STD Quarterly

Task force: Screen all pregnant women for HIV

Consider these facts: Women are the fastest-growing group in the United States with newly diagnosed HIV, and last year, an estimated 6,000-7,000 women with HIV gave birth.1,2 Almost half of those women did not consider themselves to be in a risk group.3

The U.S. Preventive Services Task Force (USPSTF) has just released new recommendations calling for all pregnant women, not just those considered at high risk, to be screened for HIV.4

"HIV screening thus has the potential to save much suffering and many lives," says Diana Petitti, MD, task force vice-chair and senior scientific advisor for health policy and medicine for Kaiser Permanente Southern California in Pasadena. "The test should be viewed as just like any other test during pregnancy: As one more thing that a woman can do to try to improve the health of her baby."

The evidence review performed prior to the issuance of the new recommendations confirms that perinatal HIV infection is an increasingly preventable disease,5 says Roger Chou, lead author of the evaluation and assistant professor of medicine and medical informatics and clinical epidemiology at Oregon Health & Science University in Portland. Perinatal transmission rates of up to 25% without treatment have been reduced to 1%-2% with the use of currently recommended interventions, he notes.

Studies indicate that screening only pregnant women who report risk factors for HIV infection could miss more than half of infected women,6 Chou points out. Many women are not aware that they have been exposed to HIV (for example, through unprotected vaginal intercourse with a male partner) or are unwilling to disclose socially undesirable high-risk behaviors, he states.

"Clearly, more complete uptake of universal prenatal HIV testing and use of recommended interventions would further reduce the incidence of perinatal HIV infection in the U.S.," states Chou. "Routine prenatal HIV screening and opt-out’ testing policies could help improve uptake of HIV testing."

Why the move?

The task force issued a recommendation in 1996 calling for a targeted strategy of routine counseling and screening of high-risk pregnant women and those who live in communities with a higher rate of HIV-positive newborns.7 The task force updated its recommendation with the advent of more recent evidence indicating wider acceptance of HIV testing among pregnant women and reports of more women diagnosed and treated for HIV prior to delivery due to universal testing.

The recommendation follows similar guidelines issued by the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP).

The USPSTF notes that ACOG, AAP, and the CDC go further in recommending that HIV testing be part of a routine battery of prenatal blood tests unless declined. The CDC and ACOG also recommend retesting women in their third trimester of pregnancy who are known to be at high risk for acquiring HIV, as well as rapid HIV testing in labor for women with undocumented HIV status, the task force notes.4

In analyzing available evidence, the task force also found evidence that elective cesarean section and avoidance of breast-feeding can further reduce the chances of a woman’s passing HIV infection to her infant.5 Since 1995, advancements in treating HIV-positive patients with highly active antiretroviral therapy (HAART), a treatment regimen that combines three or more medications, have been shown to slow the progression of the disease as well as to reduce HIV-related death rates.

"Treatment during pregnancy, planned delivery, and use of formula can reduce the risk of mother-to-infant transmission to less than 1%," says Petitti.

References

  1. Lee LM, Fleming PL. Trends in human immunodeficiency virus diagnoses among women in the United States, 1994-1998. J Am Med Womens Assoc 2001; 56:94-99.
  2. Bulterys M, Nolan ML, Jamieson DJ, et al. Advances in the prevention of mother-to-child HIV-1 transmission: Current issues, future challenges. AIDScience 2002; 2(4). Available at www.aidscience.org.
  3. Office of Inspector General, Health and Human Services. Reducing obstetrician barriers to offering HIV testing. OEI-05-01-00260. Washington, DC: Department of Health and Human Services; March 2002.
  4. US Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005; 143:32-37.
  5. Chou R, Smits AK, Huffman LH, et al. Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2005; 143:38-54.
  6. Barbacci MB, Dalabetta GA, Repke JT, et al. Human immunodeficiency virus infection in women attending an inner-city prenatal clinic: Ineffectiveness of targeted screening. Sex Transm Dis 1990; 17:122-126.
  7. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. Second ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996.

Resource

Review the U.S. Preventive Services Task Force new recommendations by visiting the Rockville, MD-based Agency for Healthcare Research and Quality web site at www.ahrq.gov. Under "Clinical Information," click on "Preventive Services." Under the heading "U.S. Preventive Services Task Force (USPSTF)," click on "Clinical Categories." Under "Infectious Diseases," click on "Human Immuno-deficiency Virus (HIV) Infection: Screening." By then clicking on "Supporting Documents," readers can download documents of the statement, review of the evidence, and evidence synthesis.