Articles >> Pregnancy >> Doctors, It's Your Responsibility

Pregnancy and HIV

Doctors, It's Your Responsibilty

All health care providers who treat women of childbearing age need to provide HIV counseling and urge all pregnant women to be tested for HIV. Studies have shown that more pregnant women readily accept HIV testing if strongly encouraged to be tested by their health care provider.

According to Public Health Service Guidelines (in PDF format: http://www.hivatis.org/guidelines/perinatal/PerinatalFeb2500.pdf ) it is now the standard of care for health care providers to counsel all pregnant women about the ways they could be infected with HIV and the importance of being tested for HIV. Voluntary testing means that after a woman receives appropriate counseling from her health care provider, she is able to make an informed decision about having an HIV test. Research shows that when a pregnant women's health care provider talks to her about the test and what it means, most women choose to be tested. Universal HIV counseling and testing with consent for all pregnant women is currently the recommendation of the Public Health Service. The American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) issued a statement in July 1999 which endorses the Institute of Medicine's (IOM) recommendation (Reducing the Odds: Preventing Perinatal Transmittal of HIV in the United States - IOM, October 1999) to make HIV testing a routine part of prenatal care by informing the woman that an HIV test will be conducted, and allowing her the opportunity to refuse taking the test. According to the AAP and ACOG statement, pretest HIV counseling may be provided, but should not serve as a barrier to HIV testing if counseling is not conducted. The Public Health Service is currently reviewing the IOM Report's recommendations and is expected to address their recommendations in guidelines to be published in late 1999 or early 2000.

The Importance of Testing of Pregnant Women for HIV

Although there were only about 380 cases of perinatally transmitted AIDS reported in the United States in 1998, between 6,000 and 7,000 HIV infected women gave birth to babies. Thus the possible prevalence for perinatally transmitted HIV infection is quite high absent universal testing. Recent studies indicate that the risk of the mother infecting her baby may be further reduced by delivering the baby by caesarean section. However, currently caesarean sections are not recommended for women with HIV disease unless medically necessary (See http://www.hcfa.gov/hiv/cesar2.htm). Recent studies have shown that drugs other than AZT may be effective in reducing perinatal transmission when the full AZT regimen cannot be administered.

Why Should Testing Be Done?

1. The Health of the Mother: Diagnosis of infection in the mother should lead to appropriate evaluations which would determine if she requires a) antiretroviral therapy and/or b) prophylaxis of opportunistic infections (like pneumocystis carinnii pneumonia (PCP) or mycobacterium avium complex (MAC).) With the advent of highly active antiretroviral therapy (use of 2 nucleoside analogue drugs with a protease inhibitor), early initiation of therapy is desirable to preserve a) immune function, b) lower viral load, c) lower viral setpoint, d) decrease disease progression, and e) improve life expectancy. None of these things can accrue unless the mother and health care provider know of her HIV infection status.
2. Counseling on Breast Feeding: HIV-infected women are advised not to breastfeed due to potential breast milk transmission of HIV. Thus, knowledge of infection status BEFORE the baby is born is critical to prevent transmission in this fashion.
3. Use of AZT to Prevent Mother to Child Transmission (See: http://www.hcfa.gov/hiv/subpg3a.htm) AZT taken during pregnancy, labor and given to the newborn reduces the risk of transmission by 2/3. AZT should be started prior to 34 weeks gestation (although even if started later it appears to be effective, although perhaps not quite as effective as the full regimen), so a mother must know her infection status to consider whether she wishes to take AZT (or other antiretroviral drugs for treatment).
4. PCP Prophylaxis of the New Born: Because PCP can be fatal in infected kids, and occurs most frequently in infants between 1 to 6 months of age, prophylaxis against PCP is recommended for ALL infants born to infected women until the newborn's infection status is determined (which requires at least two virologic tests with one done at age 4 months or older).
5. Diagnosis of Infection in the Newborn: With tests used today, about 90 percent or more of infected kids can be diagnosed by 1-2 months of age, and virtually 100 percent by 6 months of age. Antiretroviral therapy is recommended in all infected children under 12 months old as soon as they are diagnosed due to the extremely high viral loads found in perinatally infected kids.

In Summary . . .

So, to summarize, the benefits of testing include: 1) evaluation of the mother to determine if she requires antiretroviral therapy or medicines to prevent opportunistic infections: 2) counseling infected women not to breastfeed; 3) counseling infected women about the use of AZT to prevent transmission; 4) initiation of PCP prophylaxis in her child at 6 weeks of age; and 5) diagnostic testing of her infant to determine if the child is infected and to permit start of antiretroviral therapy in infected children.

Why is Universal Testing Recommended?

1. The changing epidemiology of HIV in women of child-bearing age:
• Geographic: HIV is no longer confined to urban areas: HIV is actually increasing most rapidly in rural areas of the southeast.
• HIV Acquisition: The most rapidly increasing group of infection is via heterosexual contact. Many infected women do not know their sexual partners are at risk of HIV infection. Thus, there is a blurring of "risk factors" with general behaviors in the populations, making "risk based" testing less effective.
2. It is less stigmatory to offer testing to everyone, thus taking the "blame" component away for offering testing to an individual.
3. Counseling is easier for the health care provider who no longer has to do detailed "risk" assessments, but can say they offer this test to all their prenatal patients, incorporating it into routine medical care.

Why Voluntary Testing?

The purpose of testing is to engage the woman into continuing care for herself and her baby, not to label her as infected. Compliance with medical care is likely to be greatest when the woman feels she has made an informed decision regarding testing for herself and her baby. Routine HIV counseling and offering testing to all pregnant women appears most likely to achieve this goal.

For further information on HIV transmission and testing, please visit the Centers for Disease Control and Prevention's Division of HIV/AIDS Prevention site.

In addition, the National Institutes of Health has new research data (See: http://www.hcfa.gov/hiv/subpg3b.htm ) available regarding AZT and pregnant women that you may find of interest.

The following is a list of additional HIV-related links that health care providers may find useful:

HIV/AIDS Treatment Information Service (ATIS)
This site, sponsored by the Health Care Financing Administration and five other DHHS agencies, provides comprehensive treatment information about drug therapies (AZT and other antiretroviral drugs), ACTG 076 and 185, and HIV and pregnancy. This site also maintains official current copies of DHHS endorsed HIV prevention and treatment guidelines.

The Pediatric AIDS Clinical Trial Group
This site, funded by NIAID's Division of AIDS and the National Institute of Child Health and Human Development, offers information on treatments for HIV-infected children and adolescents and on new approaches for the interruption of mother-to-infant transmission.

Center for Disease Control's National Prevention Information Network
A site designed to "facilitate the sharing of HIV/AIDS and STD resources and information about education and prevention, published materials and research findings, as well as news about related trends."

The National Institutes of Health Office of AIDS Research
NIH's Office of AIDS Research site provides recent updates, information on HIV/AIDS-related research at NIH, and other public information.

Current Clinical Information from the American Medical Association
Information for health care providers from the Journal of the American Medical Association. This document information on common issues raised by primary care physicians and allied health professionals with limited experience in HIV care.

International Association of Physicians in AIDS Care
This site is an educational resource to introduce physicians, other health care professionals, and people with HIV to some of the clinical and scientific information developed by IAPAC.

HIV Insite: A Gateway to AIDS Information
Comprehensive site with up-to-date medical information, AIDS prevention and education materials, community and research resources, etc.

Immunet: "Easy Access to Quality Information About AIDS"
An AIDS treatment website designed for doctors and patients who want to learn more about HIV and AIDS.

AIDS Education Global Information Service
This site contains the largest HIV database in the world and contains the latest HIV-related headlines, an on-line library, and information for patients that have just tested positive for HIV.

This article was produced by the Health Care Financing Administration and Department of Health and Human Services.

Web www.childbirthsolutions.com

In the Store Today

Awakening to Birth