Abstract
Undiagnosed HIV infection in children carries significant risks and national guidelines recommend that children of HIV-positive parents be tested. We reviewed the testing of HIV-positive patients' children in those new to our service from April 2008 to December 2009. Of the 86 women, 95% were asked about children. Of the 243 men, 53 were heterosexual or bisexual, and 190 identified themselves as men who have sex with men (MSM). Parental status was determined in 37 (70%) of heterosexual and bisexual men and in 14 (17%) of 84 MSM with a history of previous female partners. All untested children apart from one lived in their country of origin. In MSM, recording of parental status was uncommon. Following this audit, clinic proformas were changed to document the parental status of men of all sexual orientations, and the HIV status of all children.
INTRODUCTION
UK HIV testing guidelines 1 recommend testing all children at-risk of HIV, particularly children of HIV-positive parents. Undiagnosed HIV infection carries significant risk of morbidity, mortality and onward transmission. 1 Many children with perinatally acquired HIV are born abroad 2 and are at increased risk if their mothers were not offered HIV testing prenatally. They may remain asymptomatic into adolescence, 3 with parental perception that seemingly well children are uninfected. 4 Parents may be reluctant to reveal their own diagnosis to a child or may be unaware of their children's diagnoses, particularly those who remain abroad. 5 Encouraging testing of all children at-risk allows early identification of HIV-positive children and appropriate management.
There are few data on fatherhood and HIV-positive men. In one study, 78% of HIV-positive men who have sex with men (MSM) had not discussed fatherhood with health-care professionals. 6 In addition, of heterosexual HIV-positive men, 41% indicated some fear of discrimination if they conceived a child and 25% said they would not disclose their status at antenatal clinic. 7 One study estimated that around 25% of bisexual or homosexual men may be fathers. 8
Our policy is to determine the HIV status of all children of HIV-positive patients within six months of attending our service. From April 2008, revised clinic proformas included documentation of obstetric history and children's HIV status. This audit represents our clinic's performance with reference to the national guidelines.
METHODS
Case-notes of new HIV-positive patients from April 2008 to December 2009 were reviewed. Age, gender, sexual orientation, ethnicity and details of their children including their location and HIV status were recorded. Where the child's HIV status was unknown, we assessed whether appropriate action had been taken.
RESULTS
The audit covered 329 patients; 243 men (mean age 35 years) and 86 women (mean age 32 years). Of the 86 women, 74 (86%) were from black ethnic groups and 82 (95%) had been asked about children. There were 57 HIV-positive mothers, 50 (88%) of whom were born in Africa, with a total of 125 children (aged 4 months to 27 years). They had a median number of two children (range 1–8). Seventy-one (57%) children had been tested for HIV and 10 did not require testing as their mothers' tests were negative after completion of breastfeeding.
Forty children were currently living in the UK; 38 had been tested with two fully informed adult children considering testing. All untested children were living in Africa. Some parents were delaying the testing of their children until they entered the UK. There was no subsequent documentation and it is possible that some had since entered the UK and not been tested.
There were 53 heterosexual or bisexual men (58% from black ethnic groups) and 37 (70%) were asked about paternity. Twenty-four were fathers; 75% were of black African origin with a total of 51 children aged nine months to 22 years. Nineteen of these children had been tested for HIV and 14 did not require testing as either their mothers' tests were negative after completion of breastfeeding or their HIV-positive fathers had documented seroconversion after their birth. Of the remaining 18 untested children, only one child was living in the UK.
There were 190 MSM; median age was 32 years (range 19–70 years) and 83% were of white British origin. Previous partners' gender was documented in 154 (81%) cases; 70 (45%) were exclusive MSM and 84 (55%) reported previous female partners. In this group, the timing of the sexual relationships with women was documented in 50 (60%) men and 14 (17%) had negative HIV tests at a later date, indicating no risk of HIV transmission to children. Only 14 (17%) men with previous female partners were specifically asked about children and in 56 (67%) of these MSM it was unknown whether there were any children at risk for HIV infection.
DISCUSSION
This audit demonstrated that within our clinic, maternal status was documented in 95% of cases. Women were routinely asked their children's HIV status and, if unknown, arrangements were made for testing to take place.
Heterosexual and bisexual men were less frequently asked about children, although status was determined in all but one case for known children residing in the UK. Fewer MSM were asked about sexual relationships with women and parental status was largely undetermined.
Parents with children living abroad were advised at their initial assessment to request HIV testing for these children, but this was rarely followed up.
Following this audit, there is an increased emphasis on the determination of parenthood of women and men of all sexual orientations. Clinic proformas will be modified to ask all men if they have children, and discuss the need for HIV testing. Parents are encouraged to ascertain the HIV status of children living abroad, and re-visited at follow-up, especially when arrangements may be underway for the children to come to the UK.