WASHINGTON -- Testing for the human immunodeficiency virus (HIV) should be a routine part of prenatal care, according to a new report from a committee of the Institute of Medicine. Health care providers should notify women that HIV testing is part of the usual array of prenatal tests and women should have an opportunity to refuse. This approach could help reduce the number of pediatric AIDS cases and improve treatment for mothers with AIDS.
Current federal guidelines were put in place after discovery in 1994 of a new therapy that reduces by two-thirds the chance that an infected woman will pass HIV to her child. The guidelines advise health care providers to give extensive pre-test counseling to all pregnant women, educating them about the risks of AIDS and the benefits of being tested. These guidelines led to an increase in testing and treatment. But because many women are not tested and do not receive treatment, the number of children born with HIV is still unacceptably high, the report says.
"We have the tools to prevent HIV infection in newborns. Now we must get treatment to everyone who needs it," said committee chair Marie McCormick, professor and chair, department of maternal and child health, Harvard School of Public Health, Boston. "By making HIV screening a routine part of prenatal care for all pregnant women, regardless of their risk factors or where they live, we can further lower the number of pediatric AIDS cases and help infected women get high-quality treatment."
Making prenatal testing routine would help lower many of the barriers that keep women from being tested. It would reduce the burden on prenatal care givers to provide the extensive pre-test counseling required by current guidelines. Providers would no longer have to decide whether to encourage some women more than others to be tested, an approach that results in many cases being missed. It would lessen the stigmatization of groups in which perinatal HIV transmission is now more prevalent, which include African American and Hispanic women. And it would guard against geographic shifts in the incidence of HIV infection, which is more common among women in large cities and in parts of the northeastern and southern United States. The costs of routine prenatal testing compare favorably with the costs of treating children who have HIV.
The committee outlined a series of steps to support routine testing in prenatal care, and to meet the needs of pregnant women and health care providers. Health care plans should implement policies to facilitate routine prenatal testing, and should track their success in conducting HIV screening. Businesses and other organizations that purchase health care should support routine prenatal testing in their contracts with providers. Professional medical organizations should update their practice guidelines to recommend such testing. Providers need to be educated about the value of prenatal HIV screening, and how to deal appropriately with those who test positive. And health officials need to improve their outreach to pregnant women, to address concerns about testing and treatment.
Testing should be seamlessly linked to treatment for women found to be infected, and this care must be coordinated before, during, and after delivery, the report says. Providers must take steps, however, to ensure that their patient's confidentiality is protected, and that they are not forced into taking a test if they object.
Researchers determined in 1994 that administering the drug zidovudine (ZDV, formerly known as AZT) during pregnancy and childbirth could reduce by two-thirds the chance that a mother infected with HIV would give birth to an infected child. The finding was one of the most important since the beginning of the AIDS epidemic, because 6,000 to 7,000 HIV-infected women in the United States give birth each year.
After the initial research findings were announced in 1994, federal agencies, most states, and a number of professional organizations instituted policies, legislation, and guidelines to encourage HIV testing for pregnant women. As a result of ZDV treatment and other factors, the number of new pediatric AIDS cases dropped by about 43 percent between 1992 and 1996.
It is critical that federal funding for state and local efforts to prevent perinatal HIV transmission be maintained, the report says. The committee was not asked to take a position on mandatory testing of all newborns, but noted that such testing can only play a limited role in preventing transmission of HIV from mother to child. Under the current provisions of the Ryan White Comprehensive AIDS Resources Emergency Act Amendments of 1996, federal funds for states could become contingent upon mandatory testing of newborns. If funds that could be used for prevention are directed toward newborn testing, the federal government could actually undermine efforts to keep infants from contracting the virus.
To boost prevention efforts, the federal government should establish a regional system of perinatal HIV prevention and treatment centers. These centers would help assure optimal HIV care for all pregnant women and newborns, and would help develop and implement strategies to improve HIV testing in prenatal care. Federal, state, and local public health agencies also should maintain appropriate surveillance data on HIV-infected women and children, the report says.
This study was funded by the U.S. Department of Health and Human Services. The Institute of Medicine is a private, non-profit organization that provides health policy advice under a congressional charter granted to the National Academy of Sciences.
Pre-publication copies of REDUCING THE ODDS: PREVENTING PERINATAL
TRANSMISSION OF HIV IN THE UNITED STATES are available from the