IOM: Make prenatal HIV testing part of routine care

Opponents fear harm to doctor/patient relationship

The Institute of Medicine (IOM) in Washington, DC, has recommended universal testing for HIV as a routine part of prenatal care to reduce rates of perinatal HIV transmission. The nation’s largest group of obstetricians/gynecologists is officially endorsing the IOM recommendation, even though the organization has claimed in the past that universal testing harms the personal physician/patient relationship.

"We have the tools to prevent HIV infection in newborns," says Marie McCormick, MD, ScD, professor and chair of the department of maternal and child health at the Harvard School of Public Health in Boston and chair of the IOM’s Committee on Perinatal Transmission of HIV. The IOM is a private nonprofit organization that provides health policy advice under a congressional charter to the National Academy of Sciences.

"By making HIV screening a routine part of prenatal care for all pregnant women, regardless of their risk factors or where they live, we can further lower the number of pediatric AIDS cases and help infected women get high-quality treatment," McCormick adds.

The following advantages of routine HIV testing of pregnant women are listed by the committee in a report on its recommendations:1

• It would reduce the burden on prenatal caregivers to provide the extensive pretest counseling required by current guidelines published in 1995 by the U.S. Public Health Service, which call for universal counseling and voluntary testing of pregnant women.2 With universal screening, providers would be released from the burden of encouraging women considered to be at risk from being tested, and it would prevent some cases from being missed.

• Universal testing would lessen the stigmatization of groups, such as minorities, in which perinatal HIV transmission is more prevalent.

• It would help prevent geographic shifts in the incidence of HIV infection from larger cities and other high-prevalence areas.

• Universal testing would be cost-effective because the benefits of treatment with antiretroviral therapy far outweigh the costs of prenatal testing.

The IOM committee recommends that health plans implement routine prenatal testing and that medical organizations recommend it in their practice guidelines. Public health officials should expand their outreach efforts to pregnant women so they can be tested as well.

"Testing should be seamlessly linked to treatment for women found to be infected, and this care must be coordinated before, during, and after delivery," the report states. "Providers must take steps, however, to ensure that their patient’s confidentiality is protected and that they are not forced into taking a test if they object."

Zidovudine study important

McCormick says the recommendations are based on the findings in a landmark 1994 study showing that giving women zidovudine (AZT, Retrovir) during pregnancy and childbirth reduced the risk of their newborns contracting HIV from them by two-thirds.3 The IOM reports that between 6,000 and 7,000 women with HIV give birth in the United States each year. Still, the number of pediatric AIDS cases between 1992 and 1996 dropped by 43%.

The Washington, DC-based American College of Obste tricians and Gynecologists (ACOG) has officially opposed routine prenatal HIV testing since 1995.

"We applaud Congressional concern for and support . . . efforts to prevent the spread of the AIDS epidemic, but [we] urge that the emotion of this complex issue not overshadow the doctor/ patient relationship, which is the foundation to providing effective and efficient medical care to these women and children," says a statement first released by ACOG in August 1995.

But Michael F. Greene, MD, director of maternal/fetal medicine at Massachusetts General Hospital in Boston and chairman of ACOG’s Committee on Obstetrical Practices, says officials from ACOG and the American Academy of Pediatrics recently met in Chicago to review the IOM recommendations. The two groups have decided to adopt the IOM recommendations formally, although there are some reservations about the practice, Greene admits.

"Universal screening, I think, is important," he says. "The American College of Obstetricians and Gynecologists is planning to revise its statement to endorse the IOM recommendations. But that’s not the last frontier by any means, and there is considerable attention that needs to be paid to other problems."

For example, Greene says there are inherent complications in implementing the IOM recommendations. As the IOM report recognizes, some states such as New York, California, and Massachusetts prohibit universal HIV testing.

"What the IOM is suggesting ought to be done is illegal [in those states]," he notes.

The IOM report recognizes state laws that prohibit universal screening, but recommends that those states change those laws. Greene says it is possible that if the federal government adopts the IOM recommendations, Congress could influence states to change their laws by making Medicaid funding contingent upon adopting universal screening. States would in a sense be forced to adopt universal screening because they are dependent on federal funding for Medicaid, he adds.

Another reason ACOG traditionally has been opposed to universal HIV screening of pregnant patients is that it could harm the patient/physician relationship.

"A lot of people would like to pretend that HIV is like any other illness, but it isn’t," he says. "There’s been an analogy . . . of HIV to syphilis, and that because we routinely test all pregnant women for syphilis during pregnancy, so why shouldn’t we also test them for HIV? But the fact of the matter is . . . that it isn’t the same as syphilis, it has much broader implications.

"Syphilis is a [bacterial infection]," Greene adds. "You take treatment and you’re done. Once you’re done, you’re done. You’re no longer infected. It’s a discreet, short course of treatment, and you’re done. [But] HIV disease is a lifelong illness. You’re never finished taking treatment and you can never be confident that you’re no longer infectious. So HIV and syphilis are not the same in terms of their implications for the individual, and certainly socially they’re not the same at this point."

Greene also says screening may not ensure that pregnant patients get treated for HIV. Patients may refuse therapy, or they may not disclose HIV positivity to health care providers. He says it is not unusual for HIV status to be "buried" in a patient’s chart and for providers to be unaware that a patient is HIV-positive, even during labor and delivery.

Although ACOG is endorsing the IOM recommendations officially, some problems need to be ironed out before universal screening can be set in motion, Greene notes.

"Before anything can be done, state laws need to be changed," he concludes. "Obviously, we can’t recommend to our members that they do anything that is against the law."

Ethical issues related to confidentiality and appropriate treatment of HIV-positive women need to be addressed as well, Greene adds.

[Editor’s note: A copy of the IOM report is available for $48.95 (which includes postage and handling) from National Academy Press, 2101 Constitution Ave. NW, Lock Box 285, Washington, DC 20055. Telephone: (800) 624-6242 or (202) 334-3313. E-mail: www.nap.edu. The full text of the report is available on-line at www.nap.edu/readingroom.]

References

1. Institute of Medicine Committee on Perinatal Transmission of HIV. Reducing the Odds: Preventing Perinatal Transmission of HIV in the United States. Washington, DC: National Academy Press; 1998.

2. Centers for Disease Control and Prevention. Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS. MMWR 1987; 36: 509-515.

3. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331:1,173-1,180.