The
challenge remains for midwives to make sure that the women who decline an HIV
test at the antenatal booking appointment are offered a test again at later visits,
and that the reason for declining is established and explored. Time constraints
on the antenatal visits can make it difficult for a woman to open up to someone
she may have just met but referral to the specialist midwife or health adviser
would allow more time and privacy for longer discussion.
Midwives
also need to remember that, during pregnancy, couples will not be using condoms
for contraception and could be at risk of sexually transmitted infections,
including HIV, at any time during the pregnancy. It is all too easy to assume
that a test has been done at the booking visit and not to think about it again
later in pregnancy.
However,
the stigma and fear surrounding HIV is still all too apparent for some people
who believe they will be ostracised and treated differently if they are
diagnosed with this illness. Because of this they may be very reluctant to come
forward for retesting.
Pregnant
women themselves are somewhat targeted with a routine offer: but what about the
fathers? How can we spread the message that they too need to think about the
baby’s welfare and have an HIV test? This is a challenge for the community as a
whole as well as for midwives. A negative HIV test for Mum does not mean that
baby is fully protected.
Testing
partners is a huge task, but it would protect even more mothers and babies from
HIV infection if we started suggesting to women and their partners that they
test together. Some of the women I have cared for say to me: “If only we’d
received our diagnosis at the same time, I wouldn’t have been the one to be
blamed. By me finding out first he assumes I am the one who infected him.”
Admittedly,
not all partners attend antenatal clinic appointments and sometimes women are
infected by new partners they meet while pregnant, so we need to talk to women
about how to discuss the offer of an HIV test with their partners and to give
them information about local testing centres and places where people can access
rapid, walk-in testing (such as Know 4
Sure, run by Chelsea and
Westminster NHS Trust); this is often helpful if there is anxiety about waiting
for test results.
Newham University Hospital
in east London
ran a pilot project in which the male partners of pregnant women were offered
HIV tests.1 The project aimed to reduce late diagnosis of men by offering tests at week 20
of their partner’s pregnancy. Over 6000 women were tested as part of their
antenatal care during a one-year period, but only 16 of their partners took up
the offer. Barriers to testing may have included the fact that it involved
referral to another hospital department, and that the results were not
available immediately. A separate community testing project in Newham, using
rapid tests, has had more take-up with men.
The
National Screening Committee is reviewing the benefits of a second HIV test at
the 28- or 32-week routine antenatal visit, and there have been some pilot
studies of second-testing done at a couple of London hospitals. Looking at the
statistics, though, the incidence of women seroconverting (becoming infected)
later in pregnancy would appear to be low: roughly one HIV infection in 7700
pregnancies, compared to a general prevalence of one infection in every 575
pregnant women.2
The
BHIVA/CHIVA (British HIV Association and Children’s HIV Association) guidelines
on managing HIV in pregnancy (2008) state that: “At present, although
desirable, there is no suggestion that universal retesting in the third
trimester will become national policy; therefore case-by-case assessment to
determine whether a woman is at continuing risk of acquiring HIV infection in
pregnancy is the only option with repeat testing offered.”
There
are two concerns about this, however. Firstly, as hospitals are seeing women
earlier in pregnancy, preferably around ten to twelve weeks’ gestation, in
order to offer screening for Down’s syndrome, some infections occurring at
conception may still be in the window period and not diagnosed at this first
visit.
Secondly,
the common practice of women receiving the results of their ‘booking’ blood
tests in their notes rather than in a face-to-face interview means there is
little opportunity for women to have a post-test discussion. (These blood tests
consist of a full blood count to check for anaemia, blood group,
haemaglobinopathy screen, syphilis, hepatitis B and HIV.)
A
post-test discussion would consist of information about the meaning of a
negative HIV result. The advantages of having a second test could be raised,
and a conversation about sexual health in pregnancy generally would be helpful.
A negative HIV result so early in pregnancy could lead to a false sense of
security for everyone.
Midwives,
as a profession, need to be clear at the first test that a repeat test may be
needed later in pregnancy and be sensitive to any concerns women may have.
Women may also fear that HIV treatment will damage the baby or themselves.
There
is good evidence that even diagnosing HIV infection late in pregnancy – at
delivery or even within 48 hours after birth – can still offer a reduction in
the risk of mother-to-child transmission. Most hospitals can have an HIV test
result back within 24 hours and some even have access to point-of-care tests
(where results are available in 20 minutes).
Even
without previous treatment, treatment during labour and postnatally for the
baby, plus the avoidance of breastfeeding, will reduce the risk of transmission
to approximately 9%. A woman diagnosed in labour would be recommended oral
tablets of nevirapine (Viramune), an
elective caesarean section, an AZT drip, and combination therapy for her baby.
It
is never too late to test, particularly if a woman has had no antenatal care.
All blood tests for infection can be carried out on labour ward and
obstetricians should be open to the idea of perinatal testing.