Trends in management and outcome of pregnancies in HIV‐infected women in the UK and Ireland, 1990–2006

National data on HIV are required if meaningful trends are to be established. In this issue of the BJOG, Townsend et al. describe the epidemiological trends of HIV in pregnancy in the UK and Ireland from 1990 to 2006 and focus on the success of current antenatal HIV screening policy and clinical management guidelines of HIV in pregnancy, which has led to very low HIV mother-to-child transmission (MTCT) rates.1 This is an example of the type of robust epidemiological data that countries with high-prevalence rates of HIV should aim to achieve to plan and implement strategies to reduce the prevalence of HIV.1 HIV syndrome is one of the major challenges facing underresourced countries, particularly in sub-Saharan Africa. In these countries, women in the reproductive phase of life face the major burden of the HIV pandemic. The Annual Antenatal National HIV and Syphilis Survey is currently the most reliable form of HIV surveillance in South Africa.2 Trends from this annual national survey show that during the period 1992–1999, there was an increase in prevalence with a peak of 30.2% in 2005 among antenatal attendees in public health facilities. This figure has probably stabilised as the prevalence in 2006 was 29.1%. 2 This type of national surveillance study is probably the only mechanism by which low-income countries can obtain reliable data on HIV prevalence rates. Other data on pregnancy outcomes in Africa are commonly based on data collected from hospital registries.3 Countries in sub-Saharan Africa have also instituted antenatal screening policies to reduce perinatal HIV MTCT, but in most of the countries in this region, it is reported that only 10% of women have been tested for HIV and received the results of this test.4 Furthermore, an evaluation of a provincial perinatal MTCT programme, 5 years after its implementation and a year since the availability of highly active antiretroviral treatment for public sector patients in South Africa found that up to 30% of women did not have results of an HIV test at the time of delivery and a significant number had no results of CD4 counts.5 These findings suggest that although policies for reducing the prevalence rates in sub-Saharan Africa may be sound, the implementation of recommendations from local audits, clinical experience and research findings are difficult to sustain despite the institution of appropriate guidelines for clinical management and training. The challenges faced by under-resourced countries include cultural factors, stigma, financial resources and the lack of skilled health personnel. The UK and Ireland study shows that in a well-resourced setting, implementation of appropriate policies and clinical guidelines can be made successful, in this case leading to a considerable reduction in MTCT of HIV.1 Implementing recommendations is a complex process and requires the involvement of a number of players such as hospital managers and clinicians, each of whom has to show commitment to change. Further change in clinical practice should not be seen in isolation of the other three areas of implementing recommendations, viz. policy, administration and training. Attitudes of health professionals are crucial to achieving sustainable change in implementing recommendations.6 Of interest in the study by Townsend et al.1 is the fact that women on highly active antiretroviral therapy (HAART) had prematurity rates about 1.5 times (adjusted odds ratio = 1.51, 95% CI: 1.19–1.93) higher than women on monotherapy or dual therapy, even after adjusting for ethnicity, maternal age, clinical status and injecting drug use as the source of HIV acquisition.1 A report from Africa based on a hospital registry study suggested that treated HIV-infected women had perinatal outcomes similar to that of uninfected women. Perinatal outcomes in HIV-treated and untreated women need further