CME: Guidelines Address HIV Testing, Prophylaxis to Prevent MTCT

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Guidelines Address HIV Testing, Prophylaxis to Prevent Mother-to-Child Transmission CME/CE

News Author: Laurie Barclay, MDCME Author: Laurie Barclay, MD DisclosuresRelease Date: November 3, 2008; Valid for credit through November 3, 2009

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Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians;Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians;Nurses - 0.25 ANCC contact hours (None of these credits is in the area of pharmacology)

To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.

Learning Objectives

Upon completion of this activity, participants will be able to:

Describe recommendations for HIV testing and screening of pregnant women and newborns in the United States. Describe recommendations for HIV prophylaxis in pregnant women and in newborn infants.

Authors and Disclosures

Laurie Barclay, MDDisclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Laurie Scudder, MS, NP-CDisclosure: Laurie Scudder, MS, NP-C, has disclosed no relevant financial information.

Brande Disclosure: Brande has disclosed no relevant financial information.

November 3, 2008 — The American Academy of Pediatrics (AAP) has issued a policy statement to summarize the guidelines for HIV testing and prophylaxis to prevent mother-to-child transmission (MTCT) of HIV in the United States. This policy statement updates evidence supporting the current guidelines and suggests ways to continue improving the implementation of universal HIV testing of pregnant women during routine prenatal care.

"Continuing technologic and medical advances in the diagnosis, prevention, and treatment of pediatric HIV infection require ongoing assessment and review of recommendations relating to pediatric HIV infection, including recommendations regarding prenatal and perinatal HIV counseling and testing," write L. Havens, MD, and colleagues from the 2007-2008 Committee On Pediatric AIDS. "Current guidelines are consistent in their recognition of the importance of universal HIV testing of pregnant women in the United States as the key to prevention of...MTCT (also referred to as vertical or perinatal transmission) of HIV. The...AAP continues to support these guidelines."

Specific recommendations in the new guidelines are as follows:

As part of a comprehensive prenatal program of healthcare, pregnant women should routinely receive information about HIV infection, prevention of MTCT of HIV, and HIV antibody testing. All pregnant women in the United States should undergo documented, routine HIV antibody testing, in a manner consistent with state and local laws, after being notified that testing will be performed. However, the patient may decline HIV testing (opt-out consent or right of refusal). Healthcare professionals in states where laws and regulations require written informed maternal consent for testing should endeavor to change these laws or regulations to allow opt-out consent. All programs designed to detect HIV infection in pregnant women and their infants should undergo periodic monitoring of the proportion of women who do not receive HIV antibody testing. Those programs in which an unacceptably high proportion of women are not tested should assess the reasons and modify the program as indicated. In the third trimester, preferably before 36 weeks of gestation, repeated HIV antibody testing is recommended for the following groups:

Women aged 15 to 45 years in states with high HIV prevalence. Women delivering in hospitals in which HIV prevalence is 1 or more in 1000 pregnant women screened. Women with risk factors for HIV infection, such as diagnosis of a sexually transmitted infection during pregnancy, use of injection drugs or being a partner of an injection drug user, exchanging sex or money for drugs, being a sex partner of someone who is HIV-infected, having a new or multiple sex partners during pregnancy, or signs or symptoms of acute HIV infection.

Some experts recommend repeated HIV screening for all pregnant women in the third trimester. The rationale is that prevalence-based testing may be difficult to implement, evaluation of individual risk is unreliable, and the risk for MTCT of HIV is increased in women who first acquire HIV infection during pregnancy. Maternal HIV antibody testing with opt-out consent, with use of a rapid HIV antibody test, is recommended for women in labor when HIV-infection status during the current pregnancy is undocumented. When the mother's HIV serostatus is unknown, the newborn infant's healthcare professional should order rapid HIV antibody testing for the mother or the newborn, with appropriate consent as required by state or local law. To facilitate appropriate care and testing of the newborn infant, maternal HIV serostatus should promptly be disclosed to the healthcare professional for that infant. When results of HIV rapid antibody test are positive, the mother and newborn infant should receive antiretroviral prophylaxis without waiting for results of confirmatory HIV testing. Although women with positive results of HIV rapid antibody test should not breast-feed, they should be offered assistance with immediate initiation of hand and pump expression to stimulate milk production, in the event that confirmatory test results may be negative. If this proves to be the case, prophylaxis should be stopped and breast-feeding may be started. All facilities with an obstetric unit and/or newborn nursery of any level should have rapid HIV antibody testing available on a 24-hour basis. Infant medical records should document maternal HIV-infection status, and this documentation should be a standard measure of the adequacy of hospital care for the mother and infant. Although prophylaxis is most effective within 12 hours of birth, it may still be effective when started as late as 48 hours of life. Before hospital discharge, the full 6-week course of infant antiretroviral prophylaxis should be arranged and the family should be carefully instructed regarding administration. All third-party payers should pay for the prophylaxis. Infants should not breast-feed if either the mother or the infant has a positive test result for HIV antibody. The newborn infant should be tested for HIV antibody, preferably within the first 12 hours of life, in the absence of parental availability for consent. State and local jurisdictions should develop policies to ensure rapid assessment and testing of the infant. To guide appropriate care and follow-up testing if indicated, infants of unknown HIV exposure status at the first health supervision visit should undergo HIV antibody testing with appropriate consent. Specialists in obstetric and pediatric HIV infection should be consulted regarding care of the mother, fetus, newborn, and child with perinatal exposure to HIV.

"Identification of HIV infection early in pregnancy allows the greatest ability to treat the pregnant woman for her HIV infection for her own health and to prevent MTCT of HIV," the study authors conclude. "Rapid HIV antibody testing allows for timely identification of HIV infection in women even late in pregnancy, during labor, or in the immediate postpartum period as well as HIV exposure in their newborn infants. The results can be available quickly enough to implement successful ARV [antiretroviral] interventions that can reduce MTCT of HIV when administered to the mother started later in pregnancy or in labor or to the infant when administered within the first few hours of life."

Pediatrics. 2008;122:1127-1134.

Clinical Context

Recent progress in diagnosing, preventing, and treating pediatric HIV infection mandates ongoing evaluation and review of guidelines regarding prenatal and perinatal HIV counseling and testing. The current guidelines acknowledge the importance of universal HIV testing of pregnant women in the United States to prevent MTCT of infection.

The AAP continues to support this underlying principle. Their new policy statement offers updated evidence in support of the guidelines as well as suggestions to improve the implementation of the recommendations for universal testing during routine prenatal care.

Study Highlights

The key to preventing MTCT of HIV in the United States is universal HIV testing of pregnant women. The AAP recommends "opt out" consent or "right of refusal." After being notified that testing will be performed, all pregnant women in the United States should undergo routine HIV testing unless they decline this testing. To further decrease the rate of perinatal HIV transmission, repeated testing in the third trimester may be helpful, particularly in high-risk groups. Rapid HIV testing at labor and delivery may also be helpful, using new, rapid testing methods that can identify HIV-infected women or HIV-exposed infants in 20 to 60 minutes. Women in labor with undocumented HIV infection status during the current pregnancy should undergo immediate rapid HIV antibody testing with opt-out consent. Immunofluorescent antibody or Western blot assay should be used to confirm positive HIV antibody screening test results, but prophylaxis should not be delayed while awaiting definitive test results. Preventing MTCT of HIV is most effective when antiretroviral drugs are given to the mother during her pregnancy, continued through delivery, and then given to the newborn infant. Antiretroviral drugs are effective in reducing the risk for MTCT of HIV even when prophylaxis is started for the infant soon after birth. When rapid HIV antibody test result is positive in a pregnant woman, antiretroviral prophylaxis should be promptly given to the mother and newborn without waiting for results of confirmatory HIV testing. If the confirmatory test result is negative, prophylaxis should be discontinued. When the mother's HIV serostatus is unknown, rapid HIV antibody testing should be performed on the mother or on the newborn, and results should be reported to the healthcare professional within 12 hours after the infant's birth. If the rapid HIV antibody test result is positive, antiretroviral prophylaxis should be started as soon as possible and no later than 12 hours after delivery. Pending completion of confirmatory HIV testing, the mother should be counseled not to breast-feed, but she should be assisted with immediate initiation of hand and pump expression to stimulate milk production. If the confirmatory test result is negative, prophylaxis should be stopped and breast-feeding may begin. If the confirmatory test result is positive, the mother should not breast-feed, and the infant should receive antiretroviral prophylaxis for 6 weeks after birth.

Pearls for Practice

The key to preventing MTCT of HIV in the United States is universal HIV testing of pregnant women, using "opt out" consent or "right of refusal." To further decrease the rate of perinatal HIV transmission, repeated testing in the third trimester may be helpful, particularly in high-risk groups. New methods of rapid HIV testing at labor and delivery may identify HIV-infected women or HIV-exposed infants in 20 to 60 minutes. Preventing MTCT of HIV is most effective when antiretroviral drugs are given to the mother during her pregnancy, continued through delivery, and then given to the newborn infant. Immunofluorescent antibody or Western blot assay should be used to confirm positive HIV antibody screening test results, but prophylaxis should not be delayed while awaiting definitive test results.

Medscape Medical News 2008. ©2008 Medscape

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