The United States Centers for Disease Control and Prevention (CDC) estimates that nearly 50,000 individuals become infected with HIV annually in the country. This also includes approximately 150 infants infected by mother-to-child (vertical) transmission.
Owing to an increase in the number of HIV-infected women of childbearing age, the number of children infected with HIV has risen dramatically. As part of the routine antenatal screening, all pregnant women must undergo a blood test to check if they have HIV. If left untreated, HIV can be passed from a pregnant woman to her child.
AdvertisementTherefore, it is critical that pregnant women infected with HIV should be accurately identified in a timely manner, and measures should be undertaken to decrease the risk of HIV transmission from mother to child and also to optimize the mother's health. Antiretroviral medications given to a HIV positive woman during pregnancy and delivery; and to their newborns in the first weeks of life reduces the rate of vertical transmission from 25% to 2% or less.
New evidence also suggests that early initiation of antiretroviral therapy in the course of HIV infection reduces the rate of sexual transmission to partners who are not infected.
The conventional method for HIV diagnosis involves a reactive antibody-screening test followed by Western Blot confirmation. Since antibody testing alone might miss a considerable number of HIV infections that are detectable by virologic tests, newer antibody-antigen combination screening tests are now recommended. The screening should be performed as early as possible during each pregnancy. Women should be notified that HIV screening is recommended for all pregnant patients and that they will undergo a HIV screening test as part of the routine prenatal tests unless they decline (opt out screening approach where allowed). If a woman declines HIV testing, the obstetric provider should document this in the medical record and should discuss and address the patient's reasons for declining an HIV test.
Women who present late in pregnancy or in labor with undocumented HIV status should be offered rapid testing by using an HIV test that provides preliminary results in less than one hour. If a rapid test is reactive, immediate initiation of antiretroviral prophylaxis for mother and neonate is recommended without waiting for the results of supplemental tests. All antiretroviral prophylaxis should be discontinued if supplemental testing results are negative.
The American Academy of Pediatrics advises that infants born to women whose HIV status is unknown (due to opt out approach) should be subjected to a rapid antibody test performed as soon as possible after birth. Women should be informed of all tests performed on their neonates, and based on these results the mother and neonate must be provided with appropriate and prompt treatment.
Repeat HIV testing in the third trimester of pregnancy, preferably before 36 weeks of gestation, is recommended for women living in areas with high HIV incidence and women known to be at a higher risk of acquiring HIV infection. Repeat testing is also recommended in areas with elevated AIDS incidence and in health care facilities that identify at least one pregnant woman infected with HIV per 1,000 women during prenatal screening. Women who have signs or symptoms consistently with acute HIV infection such as fever, lymphadenopathy, myalgia, headache, oral ulcers, leukopenia, or thrombocytopenia should also be retested.
If a pregnant woman's HIV test results are positive, she should be given her results in person. The healthcare facility should provide counseling to women regarding the implications of HIV infection and the risks of transmission to the child. Additional laboratory tests, including CD4+ count, HIV viral load, testing for antiretroviral resistance, hepatitis C virus antibody and hepatitis B surface antigen will be useful before prescribing an antiretroviral therapy. Once the diagnosis of HIV infection is established, the woman should also be linked to ongoing care with a specialist in HIV care for co-management of her condition. In addition, the patient should be counseled on the importance of notifying her sexual partners about her HIV status and the importance of HIV testing for any sexual partner. Obstetricians should be aware of and comply with their states' legal requirements regarding partner notification and disclosure of HIV status to others, including the neonate's pediatrician.
These recommendations have been made by the American College of Obstetricians and Gynecologists and will help in controlling the mother-to-baby transmission of HIV.