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Revised
Recommendations for HIV Screening in Pregnant Women [CDC MMWR
2001;50: RR-19:59] The
revised guidelines represent the recommendations of an expert panel
of 48 consultants who met in April, 1999. Highlights include the
following:
Frequency of perinatal transmission: The transmission rate
in the period 1985-94 was reported at 16-25%; this decreased to
less than 11% with the ACTG 076 report [NEJM 1994;331:1173]. During
the period from 1996 to 2000, the transmission rate decreased to
5-6%, reflecting the effects of AZT and HAART, and the most recent
data, for 2000-01, shows that rates are now less than 2%. With no
detectable virus, the rate is less than 1% [NEJM 1999;341:385;
JAMA 1999;282:531; JID 2001;183:539].
Dynamics of perinatal transmission: For women who do not
breast feed, intrauterine transmission accounts for 25-40%, and
transmission during labor and delivery accounts for 60-75%. For
women who breast-feed, intrauterine transmission accounts for 20-25%;
this or early breast feeding accounts for 60-70%, and later postpartum
transmission through breast feeding accounts for 10-15% [JID
1996;174:722].
Counseling recommendations are summarized as follows:
- Who: All pregnant women
- How: Standard assay with informed consent. Rapid assay
if presents in labor.
- When: As early as possible. High-risk patients: Repeat
in 3rd trimester preferably before week 36
- Information to be provided in counseling (the bare minimum):
- HIV is the virus which causes AIDS and is spread primarily
by sex and injection drug use.
- Women may be infected and not know it.
- There are effective interventions that can protect the
infant and reduce morbidity and mortality in the mother.
- HIV serology is recommended for all pregnant women.
- Services are available to help pregnant women prevent HIV
transmission.
- Women who refuse the test will receive their care and their
infants will also receive care.
Legal considerations: The PHS guidelines endorse counseling
all pregnant women on the risk of HIV infection, the benefits of
HIV testing, and the need for voluntary testing. These have been
endorsed "by most professional organizations" and these
have been implemented by states, "but with substantial variability
in strategy." Most states have policies for HIV counseling
and testing, and 50% have laws or regulations requiring this. New
York and Connecticut are the only states that mandate testing of
newborns and no states require testing of pregnant women without
informed consent. This issue has been reviewed by the Institute
of Medicine which resulted in a 1999 recommendation that the U.S.
adopt a policy of universal HIV testing of pregnant women with patient
notification as a routine component of prenatal care. This recommendation
for universal HIV testing and patient notification is under consideration
by some states.
posted
1/7/2002
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