which could
have substantially reduced the risk to their baby of acquiring this
lifelong, serious infection. Thus, babies were becoming infected
who need not have been.

The uptake for antenatal HIV testing was consistently very low.
There were probably many reasons for this, including perhaps
midwives not making the availability of the test and its purpose
known to women.  Midwives have been reported, for
understandable reasons, to be reluctant to 'target' women whom
they perceive to be at high=er risk of HIV infection, including African
and other women from parts of the world where the infection is
epidemic. And yet this is what they perceived the policy to require
from them.

There are also women with no obvious increased risk who will not
necessarily be aware that they have been exposed to HIV.

  In addition, HIV was and remains a stigmatised condtion.  Thus, it
is possible that even women who are concerned about their HIV
status might be reluctant to single themselves out to request testing.
 Maternity care contributed to reinforcing stigma by the policy in
many Units of referring women to the GUM clinic if they wished to
have an HIV test.

Given the failure of the previous policy to reduce the transmission of
HIV infection to the babies of infected women, (a situation of
enormous import and distress to the women and families for whom
testing was not offered or provided) the policy of 'normalising' the
availablity of testing as part of antenatal care has been adopted.

The responsibility of midwives is to ensure that antenatal HIV
testing is provided with the highest regard for women's informed
choice in relation to testing.  That demands that midwives have to
receive good training with regard to the issues around offering and
discussing the test, giving women good information, responding to
women's concerns and ensuring appropriate support and care for
women who are HIV positive. It means that women who do not want
to be tested can decline without prejudice.  It also demands the
provision of excellent services and care for women and families
who choose to be tested and discover they are infected with HIV.

But, to avoid providing for pregnant women something which can
have important consequences for  their health awareness, their
health, and that of their baby seems to be a not very constructive
approach to this problem.

I include below a number of references that might be of interest to
the discussion

REFERENCES
Bedford H and Chapple J 1999 Review of antenatal HIV testing
services in London. Department of Public Health, Kensington, Chelsea
& Westminster Health Authority.
Boyd FM et al 1999 Uptake and acceptability of antenatal HIV testing.
British Journal of Midwifery 7(3): 151-156.
Connor EM et al 1994 Reduction of maternal-infant transmission of
human immunodeficiency virus type 1 with zidovudine treatment. New
England Journal of Medicine 331: 1181-1187.
Department of Health 1994 Guidelines for offering named HIV antibody
testing to women receiving ante-natal care. London: Department of
Health.
Department of Health 1999 Reducing mother to baby transmission of
HIV. HSC 1999/183.
Dunn DT et al 1992 Risk of human immunodeficiency virus type 1
transmission through breastfeeding. Lancet 340:585-588.
Gibb DM et al 1998 Factors affecting uptake of antenatal HIV testing in
London: results of a multicentre study. British Medical Journal 316: 259-
261.
Grellier R 2000 'Everyone is scared of it inside so thaty start being a bit
irrational': HIV/AIDS education within midwifery. Midwifery, 16: 56-67.
Levy V 1999 Protective steering: a grounded theory study of the
processes by which midwives facilitate informed choices during
pregnancy. Journal of Advanced Nursing. 29(1):104-112.
Meadows J, Jenkinson S, Catalan J et al 1990 Voluntary HIV testing in
the antenatal clinic: differing uptake rates for individual counselling
midwives.  AIDS Care 4:229-233.
Mercey D 1998 Antenatal HIV testing. British Medical Journal 316:241
NHS Centre for Reviews and Dissemination 1999 Getting evidence into
practice. Effective Health Care 5(1): 1-16.
Rigaud M, Pollack H, Leibovitz E, Kim M, Persaud D, Kaul A et al 1994
Efficacy of primary chemoprophylaxis against PCP during the first year
of life in infants infected with human immunodeficiency virus type 1.
Journal of Pediatrics, 125:476-480.
Sherr L, Bergenstrom A & Hudson C 2000 Consent and antenatal
testing: the limits of choice and issues of consent in HIV & AIDS. AIDS
Care, 12(3): 307-312.
Tookey P, Gibb D, Ades A et al 1998 Performance of antenatal HIV
screening strategies in the UK. Journal of Medical Screening, 5: 133-
136.
Ward C 1999 HIV testing in pregnancy: changing the policy to universal
recommendation. The Practising Midwife 2(2): 14-16.
Carolyn Roth
Lecturer in Midwifery
St Bartholomew School of Nursing & Midwifery
City University
Philpot St
London E1 2EA

Tel. 0171 505 5869