Stepping up from opt-out: Achieving 100% uptake antenatal human immunodeficiency virus testing

All pregnant women in the United Kingdom are offered and encouraged to take up screening for human immunodeficiency virus (HIV), hepatitis B and syphilis, with excellent uptake rates and engagement in care resulting in very few infants being infected with HIV in the United Kingdom. However, in that small number of women who decline testing, there remains an opportunity to offer further support to test and engage them and their baby in care, even if this happens in labour or immediately after birth. In addition, these women may be at increased risk of HIV. Our hospital is in an extremely high prevalence area for HIV, and most untested individuals are of childbearing age. We embarked on a quality improvement project to engage all women delivering at our unit in HIV testing or to test their babies via cord blood at birth. We sought to do this in a constructive and inclusive way, led by the HIV specialist midwife with the support of the HIV antenatal and the hospital senior management teams. Following an initial evaluation, the approach was modified and an innovative approach together with a trusted advocate was used to engage a particularly hard-to-reach group. We have achieved 100% uptake of HIV testing and made two HIV diagnoses that would not otherwise have been made; both in women who reported themselves not to be at risk and both engaged in care and delivered HIV-negative infants.