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Gaps in HIV testing: results from an audit of abortion services in England
  1. Merrington Omakalwala, MSc
  1. Louise Logan, MSc
  1. Livingstone Musoro, PhD
  1. Fortune Ncube, MBBS, FFPH
  1. Research Assistant/Information Analyst, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; merrington.omakalwala{at}
  2. Senior Scientist (Epidemiology), Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; Louise.Logan{at}
  3. Senior Lecturer (Health Studies), Faculty of Social Sciences and Humanities, Metropolitan University, London, UK; L.Musoro{at}
  4. Consultant Epidemiologist (Public Health Medicine/Blood Bourne Viruses), Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK; fortune.ncube{at}
  1. *Corresponding author.

Statistics from

Reducing undiagnosed and late diagnosed HIV infection in the population remains a public health priority. By the end of 2012, of the estimated 98 400 people living with HIV in the UK, approximately 1 in 3 (31 700) were women of whom about 1 in 4 (7700) were unaware of their infection.1

There were 842 200 conceptions for women aged 15–44 years in England in 2012; of these, 1 in 5 (21%) resulted in abortions.2 Over 1 in 6 of all abortions carried out in England were conducted in non-National Health Service (NHS) settings in 2012.3

Unlinked anonymous surveys last conducted in 2004 identified an HIV prevalence of 1.19% among women attending NHS abortion services in London compared to 0.57% in corresponding antenatal clincs.4 In 2008, the British HIV Association (BHIVA) recommended universal offer of testing for women attending abortion services in their National Guidelines for HIV Testing.5 Guidelines from the National Institute for Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG), both published in 2011, support the offer of a test to all women attending abortion services in accordance with the BHIVA guidelines.6 ,7 RCOG guidelines state that an abortion service provider must have an HIV testing policy in place.7

Despite the guidelines, little is known about the extent and patterns of HIV testing in abortion services in England. The RCOG has called for additional research into the epidemiology of HIV and better auditing standards in HIV testing among women being seen for abortions.7 In June 2013, Public Health England (PHE) conducted an audit, asking abortion service providers about their policies and practices around HIV testing for women attending their services.

A randomly selected sample of 140 abortion service providers in England, 131/244 eligible NHS trusts and 9/15 approved non-NHS providers, were chosen as sampling sites. Of the nine non-NHS providers, only four took part in the audit. Gynaecology clinical leads from each provider were invited by e-mail to complete a 27-item secure and anonymous online questionnaire hosted by PHE's SelectSurvey.Net.

Despite a disappointingly low response rate of 28% (39/140) we were able to make a number of observations about the delivery of HIV testing in these settings, which varied considerably and was influenced by different factors. A number of abortion service providers was not following recommended guidelines. Testing was largely dependent on whether a clinic had an HIV testing policy, of which only about two-fifths (38%, 15/39) had. Around half (54%) of the survey respondents did not have a testing policy; and of those that had a policy (16/39), one provider did not test.

Some (18/39) providers were offering some form of HIV testing: either as opt-out routine testing to all women or to women selected based on perceived HIV-related risks. Of the providers (23/39) who either did not have or did not know if their clinic had a testing policy, more than 1 in 10 (3/23) were providing HIV testing (Figure 1).

Figure 1

Proportion of abortion service providers in England with a testing policy and those offering HIV testing in abortion clinics in 2012 (n=39).

Responses from non-NHS providers revealed that HIV testing in this sector was dependent on commissioning service specifications that were agreed with local authorities.

These data show that there are gaps in the provision of HIV testing for women attending abortion services, and either absent or inadequate policies and practices. Opportunities are being missed to diagnose HIV infections promptly and reduce the number of undiagnosed infections.

PHE is developing a programme of work to investigate the inadequacies in HIV testing in these settings, and to address the barriers to commissioning services that promote HIV testing in this sector.


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  • Competing interests None.

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