The European Journal of Public Health Advance Access originally published online on September 17, 2007
The European Journal of Public Health 2007 17(5):414-418; doi:10.1093/eurpub/ckm074
Commentary |
Antenatal HIV screening in Europe: a review of policies
Jessika Deblonde, Patricia Claeys and Marleen TemmermanInternational Centre for Reproductive Health, Ghent University, Ghent, Belgium
Correspondence: Patricia Claeys, PhD, International Centre for Reproductive Health, Ghent University, De Pintelaan 185-P3, 9000 Gent – Belgium, tel: +32 9 240 35 64, fax: +32 240 38 67, e-mail: patricia.claeys{at}ugent.be
Received June 5, 2007, accepted June 8, 2007
 |
Abstract |
|---|
 Top Abstract MethodologyResultsDiscussionAcknowledgementsReferences |
|---|
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.
Keywords: Europe, HIV screening, national policies, pregnancy
HIV/AIDS remains a communicable disease of major public health importance in Europe. Relevant figures confirm that the incidence is increasing throughout the 25 EU Member States, particularly among young people between the ages of 15 and 25 years.1 There are important regional differences in the prevalence of HIV/AIDS in Europe, with Eastern Europe experiencing a fast growing HIV epidemic.2 Although injecting drug users and homo/bisexual men represent highly affected groups in most countries, HIV transmission through heterosexual contact is increasing, resulting in higher numbers of infected women. A large share of heterosexually transmitted infections has been attributed to HIV infected persons originating from countries with a high HIV prevalence.3
The increased prevalence of HIV infection in women is leading to a rising number of children born to HIV-infected mothers. As the therapeutic possibilities for preventing perinatally acquired HIV infection increase, the detection of undiagnosed HIV infections in pregnant women followed by adequate management, is of crucial interest.4,5 In the absence of any intervention, the risk of mother-to-child transmission (MTCT) of HIV is 15–30% in non-breastfeeding populations.6 This risk can be reduced to <2% by interventions that include antiretroviral (ARV) prophylaxis administered to women during pregnancy and labour, along with safe delivery practices and the avoidance of breastfeeding.7
The UNGASS Declaration8 aims to obtain a commitment from governments to reduce the proportion of infants infected with HIV by 50% by 2010 by way of ensuring access to HIV counselling and prevention and treatment for pregnant women. In order to accelerate its implementation, the governments from Europe and Central Asia adopted the Dublin Declaration,9 setting the goal to eliminate HIV infection in infants in the region by 2010.
Therapeutic protocols are being updated and increasingly applied in most European countries.7 Several MTCT cohort studies have been set up in Europe with the aim to investigate the consequences of HIV infection in pregnancy and its outcome in infected and uninfected children born to HIV infected mothers.10,11. Acknowledging that testing and counselling are the interventions needed for the prevention of MTCT of HIV, the European Consensus Statement on the management of pregnancy and HIV infection endorses the offer of an antenatal HIV test as the standard of care in Europe.7 Nevertheless, there is no structured information on the national policies and strategies with regard to antenatal HIV screening as such.
The International Guidelines on HIV/AIDS and Human Rights (1997) formulated within the UN recommend that the national states establish a transparent and coordinated HIV policy in accordance with the international human rights law.12 In this view, UNAIDS and WHO advocate for three principles which should underpin the conduction of HIV testing on individuals: HIV testing must be confidential, be accompanied by counselling and only conducted with the informed consent of the patient.13 As a consequence, a voluntary approach should be adopted in all HIV policies and programmes concerning HIV testing and counselling in health facilities. Voluntary testing strategies are of two types: opting in versus opting out. According to the opt-in approach, the HIV test is dealt with separately from other antenatal tests and is accompanied by specific pre-test information and subsequent informed consent from each pregnant woman. Under the opt-out approach, the test is offered in line with other antenatal blood tests, as a matter of routine. Patients, however, retain the right to refuse testing, thus opting out of the systematic offer.
In order to identify national policies with regard to antenatal HIV screening and its rationale, we conducted an exploratory survey. By doing this, we expected to get an adequate idea of whether policies and guidelines exist, what their content is and if a voluntary screening strategy is adopted.
|
Methodology |
|---|
|
TopAbstractMethodologyResultsDiscussionAcknowledgementsReferences |
|---|
In a first stage, a preliminary information round was organized. During this period, contacts were established with UNAIDS Europe, WHO Europe and EuroHIV with the objective of identifying key-informants in the field of HIV/AIDS policies and screening strategies in European countries.
In a second stage, a structured questionnaire was distributed among these key-informants within the ministries of health and national institutes for public health in each of the 25 EU Member States. Between December 2004 and May 2005, a total of 60 questionnaires and 20 reminders had been sent. In some cases, the initial contacts referred us to other, more specialized experts.
The main research question was this: is there a national policy with regard to antenatal HIV screening in each of the EU Member States? In order to support their responses, informants were asked to provide an extract of the text of, or at least a reference to, their national policy or guidelines, within the questionnaire. In the case of uncertainties or doubts with regard to the content of the answers obtained, informants were consulted to obtain further clarity.
|
Results |
|---|
|
TopAbstractMethodologyResultsDiscussionAcknowledgementsReferences |
|---|
With the exception of Cyprus and Luxembourg, of all the EU Member States that were contacted, at least one answer was obtained from each of them.
Of the 23 EU countries included in this review, 18 issued a national policy with regard to antenatal HIV screening and 16 countries opted for a system in which HIV testing is offered to all women attending antenatal services (table 1). Only two countries had a selective screening strategy, namely Denmark and Malta. In Denmark, universal screening was introduced in 1994, but this policy was cancelled in 1997. Low coverage and the lack of added value to HIV control and surveillance were the reasons for this. Universal screening was replaced by selective screening of pregnant women belonging to risk-groups such as immigrants from high-incidence countries, women with multiple sexual partners, women with an HIV positive partner, injecting drug users, prostitutes and women with a sexual partner belonging to one of the risk-groups. In Malta, where the incidence of HIV is generally low and extremely low in pregnant women, they had also opted for selective screening. In this country, STI clinic attendees and out of wedlock pregnancies were also considered for antenatal HIV screening, in addition to the above-mentioned risk-groups.
|
The UK previously offered selective testing to women perceived to be at higher risk, but this screening strategy was eventually deemed unsuccessful. The majority of undiagnosed, infected women remained undiagnosed during pregnancy, despite the selective offer. Research suggested that a universal offer would be cost effective and more equitable and in 1999, a universal antenatal HIV testing policy was introduced.
None of the 18 countries with a national policy supported a mandatory screening strategy, which meant that the HIV test could not be performed without the voluntary and informed consent of the pregnant women. In some countries such as France, Finland, Poland, Sweden and Spain's autonomous region Galicia, there was a mandatory offer in the sense that health care providers were obliged to offer the HIV test to all pregnant women. In the Netherlands, an HIV test is to be offered to all pregnant women as part of the standard antenatal tests since 2004. The Czech Republic and Estonia also endorsed the so-called ‘opting-out’ approach. In accordance with screening policies in the other 15 countries, the HIV test could only be performed with the specific informed consent of each pregnant woman. This is the ‘opting-in’ approach. (table 1)
In almost all EU countries with antenatal HIV screening policies, it is recommended that antenatal HIV screening should be accompanied by pre- and post-test counselling, referral of the HIV positive woman, ARV treatment for mother and child, management of the delivery, avoidance of breastfeeding and the post-partum follow-up of the HIV positive woman and her exposed child. The antenatal HIV testing policy in Estonia is restricted to the referral of a pregnant woman who tests positive and the provision of ARV treatment. In Germany, apart from pre-test counselling, no other screening conditions are documented in the policy. Only in Austria, the Czech Republic, Denmark, Finland, Lithuania, the Netherlands and Sweden was partner notification explicitly recommended.
In most of the EU countries, antenatal HIV testing is also addressed in professional guidelines. In Belgium, the Association of Gynaecologists and Obstetricians recommend antenatal HIV testing, provided that informed consent has been obtained. The following are explicitly mentioned as risk groups: women with several sexual partners, women who lived in an area where HIV/AIDS is endemic, injecting drug users and women who have a sexual partner belonging to one of these groups. The Polish Gynaecological Society recommend antenatal testing for HIV, yet it is not further defined under which conditions an HIV test should be performed.
Greece, Hungary, Italy and Slovenia have neither national policy nor professional guidelines with regard to antenatal HIV screening.
|
Discussion |
|---|
|
TopAbstractMethodologyResultsDiscussionAcknowledgementsReferences |
|---|
Although screening of pregnant women for HIV infection represents a major opportunity to prevent the transmission of the virus to infants, none of the countries referred to in this study supports a mandatory screening strategy. Also in literature, mandatory HIV screening is considered to be undesirable and ethically untenable. It is stated that such a policy deprives women of their autonomy and their right to decide whether to be tested for HIV or not.14–16 In addition, no data are available to prove that mandatory HIV testing would be de facto beneficial.15
Informed consent is one of the pillars of voluntary testing for HIV. There is no consensus on how much information is required before consent can be considered ‘informed’.17,18 No relation has been observed between the time devoted to the discussion or counselling on HIV and the uptake of testing in the antenatal care setting.18–20 Yet, the quality of counselling before testing has been shown to be correlated with test acceptance rates. Patient counselling focusing on the reduction of vertical HIV transmission, rather than on general HIV knowledge, could potentially improve rates of HIV test acceptance in antenatal care, as suggested by a cross-sectional survey among antenatal patients.20 A randomized controlled trial in Scotland, involving the different methods in which an HIV test is offered in antenatal care, demonstrated that even though midwives were provided with the same information on HIV testing, including written protocols to work from, their uptake rates were significantly different. This implies that not only should the knowledge of the health care provider be taken into account when considering the uptake of testing, but also his/her attitude to antenatal HIV screening.18 A survey among pregnant women in a low prevalence area in the UK confirmed that the policy of routinely offering and recommending screening to pregnant women is one of the major reasons why HIV testing is accepted.21 There are studies indicating that the proportion of pregnant women undergoing antenatal HIV testing in this manner is higher where the opting-out strategy has been adopted.22–24 Both the WHO and the US Centers for Disease Control and Prevention (CDC) recommend an opting-out approach in the context of provider-initiated HIV testing and counselling in health facilities.25,26 Nevertheless, this exploratory survey reveals that only three out of the 18 countries with a national policy introduced an opting-out approach.
From the 23 EU countries included in this review, 18 issued a national policy with regard to antenatal HIV screening of which only Denmark and Malta opted for a selective system in which HIV testing is offered to women belonging to risk groups. The UK shifted from a previously selective screening to a universal antenatal HIV testing policy. In the context of selective offer strategies, the failure to target the appropriate high-risk groups has been investigated. Tookey et al.17 have demonstrated that units with selective screening strategies in the UK tend to test only a minority of women at high risk and do not target all the main high risk groups. In addition, several studies have reported that high-risk groups are reluctant to present themselves for testing and no association has been found between perceived risk and acceptance rate.17–20,27 Furthermore, it appears that screening for HIV on the basis of ethnicity or country of origin is considered potentially discriminatory.17,19
The fact that policies are in place in most countries demonstrates that the role of antenatal HIV testing has been given increased prominence since interventions that reduce the risk of MTCT have been established. However, practical approaches with regard to antenatal HIV testing and counselling seem to vary widely on national and regional basis.3,7,28 Thus far, it has not been systematically assessed if and how antenatal HIV screening policies and guidelines are being implemented in Europe. Only some aspects of national or local antenatal HIV screening practices have been described in literature.
In Germany, for example, an analysis of registered cases of HIV infection revealed that in 2005, 17 cases of HIV infection were diagnosed in infants born in the country. Fourteen of them had at least one parent originating from a foreign country and two of them had an intravenous drug-using (IDU) mother. In addition, nine mothers had not had an HIV test during antenatal care, two were late antenatal care attendees and one mother had no antenatal care.29 These findings beg the question of whether there are barriers to the benefits of HIV testing in pregnancy. At community level, which are the factors determining the access to antenatal care and HIV testing, including legal, financial and social aspects? And why would health care providers fail to offer the HIV test? A systematic literature review realized by Cabana et al.30 suggest that adherence to policies and guidelines may be hindered by a variety of barriers. Amongst others, lack of awareness and knowledge of guidelines, outcome expectations, fear of offending parents and time limitations can affect health care providers’ ability to translate a recommendation into practice.31
Another question involves how to monitor antenatal HIV screening coverage, the effect of screening policy and practice and its impact on specific vulnerable groups. A survey carried out by the National Study of HIV in Pregnancy and Childhood in the UK, revealed difficulties in auditing the test uptake. This is evidenced by the fact that 20% of the maternity units included in the survey were unable to provide adequate data in order to estimate the uptake. In addition, most monitoring systems do not make allowances for the test not being carried out. In this way, one is not able to distinguish between whether a test was not offered and not accepted.32 How does one then measure the acceptance rate and evaluate the reasons for non-acceptance of the HIV test?
A survey carried out in public hospitals in Catalonia, Spain, in 2000 indicated that the uptake of HIV testing in pregnancy was 93.8% while only 68% of pregnant women in the same hospitals declared having had an HIV test. In addition, only a quarter of the interviewees thought that they had received enough information about the test.33 This leads to the obvious question of whether pregnant women are aware of being tested. Is the informed consent de facto integrated in antenatal HIV testing practices and is testing accompanied by counselling?
Due to the fact that the number of HIV infected women is increasing and HIV infections in infants still occur, the prevention of HIV infection in infants continues to be a major public health challenge. In view of recently published US CDC and WHO guidelines on HIV testing and counselling in health facilities, national policies in EU Member States should be discussed and re-assessed. 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. Special attention should be given to the manner in which policies are currently being translated into national and local practices. Further discussion should focus on what is needed to implement opting-out approaches to maximize positive outcomes and minimize potential harms to the people being tested. Specific questions include how to reach vulnerable groups, the amount of pre-test information to be provided, the need for post-test counselling for all women including those with negative HIV tests and how to ensure access to treatment and care for women who test positive. Another concern is how to put effective monitoring systems in place that provide comparable information between countries.
|
Acknowledgements |
|---|
|
TopAbstractMethodologyResultsDiscussionAcknowledgementsReferences |
|---|
This exploratory research was granted by the Ghent University, Belgium during the period January 2004 to December 2006, with contract number WBS B/04919/01.
We thank the key informants within the ministries of health and national institutes for public health in the EU Member States, who provided the data used in this review.
Conflicts of interest: None declared.
Key points
|
|
References |
|---|
|
TopAbstractMethodologyResultsDiscussionAcknowledgementsReferences |
|---|
1 UNAIDS/WHO. AIDS epidemic update. (2006) Geneva: UNAIDS/WHO. http://data.unaids.org/pub/EpiReport/2006/2006_EpiUpdate_en.pdf.
2 Hamers FF, Downs AM. HIV in Central and Eastern Europe. Lancet (2003) 361:1035–44.[CrossRef][ISI][Medline]
3 Hamers FF, Downs AM. The changing face of the HIV epidemic in Western Europe: what are the implications for public health policies? Lancet (2004) 364:83–94.[CrossRef][ISI][Medline]
4 Harrington JA. The instrumental use of autonomy: a review of AIDS law and policy in Europe. Soc Sci Med (2002) 55:1425–34.[CrossRef][ISI][Medline]
5 Sherr L, Bergenstrom A, Hudson CN. Consent and antenatal HIV testing: the limits of choice and issues of consent in HIV and AIDS. AIDS Care (2000) 12:307–12.[CrossRef][ISI][Medline]
6 Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med (1994) 331:1173–80.
7 Newell MR, Rogers M. Pregnancy and HIV infection: a European consensus on management. AIDS (2002) 16(Suppl 2):S1–18.
8 United Nations General Assembly Special Session on HIV/AIDS. Declaration of Commitment on HIV/AIDS. In: UN General Assembly Resolution R.A/RES/S-26/2 (2001).
9 Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia. (2004) Dublin: Irish EU Presidency. Website: Accessed on 24 February 2004.http://www.eu2004.ie/templates/meeting.asp?sNavlocator=5,13&list_id=25.
10 Staehelin C, Rickenbach M, Low N, et al. Migrants from sub-saharan Africa in the Swiss Cohort Study: access to antiretroviral therapy disease progression and survival. AIDS (2003) 17:2237–44.[CrossRef][ISI][Medline]
11 European Collaborative Study. Management of vertically HIV-infected children in Europe. Acta Paediatr (2003) 92:246–50.[ISI][Medline]
12 United Nations High Commissioner for Human Rights. The protection of human rights in the context of HIV/AIDS. In: Commission on Human Rights Resolution 1997/33. (E/CN.4/RES/1997/33).
13 WHO/UNAIDS. Policy Statement on HIV Testing. (2004) Geneva: UNAIDS/WHO.
14 Magnusson RS. HIV in pregnancy: commentary on legal issues. J Paediatr Child Health (2003) 39:64–6.[CrossRef][ISI]
15 Nakchbandi IA, Longenecker JC, Ricksecker MA, et al. A decision analysis of mandatory compared with voluntary HIV testing in pregnant women. Ann Int Med (1998) 128:760–7.
16 Van Casteren V, Devroey D, Sasse A, Wallyn S. An 8 year nation wide prospective registration of non-consented HIV testing in Belgium. J Public Health (2004) 26:72–6.[CrossRef]
17 Tookey PA, Gibb DM, Ades AE, et al. Performance of antenatal HIV screening strategies in the United Kingdom. J Med Screen (1998) 5:133–6.
18 Simpson WM, Johnstone FD, Boyd FM, et al. Uptake and acceptability of antenatal HIV testing: randomised controlled trial of different methods of offering the test. Br Med J (1998) 316:262–7.
19 Gibb DM, MacDoagh E, Gupta R, et al. Factors affecting uptake of antenatal HIV testing in London: results of a multicentre study. Br Med J (1998) 316:259–61.
20 Carusi D, Learman LA, Posner SF. Human Immunodeficiency Virus Test Refusal in Pregnancy: A Challenge to Voluntary Testing. Obstet Gynec (1998) 91:540–5.[CrossRef][Medline]
21 Jha S, Gee H, Coomarasamy A. Women's attitudes to HIV screening in pregnancy in an area of low prevalence. BJOG (2003) 110:145–8.[ISI][Medline]
22 Simpson WM, Johnstone FD, Goldberg DJ, et al. Antenatal HIV testing: assessment of a routine voluntary approach. Br Med J (1999) 318:1660–1.
23 Stringer EM, Stringer J, Cliver SP, et al. Evaluation of a new testing policy for human immunodeficiency virus to improve screening rates. Obstet Gynec (2001) 98:1104–8.[CrossRef][Medline]
24 Walmsley S. Opt in or opt out: What is optimal for prenatal screening for HIV infection? CMAJ (2003) 168:707–8.
25 US Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents and pregnant women in health-care settings. Morbidity and Mortality Weekly Report (2006) 55(RR-14):1–17.
26 WHO/UNAIDS. Guidance on Provider-initiated HIV Testing and Counselling in Health Facilities. (2007) Geneva: WHO.
27 Barbacci M, Repke JT. Routine prenatal screening for HIV infection. Lancet (1991) 337:709–11.[CrossRef][ISI][Medline]
28 De Cock KM, Johnson AM. From exceptionalism to normalisation: a reappraisal of attitudes and practice around HIV testing. Br Med J (1998) 316:290–3.
29 EuroHIV. HIV/AIDS Surveillance in Europe. In: End-year report 2005. (2006) Saint-Maurice: Institut de veille sanitaire. n° 73. http://www.eurohiv.org/reports/report_73/pdf/report_eurohiv_73.pdf.
30 Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA (1999) 282:1458–65.
31 Kline MW, O’Connor KG. Disparity between pediatricians’ knowledge and practices regarding perinatal human immunodeficiency virus counselling and testing. Pediatrics (2003) 112:367–70.[CrossRef]
32 Townsend CL, Cliffe S, Tookey PA. Uptake of antenatal HIV testing in the United Kingdom: 2000-2003. J Public Health (2006) 28:248–52.[CrossRef]
33 Pérez K, Blanch C, Casabona J, et al. Coverage of HIV testing among pregnant women in Catalonia, Spain. Eur J Public Health (2004) 14:261–6.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||