Select Committee on Health Appendices to the Minutes of Evidence

Attachment 10



  Around 300 babies are born to HIV infected mothers in the UK each year, a more than fivefold increase since the early 1990s. In the UK, hepatitis B infections are mainly acquired in adulthood. Estimates indicate that there are between 600 and 2,000 women with infectious hepatitis B giving birth each year in England and Wales. Although hepatitis B perinatal transmission accounts for only 5 per cent of infections in England and Wales, it is responsible for 30 per cent of the infections leading to chronic hepatitis B carriage. Consequently each year substantial numbers of children become infected by their mothers with HIV or hepatitis B virus (HBV). Almost all these infections are preventable.

  There are substantial health inequalities in this burden of infection and in the availability of prevention services. Mothers who have lived in Africa (for HIV) and other resource-poor countries (hepatitis B) are mostly affected. Though there have been improvements, eg in parts of London, it remains the case that the majority of pregnant women infected with HIV are unaware of their infection and cannot take advantage of recent medical advances that could protect their children. The situation is little better for Hepatitis B.


  An HIV positive mother can now almost completely eliminate the risk of passing her infection on to her child by taking antiviral drugs. This relatively inexpensive medication has reduced the probability of her child becoming infected from one in three to less than one in 50. In this way the number of babies born with HIV in the UK could be reduced from around 60 to under 10 per annum. Aside from the personal benefit, with overall HIV care already costing over £200 million per annum in England, the importance of maximising the chances of preventing new infections is obvious. Similarly, a mother with acute or chronic hepatitis B infection can reduce the risk of passing on her infection to her baby by 90 per cent by agreeing to immunisations of her baby at birth and in the first year of life. To take advantage of these interventions mothers with HIV and HBV infections must, of course, be aware of the risk. While testing before pregnancy would be optional the most pragmatic approach to it is through routine antenatal testing.


  Following reviews by the UK National Screening Committee, the Department of Health has indicated that HIV testing should be routinely offered and recommended across England as of December 2000 (Health Services circular No 1999/183). That has also been the case for HBV since April 2000 (HSC 1998/127). The organisation of antenatal HIV testing requires everyone involved in antenatal care, including GPs, to make HIV a priority and to present a consistent message to mothers. The same is true for HBV. Microbiology services have to deliver a highly accurate testing service for both viruses, with particular emphasis on avoidance of false positive results which might undermine confidence in the programme. Once a mother is discovered to be infected with HIV she must receive prompt high quality care, advice and support, including treatment of her own infection. For both infections, a crucial issue is to ensure that children are followed up and the required treatment/immunisations are delivered in primary or other care contexts. These arrangements require co-ordination across a wide range of agencies including Department of Health, NHS Executive, District Health Authorities, NHS Hospital and Community Trusts, and Primary Care Groups/Trusts. Voluntary, non-governmental and community based organisations play a crucial role in promoting antenatal testing and care of infected women.


  Data gathered by the PHLS and its collaborators indicate that, for HIV, the greatest determinant of whether a pregnant woman is offered and receives an HIV test, and HIV infection is diagnosed, has been the hospital or practitioner giving antenatal care, and/or where she lives. In London the proportion of all births to HIV infected mothers that were detected rose from 15 per cent in 1996 to 50 per cent in 1999, but there are still areas of poor performance and outside the capital it remains the case that a woman will rarely be routinely offered a test. Antenatal screening services are often unco-ordinated locally, and the statistics required for performance monitoring (such as the proportion of women screened or offered screening) are often not routinely available. A Department of Health Task Force, supported by the PHLS and others, is starting to address this but the new arrangements for primary care may not help, especially as infections are not a priority in Our Healthier Nation and progress on the national Communicable Disease Strategy has been slow.


  PHLS provides primary and reference testing, epidemiological data, data for policy development performance monitoring and specialist advice. However, national and local roles and responsibilities must be clarified and antenatal screening services co-ordinated. Data systems should provide data for monitoring the offering and acceptance of HBV, HIV and other routine antenatal tests. All HIV and HBV positive blood samples should be sent for confirmation to the network of reference laboratories co-ordinated by PHLS.


  Despite the public health importance and potential for health gain, the UK is still under-performing on antenatal screening for HIV and HBV. A more co-ordinated approach is essential for success.


  Intercollegiate Working Party for Enhancing Voluntary Confidential HIV Testing in Pregnancy Reducing mother to child transmission of HIV infection in the UK. Royal College of Paediatrics and Child Health, London, 1998.

  Prepared by Drs Angus Nicoll, Philip Mortimer and Koye Balogun and Mrs Susan Cliffe, Public Health Laboratory Service.

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Prepared 28 March 2001