Review of antenatal testing policies and practice for HIV and hepatitis C infection

OBJECTIVE

To investigate antenatal HIV and HCV testing policy and practice in Australia.

METHODS

A survey of private obstetricians and general practitioners (GPs) affiliated with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and directors of obstetric units in public hospitals was undertaken. Surveys were mailed to 40% and 20% random samples of private obstetricians and GPs, respectively, and all public hospital obstetric units. The questionnaires included information on type of antenatal policy, proportion of women tested for HIV and HCV, and number of HIV and HCV-positive women receiving antenatal care.

RESULTS

Of the 995 surveys distributed, 847 (85%) were returned. Of these 847, 277 (33%) were returned from practitioners or hospitals no longer involved in antenatal care. The response rates from the remaining practitioners (n=570) included 87% from private obstetricians, 78% from GPs, and 71% from public hospitals. The proportion of private obstetricians, GPs and public hospitals with an antenatal testing policy for HIV was 62%, 42% and 44%, and for HCV 65%, 41% and 39%, respectively. Universal offer of antenatal testing among private obstetricians, GPs and public hospitals was 47%, 62% and 23% for HIV and 54%, 46% and 23% for HCV, respectively. During 1999, an estimated 33% of pregnant women were tested for HIV and 37% for HCV. Based on reported numbers of women in antenatal care, prevalence rates were estimated at 0.23 per 1,000 and 13 per 1,000, for HIV and HCV, respectively.

CONCLUSIONS

Antenatal testing policy and practice varies widely in Australia. The lack of uniformity may reflect differing policies among clinical and public health bodies.

An unbridgeable gap? Comparing the HIV/AIDS epidemics in Australia and sub-Saharan Africa

OBJECTIVE

To compare the HIV/AIDS epidemics in Australia and sub-Saharan Africa, to outline reasons for differences, and to consider implications for the Asia and Pacific region.

METHODS

Comparison of key indicators of the epidemic in Australia, and Africa viewed largely through the experience of the Hlabisa health district, South Africa.

RESULTS

To the end of 1997, for all Australia, the estimated cumulative number of HIV infections was approximately 19,000, whereas in Hlabisa 31,000 infections are estimated to have occurred. Compared with the low and declining incidence of HIV in Australia (< 1%), estimated incidence in Hlabisa rose to 10% in 1997. In all, 94% of Australian infections have been amongst men; in Hlabisa equal numbers of males and females are infected. Consequently, whereas 3000 children were perinatally exposed to HIV in Hlabisa in 1998 alone, 160 Australian children have been exposed this way. In Australia, HIV-related disease is characterised by opportunistic infection whereas in Hlabisa tuberculosis and wasting dominate. Surveys among gay men in Sydney and Melbourne indicate > 80% of HIV infected people receive antiretroviral therapy whereas in Hlabisa these drugs are not available.

IMPLICATIONS

It seems possible that Asia and the Pacific will experience a similar HIV/AIDS epidemic to that in Africa. Levels of HIV are already high in parts of Asia, and social conditions in parts of the region might be considered ripe for the spread of HIV. As Australia strengthens economic and political ties within the region, so should more be done to help Pacific and Asian neighbours to prevent and respond to the HIV epidemic.

Monitoring of HIV-1 infection prevalence and trends in the general population using pregnant women as a sentinel population: 9 years experience from the Kagera region of Tanzania

In the Kagera region of Tanzania, a population-based study was initiated in 1987 followed by the establishment of antenatal-clinic-based sentinel surveillance system in the town of Bukoba in 1990. Repeat studies in both populations in Bukoba in 1993 and 1996 made it possible to study the dynamics of HIV infection prevalence and incidence in the area. This study aims at comparing the findings from this sentinel surveillance system with those of cross-sectional studies in the general population to assess its validity in estimating HIV prevalence and their trends in the general population. A multistage cluster sampling technique was used in the population-based studies whereas the antenatal-clinic-based population was obtained by consecutively recruiting antenatal care attenders coming for the first time during a given pregnancy. Antibodies against HIV infection were tested using two independent enzyme-linked immunosorbent assay (ELISA) antibody detection tests. Unlinked anonymous testing strategy was adopted for the sentinel population. Age-adjusted prevalence among antenatal care attenders decreased from 22.4% (95% confidence interval [CI], 20.6-25.2) in 1990 to 16.1% (95% CI, 15.9-18.8) in 1993 and further to 13.7% (95% CI, 11.8-14.3) in 1996. These results closely resemble those of the general population of adult women in the clinic's catchment area (the town of Bukoba) where the age-adjusted prevalence of 29.1% (95% CI, 24.4-34.6) in 1987 showed a decrease in the studies in 1993 18.7% (95% CI, 15.1-23.0) and in 1996 14.9% (95% CI, 12.0-17.1). The study indicates that general population trend estimates can be generated using sentinel surveillance data based on pregnant women visiting an antenatal clinic for the first time during a given pregnancy. The benefits of using this group outweigh its limitations that are brought about by possible selection bias. Continued surveillance of the epidemic based on antenatal care patients as a sentinel population is therefore recommended.

Worldwide prevention of vertical human immunodeficiency virus (HIV) transmission

Most human immunodeficiency virus (HIV) infected children acquire the infection by perinatal transmission. Strategies for the prevention of perinatal HIV transmission mainly focus on conditions that prevail in industrialized countries, although most of these children are born in areas with less privileged circumstances. This review takes these circumstances into consideration when addressing six potential strategies to reduce perinatal HIV transmission.

Perinatal exposure to HIV in Australia, 1982-1994

OBJECTIVE

To describe the pattern of perinatal exposure to HIV in Australia from 1 January 1982 to 31 December 1994.

DESIGN

National surveillance for perinatal exposure to HIV.

PARTICIPANTS AND SETTING

Women with diagnosed HIV infection in Australia whose children were exposed to HIV perinatally.

OUTCOME MEASURES

Number of reported cases of women with diagnosed HIV infection who have had perinatally HIV-exposed children.

RESULTS

By 31 December 1994, 91 women diagnosed with HIV infection had had 111 perinatally exposed children. While the rate of perinatal exposure to HIV was highest in the Australian Capital Territory and New South Wales, the rate was substantially lower than the rate of diagnoses of HIV and AIDS in women of child-bearing age. Before 1989, only 15% (6/39) of women knew of their HIV infection before the birth of their first perinatally exposed child: by 1989-1994, this had increased to 64% (32/52; P < 0.0005). Overall, exposure to HIV was attributed to heterosexual contact only, injecting drug use or receipt of blood or tissue by 48%, 31% and 18% of women, respectively. Source of HIV exposure changed from a history of receipt of blood in 78% of women whose first exposed child was born in 1982-1985 to heterosexual contact only in 61% of women whose first exposed child was born in 1992-1994. 38 children acquired HIV infection perinatally. The HIV transmission rate to children born to women diagnosed with HIV infection before delivery was 21.6% (11/51).

CONCLUSIONS

Perinatal exposure to HIV in Australia remains rare. While the proportion of women diagnosed with HIV infection after delivery decreased, a substantial number continued to be diagnosed after delivery, precluding use of current interventions that can reduce the risk of perinatal transmission. It may be appropriate to review the application of HIV testing during pregnancy in Australia.

Testing for HIV without specific consent: a short review

The practice of testing for human immunodeficiency virus (HIV) without the specific knowledge and consent of the patient raises ethical and legal issues. This report argues that diagnostic HIV testing of specific patients, without their consent, is unethical and may also be illegal. Testing for HIV prevalence on an anonymous, unlinked basis, however, is an important aspect of public health surveillance, and the ethics of clinical intervention should not be confused with the ethics of epidemiological research. Specific consent is usually desirable in view of privacy concerns, the importance of patient autonomy, and the potential for conflict of interest. However, where otherwise appropriate, the law should be clarified to permit nonconsensual HIV testing to proceed legally, possibly following scrutiny by an institutional ethics committee.

Antenatal HIV antibody testing in Australia

OBJECTIVE

To evaluate the role of voluntary antenatal testing in HIV surveillance and prevention by examining antenatal HIV antibody testing practice and policy in Australia.

DESIGN

Cross-sectional study using a self-administered questionnaire.

SUBJECTS AND SETTING

Specialist obstetricians and gynaecologists and general practitioners (GPs) affiliated with the Royal Australian College of Obstetricians and Gynaecologists and Australian public hospital antenatal clinics, August-November 1992.

MAIN OUTCOME MEASURES

The percentage of public hospital antenatal clinics and specialist and GP obstetricians in Australia who tested pregnant women for HIV antibody as part of their antenatal care, and the proportion of pregnant women in Australia who had an antenatal HIV antibody test in the 1991-92 financial year.

RESULTS

Questionnaires concerning antenatal HIV antibody testing were completed by 90% (993/1108) of specialists, 87% (2134/2461) of GPs and 93% (215/230) of public hospitals surveyed. Of the 706 specialists and 1503 GPs who reported that they were currently engaged in obstetric care, approximately 60% (430/706) and 935/1503, respectively) offered antenatal HIV testing either to all pregnant women or to selected groups at risk. There were significant differences in testing patterns between States and Territories. For the 95 public hospitals with antenatal clinics, 81% (77) offered the HIV antibody test to all or selected groups of pregnant women; these percentages did not differ significantly between States and Territories. It was estimated that 25% of pregnant women seen by specialists, 29% seen by GPs and 9% seen in public hospital clinics were tested for HIV antibody as part of their antenatal care in 1991-92.

CONCLUSIONS

In Australia approximately one in five pregnant women were tested for HIV antibody as part of their antenatal care in 1991-92. Voluntary HIV testing in pregnancy may provide unrepresentative data for measuring the prevalence of HIV infection in pregnant women.