Taboos: Another HIV negative
Government plans to get all pregnant women taking HIV tests are unnecessary and unhelpful, says Ann Bradley
By the end of the year, every pregnant woman in England will be expected to discuss her possible HIV status with her midwife. This summer, the minister for public health Tessa Jowell used a photo opportunity at a new sexual health unit at a London hospital to announce a new set of targets aimed at reducing the number of babies born HIV positive.
The plan is to recommend that pregnant women undergo an HIV test along with the existing routine antenatal tests. If mothers - to-be are identified as HIV positive, then measures can be taken to reduce the risk of babies being infected by 'maternal transmission'. The minister has been at pains to point out that there will be no element of compulsion in the tests, but all health authorities are being asked to meet ambitious targets. Local uptake of testing by women is supposed to reach 50 percent by the end of the year 2000, and 90 percent by 2002.
On the surface the proposal seems to make sense. While HIV remains incurable, the introduction of new, more effective drugs have meant that it is increasingly regarded as treatable. In the USA, health promotion organisations are even worried that gay men, who no longer see HIV infection as a death sentence, are rejecting condoms once again to enjoy unprotected sex.
There are benefits to a pregnant woman finding out that she is HIV positive. Various measures can now be taken to reduce the risk of transmitting the infection, from one in six to less than one in 20. These include careful obstetric management; antiretroviral drugs taken in pregnancy by the woman, and given to the child at birth and during the first weeks of life; delivery by caesarean section; and bottle rather than breastfeeding
Launching the new scheme, Tessa Jowell claimed that seven out of 10 HIV-infected mothers do not find out that they have the virus until their baby becomes ill and dies. Typically, investigations reveal the child has HIV antibodies and this leads to an investigation of the mother. Jowell hopes that if pregnant women were routinely offered, and encouraged to accept, HIV tests, this situation would change. 'What mother would not want to be screened for any condition which her baby could develop, and which is preventable?' she asked journalists: 'There is a public health imperative that we begin to do better by these mothers and their babies.'
But look a little more closely at the scale of maternal transmission of HIV to babies. When you do, it seems very low down on the scale of public health problems.
According to official figures, in 1997 there were just 265 live births in the whole of Britain to HIV-infected women; of these babies, 71 were HIV positive. The first babies infected with HIV transmitted by their mother were born in 1985, since when there have been a total of 273 boys and 276 girls born with maternally transmitted HIV. Last year, in all, 59 children were infected with HIV by maternal transmission.
These statistics suggest two things. First, that maternal transmission is rare, surely too rare to be defined as a public health problem. Second, that numbers have already started to fall - without a programme that involves cajoling 600 000 women into an HIV test, at a cost that the department of health has estimated at £3 a head not including staff/counselling costs.
Like many other sexual health policies to emerge from the desk of Ms Jowell, this one turns out to be totally irrational. It is hard to imagine that many of the country's leading paediatricians, having accepted the government-promoted principle of 'healthcare prioritisation' would argue that a windfall of a few million should be spent on this kind of programme when far greater numbers of lives could be saved by investments in other areas. The scale of problems caused by severe prematurity, for example, is far greater than those caused by HIV. To put it bluntly, from a public health perspective, if health ministers were only interested in saving the lives of babies there are better things to spend money on.
It seems that there are also better things to spend the money on if, from a public health perspective, health ministers are genuinely interested in tackling the spread of HIV. Children who have acquired HIV by maternal transmission account for just two percent of HIV cases.
Even if we were to accept that there is a public health imperative to address the maternal transmission issue, the available evidence suggests that the current geographically targeted screening programmes are the best way to identify children at risk. It is no secret that, in the UK, HIV infection is geographically clustered into certain cosmopolitan centres. And it would have come as no surprise to health officials that almost three quarters of HIV-positive women (195 out of 265) who gave birth in 1997 lived in London.
Already HIV testing is being offered routinely in many areas where rates of HIV infection are high. King's College Hospital in south London now convinces 90 percent of women seen for antenatal care to accept an HIV test. In this area of south London, it has been estimated that the incidence of HIV infection of pregnant women is one in 20; in other parts of the country, the rate is estimated to be one in 6000. Surely it is sensible to target healthcare resources where they are most needed? Forget testing the worried well from the Cotswolds; concentrate on inner-city areas with high levels of intravenous drug use and populations from countries where HIV is a genuine epidemic.
Indeed, the policy of routinely offering HIV tests in higher risk areas probably explains why the number of cases of maternal transmission is already falling. The current trajectory means that, even if ministers fail to meet the target of testing 90 percent of women nationally by the year 2002, they should still be able to announce that the numbers of babies born with HIV has fallen by the desired 80 percent.
So what is the government's unnecessary initiative on HIV testing of pregnant women really all about? There are several factors at play.
For Tessa Jowell, the combination of AIDS and babies is a convenient one. Jowell finds the sexual health part of her portfolio difficult to balance. She, more than anybody else in the government, is terrified of controversy and of earning the Daily Mail's approbation. She shies away from any sexual health initiative that could be seen to condone recreational sex. An AIDS/infants initiative allows her to demonstrate a commitment to the prevention of HIV without having to get into that difficult sex stuff - especially gay sex stuff.
The untargeted, national approach to an HIV-screening programme is also a useful reaffirmation of the politically correct, if not factually correct, mantra that we are all of us at risk of HIV and had better behave with appropriate sexual and social caution. Media reports of the initiative were accompanied by a predictable selection of case histories: 'Thank God the midwife encouraged me to be tested - I would never have thought I could be infected.' The lottery may have dropped 'It could be you' as a slogan, but when it comes to HIV/AIDS campaigns the message has been programmed so deeply into the minds of health officials that they can't let go of it.
To say that some women are not at risk of HIV, and never have been, should be to state the obvious. It is irrational and alarmist to insist that couples who have only shared each other's bed should be concerned in case they are infected with HIV. Even those who have 'put it about a bit' are at much lower risk than popular prejudice, inspired by health promotion messages, would have us believe. HIV is relatively difficult to catch. The government's own Social Exclusion Unit's report confirms that the chance of infection from a single act of unprotected heterosexual penetrative sex with an HIV-positive partner is one in a hundred. We have all seen the tragic headlines of young girls who claim to have contracted HIV from the first boy they ever had sex with. But then we have also seen happy headlines about the national lottery. Yes, in theory, it could be you, but the overwhelming odds are that it won't be.
Pregnant women have a lot on their minds. Pregnancy is stressful, antenatal tests are particularly so. This is not the time to try to persuade a woman to rack her brains about whether at any time in her past she has put herself at a tiny risk of HIV. It is not the time to encourage her to interrogate her partner about whether he has ever strayed and so put her at risk. Tessa Jowell is right to suggest that there are few women who would not want to take action to maximise their child-to-be's future health and wellbeing. She is wrong to promote an initiative that is more likely to worry women needlessly than benefit their health.
Reproduced from LM issue 124, October 1999