Universal HIV tests eyed for prenatal care

Which women should undergo prenatal HIV testing? All of them, according to a new education campaign launched by the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG). Every pregnant woman, regardless of her apparent risk for HIV, should be tested for evidence of the infection, along with being informed that the test will be run, according to ACOG. While the test is not mandatory — women can refuse it — the organization hopes the campaign will make HIV testing an ordinary part of the prenatal screening process.

The new standard of "universal, routine testing with patient notification" has been adopted by ACOG and the Elk Grove Village, IL-based American Academy of Pediatrics following the 1998 recommendation of such practice by the Institute of Medicine (IOM) in Bethesda, MD.1

A grant from the Centers for Disease Control and Prevention (CDC) in Atlanta has enabled ACOG to produce and distribute packets of provider and patient information to all its members, according to Stanley Zinberg, MD, vice president of ACOG’s practice activities division. While the funds don’t cover distribution to other groups, ACOG plans to share the educational material with other professional organizations in hopes it can be replicated for other providers, says Zinberg.

Why should HIV testing become a routine part of pregnant women’s prenatal care? Patients may ask this question, particularly if they are in a stable, monogamous relationship. ACOG sums up the reason in its patient information materials:2 "You can have HIV for years and not know it or feel sick. To get early help for yourself, you need to know for sure." Without treatment, one in four babies born to women infected with HIV will become infected, notes ACOG. However, taking special medication for HIV during pregnancy can greatly reduce the risk of an infant getting HIV.

Indeed, there has been much progress since 1994 in prevention of transmission of HIV from mothers to babies in the United States, notes Mary Glenn Fowler, MD, chief of the maternal-child transmission section of the epidemiology branch of the CDC’s Division of HIV/AIDS Prevention. The current strategy is to eliminate as many cases as possible of perinatal HIV transmission, she says.

According to research data, use of the drug zidovudine during pregnancy and the neonatal period reduces the rate of mother-to-child HIV transmission by about two-thirds.3,4 New cases of AIDS in newborns declined 67% between 1992 and 1997, due in large part to increased treatment with zidovudine.5

"Given all the new, effective interventions for preventing mother-to-child transmission and also for HIV-infected women’s health care, we thought it was very important that every woman be offered [testing]," says Fowler. "She then can make her decision whether she accepts testing or not."

To reach those women who had not been covered under existing perinatal prevention programs, the CDC determined that obstetricians should be included in the effort, explains Fowler. ACOG, which estimates that its members perform about 85% of the nation’s 3.9 million deliveries each year, was tapped for the CDC partnership.

In further efforts to reduce the rate of perinatal HIV transmission, ACOG has released a new committee opinion that recommends HIV-positive pregnant women with high viral loads be counseled by providers about both the benefits and risks of elective cesarean delivery.6

For women being treated with zidovudine, a cesarean delivery before the onset of labor and rupture of membranes reduces the likelihood of HIV transmission to the newborn to about 2%; however, cesarean delivery is associated with higher maternal complications. Patients will need to be counseled on the risks and benefits associated with the procedure and make their own decision about delivery.

Check state laws

While ACOG recommends that its members adopt the new testing standard, it also recognizes that laws or policies in many states require counseling and informed consent for HIV testing, says Zinberg. ACOG encourages members to include counseling as a routine part of care but not as a prerequisite to prenatal HIV testing, unless it is required by state law. Check with your state department of health to determine whether it is a requirement.

"We still feel pretty strongly that counseling is an important component, and we said this in our joint statement with the pediatricians, even though we are accepting the IOM’s recommendation," Zinberg notes.

The education packets include tear pads of information, written in English and Spanish, to inform patients about perinatal HIV testing and treatments, as well as patient pamphlets and posters to emphasize the importance of testing for all women. The tear pad is very informative, Zinberg observes. It addresses the general prenatal tests performed near or at the first provider visit and concentrates on the HIV test. A laminated card with HIV facts for the provider is included for use in discussing the HIV test.

Counseling requirements indeed may vary from state to state, notes Fowler; however, many state laws have language with "strong urging" for obstetricians and other health care providers to offer testing. "Some states are a little bit stronger on how it’s worded," she says. "I think the thrust of the states has been very much in line in making it much more available to all pregnant women."

References

1. Stoto MA, Almario DA, McCormick MC, eds. Reducing the Odds. Preventing Perinatal Transmission of HIV in the United States. Bethesda: Institute of Medicine; 1998.

2. American College of Obstetricians and Gynecologists. Important News for Pregnant Women. Washington, DC; 2000.

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.

4. Sperling RS, Shapiro DE, Coombs RW, et al. Maternal viral load, zidovudine treatment and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. N Engl J Med 1996; 335:1,621-1,629.

5. Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999; 282:531-538.

6. American College of Obstetricians and Gynecologists. Scheduled Cesarean Delivery and the Prevention of Vertical Transmission of HIV Infection. ACOG Committee Opinion 219: Washington, DC; 1999.