Performance of antenatal HIV screening strategies in the United Kingdom

Estimating the number of livebirths to Hepatitis C seropositive women in England in 2013 and 2018 using Bayesian modelling

BACKGROUND

The UK National Screening Committee currently recommends against antenatal screening for Hepatitis C virus (HCV) infection in England due to lack of HCV prevalence data and treatment licensed for use in pregnancy. We aimed to produce regional and national estimates of the number and proportion of livebirths to HCV seropositive women in England in 2013 and 2018.

METHODS

A logistic regression model fitted in the Bayesian framework estimated probabilities of HCV seropositivity among 24,599 mothers delivering in the North Thames area of England in 2012 adjusted by maternal age and region of birth. These probabilities were applied to the underlying population structures of women delivering livebirths in England in 2013 and 2018 to estimate the number of livebirths to HCV seropositive women in these years nationally and by region. The Bayesian approach allowed the uncertainty associated with all estimates to be properly quantified.

RESULTS

Nationally, the estimated number of livebirths to women seropositive for HCV for England was 464 (95% credible interval [CI] 300-692) in 2013 and 481 (95%CI 310-716) in 2018, or 70.0 (95%CI 45.0-104.1) per 100,000 and 76.9 (95%CI 49.5-114.4) per 100,000 in these years respectively. Regions with the highest estimated number of livebirths to HCV seropositive women in 2013 and 2018 included London with 118.5 and 124.4 and the South East with 67.0 and 74.0 per 100,000 livebirths.

CONCLUSION

Few previous studies have investigated HCV among pregnant women in England. These findings complement and supplement existing research by providing national and regional estimates for the number of livebirths to HCV seropositive women in England. Bayesian modelling allows future national and regional estimates to be produced and the associated uncertainty to be properly quantified.

Barriers to HIV testing in Europe: a systematic review

BACKGROUND

In the European Union (EU) and neighbouring countries, HIV/AIDS, of all infectious diseases, has one of the highest morbidity and mortality rates. An estimated 30% of people living with HIV are unaware of their infection, and may therefore not benefit from timely treatment or may transmit HIV to others, unknowingly. Evidence shows that opportunities are being missed to diagnose HIV infections in EU Member States, particularly in regular health care settings. There is a need to better understand the barriers to HIV testing and counselling with the aim to contribute to the decrease of the number of undiagnosed people.

METHODS

A systematic review of literature on HIV testing barriers in Europe was conducted, applying a free text strategy with a set of search terms.

RESULTS

A total of 24 studies published in international peer-reviewed journals and meeting the review's eligibility criteria were identified. Fourteen studies report on barriers at the level of the patient; six on barriers at health care provider level and seven on institutional barriers referring to the policy level. The barriers described are centralized around low-risk perception; fear and worries; accessibility of health services, reluctance to address HIV and to offer the test; and scarcity of financial and well trained human resources.

CONCLUSIONS

Some barriers to HIV testing and counselling have been illustrated in the literature. Nevertheless, there is lack of structured information on barriers considering (i) legal, administrative and financial factors, (ii) attitudes and practices of health care providers and (iii) perception of patients. Such data is critical to improve effectiveness of HIV testing and counselling.

Antenatal HIV screening in Europe: a review of policies

BACKGROUND

The increased prevalence of HIV infection in women is leading to a rising number of children born to HIV-infected mothers. As therapeutic possibilities for HIV/AIDS increase, the detection of undiagnosed HIV infections in pregnant women, followed by adequate management, is of crucial interest. Therapeutic protocols are being updated and increasingly applied in most European countries, but there is no structured information on policies and strategies with regard to antenatal HIV screening as such.

METHODS

In order to identify national policies with regard to antenatal HIV screening, a structured questionnaire was sent to key-informants within the ministries of health and national institutes for public health in each of the 25 EU Member States.

RESULTS

Information was obtained from all EU Member States with the exception of Cyprus and Luxembourg. Eighteen countries issued a national policy with regard to antenatal HIV screening, 16 opted for a system in which HIV testing is offered to all women attending antenatal services while only two opted for selective screening. None of the 18 countries with a national policy supports a mandatory screening strategy. The voluntary testing strategies are of two types: opting in versus opting out. In almost all EU countries with antenatal HIV screening policies, screening conditions are defined.

CONCLUSION

Policies are in place in most EU countries. Nevertheless, there is a need for more integrated European policies and region-specific recommendations on the performance of antenatal HIV screening as an opportunity for comprehensive HIV/AIDS service delivery. This would enable the different aspects of prevention to be linked and also address both the needs of pregnant women and mothers as well as that of their infants.

Voluntary counselling and testing: uptake, impact on sexual behaviour, and HIV incidence in a rural Zimbabwean cohort

OBJECTIVES

To examine the determinants of uptake of voluntary counselling and testing (VCT) services, to assess changes in sexual risk behaviour following VCT, and to compare HIV incidence amongst testers and non-testers.

METHODS

Prospective population-based cohort study of adult men and women in the Manicaland province of eastern Zimbabwe. Demographic, socioeconomic, sexual behaviour and VCT utilization data were collected at baseline (1998-2000) and follow-up (3 years later). HIV status was determined by HIV-1 antibody detection. In addition to services provided by the government and non-governmental organizations, a mobile VCT clinic was available at study sites.

RESULTS

Lifetime uptake of VCT increased from under 6% to 11% at follow-up. Age, increasing education and knowledge of HIV were associated with VCT uptake. Women who took a test were more likely to be HIV positive and to have greater HIV knowledge and fewer total lifetime partners. After controlling for demographic characteristics, sexual behaviour was not independently associated with VCT uptake. Women who tested positive reported increased consistent condom use in their regular partnerships. However, individuals who tested negative were more likely to adopt more risky behaviours in terms of numbers of partnerships in the last month, the last year and in concurrent partnerships. HIV incidence during follow-up did not differ between testers and non-testers.

CONCLUSION

Motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimized with appropriate pre- and post-test counselling.

Sustaining HIV testing in pregnancy- evaluation of routine offer of HIV testing in three London hospitals over 2 years

This study sets out to examine how routine offers of HIV testing for pregnant women in ante-natal (prenatal) clinics are managed over time. Data was collected over two time periods (2002, 2004) from all women booking clinics at three London hospitals. Data from 3,560 women, comprising 2,710 in 2002 (time 1) and 850 in 2004 (time 2) were gathered. Uptake of HIV testing, demographic variables, HIV-associated risks, pregnancy variables and uptake of other ante-natal tests were monitored. In the later study, details of partner testing and time spent discussing HIV was monitored. HIV test uptake with routine offer (RCT) was high. There was a significant increase in HIV testing over time from 85 to 91% (p<0.0001). In 2004, significantly more women had been previously tested for HIV (25 versus 41%, p<0.0001), more women refused all other ante-natal tests (rubella [0 versus 4% p<0.0001], syphilis [1 versus 5%, p<0.0001], Haemoglobin [1 versus 3%, p<0.0001], Down's syndrome [0 versus 13%, p<0.0001] and hepatitis B [1 versus 5%, p<0.0001]). Significantly less women refused HIV test (15 versus 9%, p<0.0001). Initially, HIV was the most frequently refused test (15%), whereas at time 2 Down's syndrome tests were most frequently declined. At time 1, 2% declined any test. By time 2, 14% of the sample declined any test (p<0.0001). Three percent of women had an established HIV risk at time 1 and 6% at time 2. Women with risk factors were significantly less likely to accept testing at time 2, but not at time 1 or not overall. Multivariable analysis was carried out to look at predictors of opting in and opting out of testing. At time 2 HIV test uptake was more likely if less than 3 min was spent discussing it (chi2=9.3, p=0.002). This information was not available at time 1. HIV testing in ante-natal care can be sustained over time. Challenges for the future relate to complex cases, test declining, ensuring that women with risk factors do not systematically decline and providing skills for midwives or referral pathways to deal with more demanding cases. It has been possible to normalise HIV testing. Women have responded with high HIV test uptake, but are also questioning other tests which were previously routinely offered.

Uptake of antenatal HIV testing in the United Kingdom: 2000–2003

BACKGROUND

A policy for routine antenatal HIV testing was introduced in England in 1999, with uptake targets for 2000 and 2002; similar policies were subsequently introduced throughout the UK.

METHODS

Date of implementation of the policy and data for estimating annual uptake of testing 2000-2003 were collected through postal survey of unit-based obstetric respondents to the National Study of HIV in Pregnancy and Childhood (NSHPC).

RESULTS

Implementation date was reported for every unit; uptake data were provided for about three-quarters of implementing units each year. The policy was implemented in 78% (152/195) of English units by end of 2000; 78% (89/114) of units providing data achieved at least 50% uptake that year. By 2002, almost one-third (46/151) of English units reported 90% uptake or more, and over half (84/151) 80%. All but three UK units introduced the policy by the end of 2003, and of those providing adequate uptake data, 38% (66/175) reported at least 90% uptake and 69% (121/175) at least 80%; however, 19% (41/216) of respondents still had difficulty providing adequate data for estimating uptake.

CONCLUSIONS

High uptake of HIV testing was reported from most UK units for 2003, but simple, robust and uniform methods for monitoring uptake at local and regional levels are still required.

Refusing HIV testing in an urgent care setting: results from the "Think HIV" program

Efforts to increase HIV case identification through routine, voluntary HIV testing are hindered by high refusal rates. Our objective was to identify patients most likely to refuse routine HIV testing. We developed a new HIV testing program at four Massachusetts urgent care centers. Patients were asked if they were interested in routine HIV testing. We performed analyses to assess differences in characteristics between those who refused testing and those who accepted it. Data were available for 9129/10,354 (88%) patients offered routine HIV testing from January to December 2002. Of these 9129 patients, 67% refused testing. In the crude analysis, HIV test refusal was associated with female gender, white race, older age, and higher educational level. In multivariate analysis, non-English-speaking patients who were Hispanic, Haitian, and other race were more likely to refuse testing than their English-speaking counterparts. Among all patients, "not at risk" and "already tested" were the most common reasons for test refusal. Two thirds of patients refused routine HIV testing when it was offered in a statewide urgent care-based program. If routine HIV testing programs are to be successful, strategies must be developed to increase HIV test acceptance among patients most likely to refrain from testing.

Fatherhood and HIV-positive heterosexual men

OBJECTIVES

The study of HIV and issues of reproduction is women-focused. HIV-positive men are overlooked and understudied. This study examined views on reproduction of heterosexual HIV-positive men.

METHODS

Systematic questionnaire data were gathered from HIV-positive men (n=32) attending an HIV clinic in London.

RESULTS

Heterosexual men were rarely given medical advice on reproduction (only 9.4%). Few felt fully informed (21.9%), while many felt uninformed (46.9%) or needed more information (28.1%). Over half would value fertility/fathering consultations, up-to-date information and quick referral to fertility clinics. Nearly half (43.8%) had considered having children and 37.5% had had a child prior to HIV diagnosis. HIV status affected views on fathering, and the advent of new treatments changed views in over half of the men. Almost half (41%) believed they would experience discrimination if they conceived a baby and a quarter would withhold their HIV status when attending antenatal clinics. The majority (81%) believed that a child gave meaning to life and something to live for - only 3.1% felt a child would be a burden. Most men overestimated potential vertical transmission and would value time to discuss fathering and fatherhood.

CONCLUSIONS

There are gaps in provision. The majority of men felt that children gave meaning to life and a reason to live. Reproduction issues are not raised with HIV-positive men who are uninformed and unclear where to turn for information. Fatherhood should not be shunned as an issue for all HIV-positive men.

Economic issues in the prevention of vertical transmission of HIV

In the absence of interventions, 20% of infants born to women infected with HIV acquire infection from their mother at or before delivery. A further 15% are infected through breast feeding. Prenatal testing for HIV allows infected women to be reliably identified so that they can receive antiretroviral therapy and, in countries with safe water supplies, be advised not to breast feed. These and other interventions can reduce the risk of transmission to 5% or less. Economic evaluations of prenatal testing for HIV are reviewed and compared in this article, and future research priorities outlined. These studies set the costs of testing and intervention against the averted lifetime costs of paediatric infection, and generate estimates of the HIV prevalence threshold above which there would be a net cost saving, or calculate the cost per life-year saved given a particular prevalence. In the developed world, prenatal testing has been adopted in many countries, and recent economic analyses broadly support this. Future research is likely to focus on the incremental benefits of different antiretroviral regimens in lowering transmission rates still further, with or without elective caesarean section, and the possibility that some may lead to adverse effects in uninfected infants exposed to them in utero. Some earlier assessments in resource-poor settings concluded that prenatal testing was unaffordable or of doubtful cost effectiveness. This negative conclusion appears to be the result of very low estimates of the lifetime costs of paediatric HIV infection, together with developed world conceptions of pre-test counselling. The demonstration that nevirapine reduces transmission risk at a low cost has transformed the outlook, and there is hope that antiretrovirals can act prophylactically to prevent infection of the breast-fed child. However, to achieve a sustained reduction in vertical transmission there may be a need to evaluate the need for a strengthened infrastructure to deliver prenatal HIV testing and treatment, as well as programmes to reduce HIV incidence in adults.

'Everyone is scared of it inside so they start being a bit irrational': HIV/AIDS education within midwifery

OBJECTIVE

To describe views put forward by student midwives and lecturers about education on the human immunodeficiency virus (HIV).

DESIGN

Multi-method. Participants completed a questionnaire containing open and closed questions, and took part in focus-group discussions.

SETTING

All institutions providing pre-registration midwifery education in the South Thames Region of the UK.

PARTICIPANTS

Students (n = 336) and lecturers of midwifery (n = 51).

MEASUREMENTS

Closed questions from the questionnaire were analysed for frequency distributions, intra-group cross tabulations of selected variables and inter-group comparisons. Open questions from the questionnaire and transcripts of focus group discussions were investigated using thematic analysis and constant comparative techniques.

FINDINGS

Recent structural changes within midwifery education had increased lecturers' workloads. Curriculum pressures led to lecturers making assumptions about students' existing levels of knowledge, particularly regarding universal precautions, although both lecturers' and students' weakest areas of knowledge in relation to HIV were those specifically related to midwifery. The perceived risk of occupational infection was relatively high and linked to individual perceptions of the virus. However, neither anxiety nor knowledge levels were reflected by consistent use of universal precautions.

KEY CONCLUSIONS

Knowledge obtained within midwifery education may be difficult to translate into clinical practice. Underlying issues such as perceptions of the virus and orthodoxies of midwifery practice inhibited students from using universal precautions, even when they recognised that consistent use of universal precautions could help reduce the risk of occupational transmission of HIV. The social construction of HIV and ideological constructions of midwifery practice, such as the client/midwife relationship, may be sufficiently powerful to have an effect on clinical practice and reduce the use of universal precautions.

IMPLICATIONS FOR PRACTICE

Emphasising the place of clinical knowledge within a broader issue-based context may help lecturers and students address the challenge of implementing safe, non-discriminatory use of universal precautions.

Cost effectiveness analysis of antenatal HIV screening in United Kingdom

OBJECTIVE

To assess the cost effectiveness of universal antenatal HIV screening compared with selective screening in the United Kingdom.

DESIGN

Incremental cost effectiveness analysis relating additional costs of screening to life years gained. Maternal and paediatric costs and life years were combined.

SETTING

United Kingdom.

MAIN OUTCOME MEASURES

Number of districts for which universal screening would be cost effective compared with selective screening under various conditions.

RESULTS

On base case assumptions, a new diagnosis of a pregnant woman with HIV results in a gain of 6.392 life years and additional expenditure of 14 833 pounds. If decision makers are prepared to pay up to 10 000 pounds an additional life year, this would imply a net benefit of 49 090 pounds (range 12 300 pounds- 59 000 pounds), which would be available to detect each additional infected woman in an antenatal screening programme. In London, universal antenatal screening would be cost effective compared with a selective screening under any reasonable assumptions about screening costs. Outside London, universal screening with uptake above 90% would be cost effective with a 0.60 pounds HIV antibody test cost and up to 3.5 minutes for pretest discussion. Cost effectiveness of universal testing is lower if selective testing can achieve high uptake among those at higher risk. A universal strategy with only 50% uptake may not be less cost effective in low prevalence districts and may cost more and be less effective than a well run selective strategy.

CONCLUSIONS

Universal screening with pretest discussion should be adopted throughout the United Kingdom as part of routine antenatal care as long as test costs can be kept low and uptake high.

Selective versus universal antenatal HIV testing: epidemiological and implementational factors in policy choice

OBJECTIVE

To develop an epidemiological basis for economic analyses of selective and universal antenatal screening strategies, and to apply it to the UK.

METHODS

The prevalence of higher-risk women and the prevalence of undiagnosed infection within groups of high-risk and low-risk women was estimated from surveillance and survey data. The numbers of women tested and the numbers of infected women who would be identified by universal and selective strategies were then calculated under a range of assumptions about the identification of higher-risk women and acceptance of testing.

RESULTS

In higher-risk women estimated prevalence of undiagnosed infection was between 0.06% and 2.8%, comparing well with independent estimates. In low-risk women, estimates ranged from 0.014% in London to 0.002% in the rest of the UK. If uptake among the high-risk women was the same in selective and universal strategies, universal testing would entail testing between 7100 (London) and 50000 (rest of England) additional women to detect an additional case. However, if selective screening identified only 60% of those at high risk and achieved only 60% acceptance compared with a universal programme, then universal screening would require only 1150 additional women to identify one additional case in London, compared to 6470 in Scotland and 13140 in the rest of the UK.

CONCLUSIONS

Overall prevalence does not form an adequate basis for determining screening strategy. Instead, universal screening can be justified either because the prevalence of HIV in the low-risk group is sufficiently high, or because it achieves sufficiently higher uptake relative to selective screening among those at higher risk.