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Journal of Public Health Advance Access originally published online on July 10, 2006
Journal of Public Health 2006 28(3):248-252; doi:10.1093/pubmed/fdl026
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© The Author 2006, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved.

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



Claire L. Townsend, Research Fellow

Susan Cliffe, MRC Fellow

Pat A. Tookey, Senior Lecturer in Paediatric Epidemiology
Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK

Address correspondence to Pat A. Tookey, E-mail: p.tookey{at}ich.ucl.ac.uk

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.

Keywords: epidemiology, screening


   Introduction
TOP
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Contribution to paper
 Competing interests
 Acknowledgements
 References
 
The risk of mother-to-child transmission of HIV can be substantially reduced by the use of antiretroviral therapy in pregnancy, elective caesarean section delivery and avoidance of breastfeeding, but only women diagnosed before delivery can choose whether to take up these interventions. Throughout the 1990s, universal testing was offered in very few maternity units in the UK, and even in those, uptake was low.1 Most units only provided HIV testing at the direct request of individual women or for selected groups of women perceived to be at higher risk, and most HIV-infected women remained undiagnosed at delivery.1,2

In 1999, the Department of Health directed that a policy for the routine offer and recommendation of antenatal HIV testing should be implemented in England by the end of 2000.3 Health authorities were set a target of 50% uptake of testing by the end of 2000 and 90% by the end of 2002, with the aim of diagnosing 80% of HIV-infected pregnant women and offering them advice and treatment during pregnancy; information systems for auditing uptake of testing were also to be put in place.3 Similar policies were adopted in Scotland, Wales and Northern Ireland in 2002 and 2003.4–6

Data from national surveillance and unlinked anonymous seroprevalence surveys have provided evidence of the policy’s success: the estimated proportion of infected women diagnosed before or during pregnancy increased dramatically, from <25% before 19972 to ~90% in 2003 and 2004.7 However, it was not clear whether this had been achieved in the context of a universally high uptake of testing or in spite of continuing substantial regional and local variation in uptake. The aim of this survey was to measure uptake of testing over time in all 246 maternity units in the UK, in relation to when the routine offer policy was implemented and to Department of Health targets.


   Methods
TOP
 Introduction
 Methods
Results
 Discussion
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 References
 
Surveillance of obstetric HIV infection in the UK is carried out through the National Study of HIV in Pregnancy and Childhood (NSHPC), a confidential voluntary active reporting scheme for pregnancies in women with diagnosed HIV, established in 1989 under the auspices of the Royal College of Obstetricians and Gynaecologists (RCOG).8 Regular quarterly contact is maintained with a staff member (mainly specialist midwives or members of RCOG) in every maternity unit in the UK (195 units in England, 22 in Scotland, 16 in Wales and 13 in Northern Ireland during the period of this survey). Information on antenatal testing policy and uptake over the 4-year period 2000–2003 was collated from short survey forms sent to each of these 246 obstetric respondents on at least three occasions (with written or telephone follow-up as required) between 2001 and 2004. Data requested included the date of implementation of the routine offer policy, the number of women who booked for antenatal care (denominator) and who were tested for HIV (numerator) each year, and the data sources from which these numbers were derived. The annual uptake of testing was estimated for each unit where the routine offer policy had been implemented and adequate data were provided. Data were considered adequate if (i) data source was provided, (ii) neither numerator nor denominator was estimated, and (iii) data were consistent (i.e. number of tests did not exceed number of bookings). In addition, for each unit, for the year in which implementation occurred, estimated test uptake was calculated regardless of the number of months for which data were provided; for subsequent years, uptake was only calculated if data were provided for at least 6 of the 12 months.

Data were managed in a Microsoft Access 2002 database and analysed using Stata 8.2.9 Differences in proportions were assessed using {chi}2 tests, and associations between uptake of testing and unit size by logistic regression. In order to estimate the proportion of units in which uptake increased/decreased between 2002 and 2003, we assessed the difference in uptake in each unit using the normal approximation for comparing proportions in independent samples.


   Results
TOP
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Contribution to paper
 Competing interests
 Acknowledgements
 References
 
Implementation of the routine offer policy
All respondents provided information on at least one occasion, and date of implementation of the routine offer and recommendation policy was reported for all units (Table 1). By the end of 1999, 81% (25/31) of London units already had such a policy, compared with only 3% (5/164) of units elsewhere in England. By the end of 2000, all 31 London units had implemented the policy, as had 74% (121/164) of units elsewhere in England; all but five of the remaining English units did so by the end of 2001. In Wales, most units introduced the routine offer in 2002, and all had done so by the end of 2003. The greatest variation in the timing of the introduction of the policy was in Scotland, where a few units introduced universal testing in the early 1990s, whereas three had still not done so by the end of 2003 (one of the three closed late in 2003, and the other two introduced the policy early in 2004). All units in Northern Ireland were making the routine offer by the end of 2003. Overall, 99% (243/246) of all UK units implemented the routine offer by the end of 2003.


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  		Table 1 Year of implementation of the routine offer policy

 

Data source and quality
Over the period surveyed, a variety of local and regional systems were used or developed to monitor the uptake of testing. Most respondents used the number of bookings recorded in the clinic or the number of blood samples sent for laboratory testing (e.g. booking bloods or samples tested for rubella susceptibility) as their denominator data, but others used the number of women attending for first scan or the number of deliveries. Some specifically pointed out that their information systems did not include data about certain types of pregnancies, for example, women who presented for the first time in labour or delivered at a different unit, community bookings (as opposed to those booking in the antenatal clinic) and pregnancies which ended in miscarriage.

The number of HIV tests carried out (numerator) was also derived from a range of sources, again mostly laboratory or maternity clinic data. In 2003, 35% (61/175) of respondents who provided adequate data for that year used laboratory records for both the numerator and the denominator, 15% (26/175) used maternity records for both and 21% (37/175) combined data from these two sources; 29% (51/175) used a combination of these and other specified data sources. Another 15 respondents provided their own estimate of uptake for 2003 but supplied no raw data or adequate information about their data sources; these estimates were therefore excluded. In most cases, respondents provided 12 months of data for each year after implementation, but in 16% of cases, uptake was calculated on the basis of 6–11 months of data.

Availability of data
Among English units in which the routine offer policy had been implemented (Table 1), adequate data for estimating uptake were provided for 75% (114/152) in 2000, 69% (131/190) in 2001, 78% (151/194) in 2002 and 75% (147/195) in 2003. Overall, 90% (176/195) of respondents provided adequate uptake data for at least 1 year following implementation of the policy. Among units elsewhere in the UK in which the policy had been implemented, data were provided for ~60% of Scottish units (6/10 in 2002, 11/19 in 2003), over 60% of Welsh units (8/12 in 2002, 10/16 in 2003) and 54% (7/13 in 2003) of units in Northern Ireland.

Of the 216 respondents who returned information for 2003, 175 (81%) provided enough adequate data for uptake to be estimated, 15 (7%) provided their own estimate of uptake without detailing the source of the data, 3 (1%) provided inconsistent data (the number of tests exceeded the number of bookings) and 3 (1%) had not implemented the policy. The remaining 20 (9%) respondents could not provide any data; reasons cited included lack of electronic monitoring systems, difficulties with disaggregating data collected across units and recent implementation of the policy.

There was no statistically significant evidence that unit size (bookings/year) was associated with providing or failing to provide adequate uptake data in different years, nor to suggest that failure to provide adequate data in later years was associated with lower uptake in earlier years (data not shown).

Uptake of antenatal HIV testing
The routine offer was in place in 152 units in England by the end of 2000 (Table 1), and 114 (75%) respondents provided uptake data for that year: 78% of those (89/114) achieved the Department of Health target of at least 50% uptake by the end of 2000 and 92% (120/131) achieved 50% or more in 2001. A 90% uptake target was established for 2002: 30% (46/151) achieved this, rising to 36% (53/147) in 2003.

Although less than a third (46/151) of English units reached the 90% target in 2002, most respondents reported high uptake (Fig. 1): at least 80% uptake was reported for 56% (84/151) of units in 2002, rising to 68% (100/147) in 2003. The proportion of units achieving at least 80% uptake was significantly higher in London than elsewhere in England in both years (2002, P = 0.008; 2003, P = 0.005). This was probably related to earlier implementation of the policy in London, compared with elsewhere in England (Table 1). Among the 136 units in England for which data were available for both 2002 and 2003, uptake increased significantly (P < 0.05) in 60% (82/136) of units [median increase in uptake, 5%; interquartile range (IQR): (4,9)], and in 24% (32/136) of units, there was no statistically significant difference between the 2 years (P ≥ 0.05). Uptake decreased significantly in the remaining 16% (22/136) of units [median decrease in uptake, –3%; IQR, (–5,–2)]. Uptake below 50% was only reported by 5 of 147 respondents for English units in 2003, all outside London.


Figure 1
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  		Fig. 1 Uptake of antenatal HIV testing over time in London and elsewhere in England, among units in which the routine offer policy had been implemented and for which adequate data were provided.

 

Elsewhere in the UK, no respondent from a unit with a routine offer policy and adequate data reported uptake of <50% in 2003. In Scotland, at least 80% uptake was reported for 4/6 units in 2002; in 2003, 10/11 achieved at least 80% uptake and 6/11 at least 90%. In Wales, uptake was lower than elsewhere: only 1/8 units in 2002 and 4/10 in 2003 achieved 80% uptake (none above 90%). In Northern Ireland, despite later implementation of the policy (Table 1), all seven units for which data were provided achieved at least 90% uptake in 2003.

Overall in 2003, 243 units in the UK had a routine offer in place, and 72% (175/243) of respondents were able to provide adequate uptake data for that year: 3% (5/175) reported uptake of <50%, 28% (49/175) reported 50–79% uptake, 31% (55/175) 80–89% uptake, and 38% (66/175) reported 90% uptake or more. There was no significant association between unit size (bookings/year) and uptake of antenatal HIV testing (≥80 or <80%) (2002, P = 0.582; 2003, P = 0.747).


   Discussion
TOP
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Contribution to paper
 Competing interests
 Acknowledgements
 References
 
Main findings
In this article, we present country-specific data on the uptake of antenatal HIV testing in the UK during the period when the routine offer and recommendation policy was rolled out. This policy was implemented in almost all units in England by the end of 2001, and although just under a third achieved the 90% target in 2002, over half achieved 80% uptake or more, and uptake in most units improved or stabilized in 2003, indicating that the policy was being put into practice. In the rest of the UK, although the policy was implemented later, virtually all units introduced the policy by the end of 2003, and high uptake levels were generally achieved at that time.

Marked variability in the formal systems in place for monitoring test uptake was reported, and even in 2003, about one in five respondents were unable to provide adequate data. Some reported specifically that certain types of pregnancies were excluded from their monitoring systems.

What is already known on this topic
Before the introduction of the routine offer policy, uptake of antenatal HIV testing was extremely low: <10% in most units.1 Local studies reported uptake rates varying from 44 to 100% in the 2 years following the introduction of routine screening.10–14 However, it is not clear whether such variations reflected the situation in the country as a whole or whether the situation subsequently improved.

Standards for monitoring antenatal screening for HIV and other infections were agreed by Department of Health expert committees and the UK National Screening Committee in 2003,11 and routine standard systems to encourage and audit the uptake of infection screening in pregnancy, including HIV, are currently being promoted at a regional level in England (http://www.screening.nhs.uk/cpd/infectious.htm).

Since 2002, despite the fact that only a minority of units achieved the 90% test uptake target, the alignment of reports to the NSHPC with unlinked anonymous seroprevalence surveys have suggested that the Department of Health’s target for at least 80% of HIV-infected pregnant women to be diagnosed before delivery has been exceeded.7 However, because of the continuing rise in prevalence of infection, a substantial number of women remain undiagnosed by the time of delivery (probably about 70–80 a year in the UK in 2003 and 2004, based on data available to date7), leading to potentially avoidable cases of mother-to-child transmission of infection. By the end of 2005, ~30 infants born to undiagnosed women in the UK in 2003 and 2004 had been reported to the NSHPC; about half of these were known to be infected (unpublished surveillance data).

What this study adds
This study shows that the routine offer and recommendation of antenatal HIV testing was implemented in almost all units in the UK by the end of 2003. It provides evidence that significant improvements in uptake of testing occurred across all regions between 2000 and 2003, with most units reporting high uptake rates in 2003. Most respondents had access to reasonably robust data sources and provided adequate data from which uptake of testing could be estimated. The results reported here provide the best available estimate of the general pattern of uptake across the UK and over time between 2000 and 2003, in relation to the timing of implementation of the routine offer policy.

This study also highlights certain shortfalls in the implementation of the policy, including low uptake of testing in a substantial minority of units and poor collection of uptake data in others. Although the 1999 Department of Health guidelines required units to monitor uptake of testing, many units still had no system in place in 2003.

Limitations of this study
Estimates of uptake of testing were derived from routinely collected maternity and laboratory data. Direct comparability between individual units was limited, to some extent, by the variety of data sources. In units where uptake was low, we could not assess whether this was because of women declining the test, or not being offered it, because most systems did not differentiate between reasons for the test not being carried out.

We attempted to assess whether units with lower uptake disproportionately failed to provide data by exploring whether units with high uptake in one year were more likely than those with low uptake to provide data in the following year. We also explored whether larger units were more or less likely to provide adequate data. Although there was no statistically significant evidence of any differences, numbers were small, and we cannot therefore exclude the possibility of some reporting bias in these respects.


   Conclusions
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Contribution to paper
 Competing interests
 Acknowledgements
 References
 
Between 2000 and 2003, the proportion of UK maternity units routinely offering antenatal HIV testing rose from under 35% to almost 100%. Despite this success, it is clear that improvements in the delivery and monitoring of the routine offer and its uptake are still needed, particularly as prevalence of infection in pregnancy is continuing to rise throughout the UK, especially in the English regions outside London.7 It is encouraging to note, however, that most units achieved uptake rates in excess of 80% in 2002 and 2003.

In the era of routine antenatal testing for HIV, uptake rates above 90% may not be required to maintain high detection rates. However, it is important to ensure that HIV testing is offered equitably and universally, in order to minimize avoidable transmissions. All pregnant women should be offered HIV testing, and likewise, systems for monitoring uptake should include them all. Simple, robust and uniform systems are needed in all units to record the number of women booking for antenatal care, being offered an HIV test, declining or accepting the offer and being tested.


   Contribution to paper
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Contribution to paper
Competing interests
 Acknowledgements
 References
 
P.T. and S.C. collected the data for 2000 and 2001, and C.T. for 2002 and 2003. C.T. carried out the data analysis. All authors participated in writing the paper. P.T. is the guarantor.


   Competing interests
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Contribution to paper
 Competing interests
Acknowledgements
 References
 
None declared.


   Acknowledgements
TOP
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Contribution to paper
 Competing interests
 Acknowledgements
References
 
We are grateful to Janet Masters and Catherine Peckham for their input in earlier stages of the survey and their helpful comments on this paper and to Mario Cortina-Borja for providing statistical advice. We thank English regional antenatal screening co-ordinators who helped obtain some of the data, as well as Louise Shaw (Health Protection Scotland) and Rosemary Johnson (Antenatal Screening Wales). We also thank everyone who completed the questionnaires, both the regular respondents who report to the NSHPC under the auspices of RCOG and the colleagues whose assistance they sought. Finally, we acknowledge the helpful suggestions and comments of the anonymous reviewers.

Funding
This work was undertaken at the Institute of Child Health with funding from the Department of Health; the views expressed in the publication are those of the authors and not necessarily those of the Department of Health. Research at the Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust benefits from Research & Development funding received from the NHS Executive.


   References
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 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Contribution to paper
 Competing interests
 Acknowledgements
 References
 

  1. 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.[Abstract/Free Full Text]
  2. Nicoll A, McGarrigle C, Brady AR et al. Epidemiology and detection of HIV-1 among pregnant women in the United Kingdom: results from national surveillance 1988–96. BMJ 1998;316:253–8.[Abstract/Free Full Text]
  3. NHS Executive. Reducing Mother to Baby Transmission of HIV. HSC 1999/183. London: Department of Health. Health Services Circular, 1999. http://www.dh.gov.uk/assetRoot/04/01/21/28/04012128.pdf (24 June 2005, date last accessed).
  4. Scottish Executive, Health Department. Offering HIV testing to women receiving antenatal care. HDL(2002)52. June 2002. http://www.show.scot.nhs.uk/sehd/viewpublication.asp?PublicationID=648 (24 June 2005, date last accessed).
  5. National Institute for Clinical Excellence. Antenatal care – Routine care for the healthy pregnant woman. Clinical guideline 6. October 2003. http://www.nelh.nhs.uk/guidelinesdb/html/antenatal_care/front.asp (24 June 2005, date last accessed).
  6. Communicable Disease Surveillance Centre NI. Routine antenatal infection screening extended to include HIV infection. Communicable Diseases Monthly Report 2003;11:6.
  7. The UK Collaborative Group for HIV and STI Surveillance. Mapping the Issues. HIV and Other Sexually Transmitted Infections in the United Kingdom: 2005. London: Health Protection Agency Centre for Infections, November 2005.
  8. Ades AE, Davison CF, Holland FJ et al. Vertically transmitted HIV infection in the British Isles. BMJ 1993;306:1296–9.[ISI][Medline]
  9. Stata Corporation. Stata 8.2 for Windows. Texas: Stata Corporation, 2003.
  10. 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]
  11. Conaty SJ, Cassell JA, Harrisson U et al. Women who decline antenatal screening for HIV infection in the era of universal testing: results of an audit of uptake in three London hospitals. J Public Health (Oxf) 2005;27:114–7.
  12. Boxall EH, Smith N. Antenatal screening for HIV; are those who refuse testing at higher risk than those who accept testing? J Public Health (Oxf) 2004;26:285–7.
  13. Dean G, Fisher M, Ottewill M. Uptake of antenatal screening for HIV infection can be high outside London too. BMJ 2001;323:1188–9.[Free Full Text]
  14. Keane FE, Neale J, Phillips T et al. Offering routine antenatal testing for HIV and hepatitis B in the rural setting of Cornwall. Sex Transm Infect 2002;78:133–4.[Abstract/Free Full Text]

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