Prenatal HIV screening in a tertiary care centre

High uptake of HIV testing in pregnant women in Ontario, Canada

In 1999, Ontario implemented a policy to offer HIV counseling and testing to all pregnant women and undertook measures to increase HIV testing. We evaluated the effectiveness of the new policy by examining HIV test uptake, the number of HIV-infected women identified and, in 2002, the HIV rate in women not tested during prenatal care. We analyzed test uptake among women receiving prenatal care from 1999 to 2010. We examined HIV test uptake and HIV rate by year, age and health region. In an anonymous, unlinked study, we determined the HIV rate in pregnant women not tested. Prenatal HIV test uptake in Ontario increased dramatically, from 33% in the first quarter of 1999 to 96% in 2010. Test uptake was highest in younger women but increased in all age groups. All health regions improved and experienced similar test uptake in recent years. The HIV rate among pregnant women tested in 2010 was 0.13/1,000; in Toronto, the rate was 0.28 per 1,000. In the 2002 unlinked study, the HIV rate was 0.62/1,000 among women not tested in pregnancy compared to 0.31/1,000 among tested women. HIV incidence among women who tested more than once was 0.05/1,000 person-years. In response to the new policy in Ontario, prenatal HIV testing uptake improved dramatically among women in all age groups and health regions. A reminder to physicians who had not ordered a prenatal HIV test appeared to be very effective. In 2002, the HIV rate in women who were not tested was twice that of tested women: though 77% of pregnant women had been tested, only 63% of HIV-infected women were tested. HIV testing uptake was estimated at 98% in 2010.

What are the barriers to offering HIV testing in an antenatal setting? A national study of obstetricians

OBJECTIVE

To investigate factors that influence the antenatal screening practice of obstetricians and identify barriers to the implementation of universal antenatal HIV screening.

DESIGN

A survey of all obstetricians registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

METHODS

A questionnaire was mailed to all obstetricians in Australia, followed by two reminders.

RESULTS

The overall response rate was 70% (817/1172) and of these 70% always offered an HIV test during pregnancy. Obstetricians offering the test were more likely to female or younger in age. Of respondents who always offered testing, 90% disagreed with only testing women with risk factors compared with only 34% of those who undertook a selective screening approach (adjusted odds ratio, 87.7; 95% confidence interval, 40-192; P = 0.001). Obstetricians who practiced selective screening were influenced by whether the woman had antenatal blood tests prior to her obstetric appointment or a previous negative HIV test. Obstetricians who practiced universal screening were more likely to be concerned about false-positive results. Many obstetricians, irrespective of their screening practice, agreed that many of the components of pretest counseling were inappropriate for the majority of women.

CONCLUSIONS

A majority of obstetricians in Australia are offering all pregnant women an HIV test. Consideration should be given to tailoring pretest counseling requirements to the antenatal setting. Ongoing education regarding the limitations of selective screening and management of women with false-positive results is also highlighted by this study.

Mother-to-child transmission of HIV in Canada: a population health risk management perspective

The standard of prenatal care in Canada for preventing transmission of the human immunodeficiency virus (HIV) from mother to infant is universal counselling and voluntary testing of pregnant women for the virus. Appropriate treatment of HIV-positive women reduces the risk of viral transmission to the infant to less than 1%. Despite this, too many children in Canada are born with HIV because their mothers were not tested. The barriers to screening include lack of appropriate resources and lack of training in this area. As a result, physicians find HIV test-counselling too time-consuming or believe that testing is not relevant to their patient population. Risk management strategies to improve screening rates and decrease transmission, including community action and technological strategies such as vaccines and rapid testing kits, are reviewed. The "advisory" option, the process of risk communication between health-care providers, the government, and the public, for the purpose of making recommendations, is a key component toward the success of universal screening. A shift to simplified screening and "opt-out" testing procedures is recommended.