Prenatal HIV Testing in Ontario
Guenter, Dale, Carroll, June, Kaczorowski, Janusz, Sellors, John, Canadian Journal of Public Health
Knowledge, Attitudes and Practices of Prenatal Care
Providers in a Province with Low Testing Rates
Objective: To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing.
Methods: A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire.
Results: Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians.
Conclusion: Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.
Pregnant women with HIV infection can benefit from treatment with antiretroviral therapy,1 and the risk of transmission to their newborn infants can be reduced to 1% through a variety of interventions.2 In order for these benefits to be realized, HIV infection must be diagnosed prior to or during pregnancy. Different prenatal HIV testing policies have been adopted in different Canadian provinces.3-5 In December 1998, the Ministry of Health and Long-Term Care in Ontario changed its policy of voluntary HIV testing for women in high-risk groups to a policy of offering testing to all pregnant women, regardless of risk.
The burden of preventable disease is increasing. It has been estimated that HIV prevalence among women in Ontario increased from 2.2/10,000 women in 1990 to 7.5/10,000 in 1998.6 One hundred seven confirmed childhood infections in Ontario occurred through vertical transmission from 1984 through 1998. In spite of this, laboratory data indicate that 51% of pregnant women in Ontario were tested for HIV during 1999 and 2000, substantially lower than in several other provinces.5 At least six children have thus far been identified as being infected during the same period through vertical transmission from mothers who were not tested.7
Substantial evidence suggests that offering HIV testing to women with risk factors for HIV is less effective than offering testing to all women. Studies from the United States and the United Kingdom report that 21% to 75% of women who are HIV positive are not known to have risk factors at the time a screening history is taken.8-13 More HIV infections are diagnosed by offering testing to all women than by offering testing to women with known risk factors.14,15
Current testing rates in Ontario are insufficient to prevent all newborns from being infected. Understanding the knowledge, attitudes and practices of providers with respect to prenatal HIV testing may offer an explanation for this situation. To explore this possibility, we carried out a province-- wide survey of family physicians, obstetricians and midwives in order to describe what they understood about prenatal HIV testing, how they felt about various aspects of the informed consent and testing procedure, and how they were actually carrying out HIV testing in their practices.
Three of the six health-planning regions in Ontario were selected for sampling: Northern, Central East (including Toronto), and Eastern (including Ottawa). These regions were selected to represent areas with high, low, and medium uptake of testing respectively, based on laboratory data available at the time that the study was planned. They represented 7,495,242/11,100,900 (67.5%) of the general population of Ontario (based on 1996 Canadian Census data).
The sample was drawn from Southam Medical Lists (Southam Medical Group, Don Mills, Ontario), which includes updated information from physician licencing bodies. …