Ontario joins prenatal HIV-screening movement
CMAJ 1999;160:173
© 1999 Ann Silversides
Ontario joined ranks with 7 other provinces and territories last month when it announced a program of universal prenatal HIV counselling and voluntary testing. The announcement was made on World AIDS Day, Dec. 1. However, some experts are concerned that the province has made little effort to inform doctors about the tests, which can be done only with a pregnant woman's informed consent.
"Doctors who have never really thought about HIV often know very little about it, and are uncomfortable — we've seen this a lot," says Dr. Susan King, a pediatrician and infectious disease specialist at Toronto's Hospital for Sick Children. She thinks it will take obstetricians in some communities "quite a while to become comfortable" enough to discuss the tests with patients. An information package of brochures for patients and guidelines for doctors was not available when Health Minister Elizabeth Witmer announced the program.
British Columbia, the first province to act, launched its program in 1994, and King is pleased that Ontario has finally taken the same step. "We're still picking up kids who were infected as infants. We just had a 3-year-old referred to us. If we'd had a program in '95, that might have been prevented."
Ontario's standard prenatal laboratory test forms are being revised to include the HIV test and doctors will be required to tick a box indicating that pretest counselling was done. If a test is ordered, a second box specifying that informed consent was obtained must also be ticked.
The province expects that about 150 000 prenatal HIV tests — roughly equal to the number of expected births — will be performed annually at a cost of about $775 000. Previously, only about 12% of pregnant women were tested for HIV in Ontario. King says the provincial laboratory will not perform an HIV test, even if one has been requested, unless the counselling and informed-consent boxes have been ticked. Under those circumstances, the laboratory will contact the physician involved.
King says many doctors test patients using only initials, or false names, but when a test result is obtained it becomes part of the patient's medical record. Pregnant women are also supposed to be told that anonymous testing is available at 33 different sites in Ontario. "We will need to know if testing is happening, if it is being done in a reasonable way and if women are being made unduly anxious," says King, who noted that the province has not yet committed itself to such an evaluation.
Knowledge of a pregnant woman's HIV status is crucial. Research published in 1994 revealed that perinatal transmission of HIV can be reduced by two-thirds if pregnant women are treated with zidovudine. More recent research has indicated that treatment with protease inhibitors can reduce the risk of transmission almost completely. However, the long-term effects of that drug treatment on the fetus are not known.
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