Testing for HIV infection in pregnancy

Question 1

What are some suggestions regarding implementation of a strategy to reduce perinatal HIV transmission?

Answer 1

1. Obstetric care providers should identify HIV-positive pregnant women and provide access for them to receive HIV care;
2. HCPs who care for HIV-positive women should help with HIV management during pregnancy, including the selection of antiretroviral therapy and give advice on prevention of transmission to sexual partners;
3. HCPs who provide intrapartum care should provide intrapartum antiretroviral therapy and counselling on the risks of HIV transmission when selecting the mode of delivery; and
4. HCPs who care for newborns should provide appropriate antiretroviral therapy, timely diagnostic HIV testing and should monitor both the short- and long-term outcomes of these HIV-exposed children.

Question 2

What are five factors of critical importance in a screening program?

Answer 2

1. Sensitivity and specificity of the diagnostic test;
2. Acceptability and feasibility of the diagnostic test;
3. Benefit of early detection;
4. Disadvantages of testing
5. Prevalence of disease.

Question 3

How is HIV infection diagnosed in North America?

Answer 3

1. Enzyme immunoassay (EIA) for HIV antibodies @ 4-6 weeks post infection
2. Western blot confirmation
3. Rapid HIV antibody testing (<30min)

Question 4

What is the rate of perinatal HIV transmission without interventions?

Answer 4

25%

Question 5

What is the rate of perinatal HIV transmission with use of zidovudine in mother and in the infant?

Answer 5

<2%

Question 6

What is the rate of transmission of HIV with breastfeeding per year?

Answer 6

9%

Question 7

What are the recommendations regarding breastfeeding in HIV positive mothers?

Answer 7

Do not breastfeed

Question 8

What are the recommendations regarding elective caesarian delivery without ROM?

Answer 8

Elective cesarian section or vaginal delivery maybe appropriate for women whose viral load is incompletely suppressed yet less than 1000copies/mL

Question 9

What are recommendations regarding HIV testing in pregnancy?

Answer 9

1. HIV testing should be offered routinely to all women as early as possible during pregnancy, with testing repeated later in the pregnancy stage if there is suspected ongoing exposure to HIV infection.
2. All HIV testing of women and children should be accompanied by appropriate confidentiality and counselling.
3. Testing in the perinatal period must be part of a program that includes pre- and post-test counselling, follow-up testing of the HIV-exposed child, medical and supportive care for the mother and child, and where applicable, for the father and siblings.
4. Physicians caring for pregnant women must ensure that the HIV status of the mother is available to the team caring for her at the moment of delivery. Failure to ensure availability of this information dramatically increases the risk of neonatal HIV acquisition and sometimes results in unnecessary exposure of the newborn to antiretrovirals (empirical infant therapy is sometimes started in very high-risk situations pending test results).
5. If the mother has not been tested during pregnancy or has risk factors for acquiring HIV (drug use, multiple sexual partners and sexual partner with HIV), and was not retested late in pregnancy, then every effort should be made to perform expedited HIV serology on the mother with informed consent during labour or even after delivery. If the mother is not available, expedited HIV serology should be performed on the newborn with appropriate consent.
6. If the mother refuses testing, this should be documented, and testing offered again, with consideration of a referral to a counsellor experienced in HIV counselling. The newborn should be followed as a child of unknown HIV status, in consultation with experts who may recommend antiretroviral therapy for the newborn if the mother is in a high-risk situation.
7. HIV-positive pregnant women should be given information on factors that reduce perinatal HIV transmission, which includes antiretroviral therapy, obstetrical options and resources for formula feeding.
8. Management of the HIV-positive pregnant woman and her child should be done in consultation with an HIV expert.
9. All provinces and territories must ensure that they have comprehensive, accessible programs for HIV testing in pregnancy that result in informed testing of women and provide appropriate follow-up and care for HIV-infected women and their children. These programs must be evaluated for their effectiveness, including the prevention of perinatally acquired HIV infection.