HIV Testing and Prophylaxis to Prevent Mother-to-Child Transmission in the United States

Abstract

Universal HIV testing of pregnant women in the United States is the key to prevention of mother-to-child transmission of HIV. Repeat testing in the third trimester and rapid HIV testing at labor and delivery are additional strategies to further reduce the rate of perinatal HIV transmission. Prevention of mother-to-child transmission of HIV is most effective when antiretroviral drugs are received by the mother during her pregnancy and continued through delivery and then administered to the infant after birth. Antiretroviral drugs are effective in reducing the risk of mother-to-child transmission of HIV even when prophylaxis is started for the infant soon after birth. New rapid testing methods allow identification of HIV-infected women or HIV-exposed infants in 20 to 60 minutes. The American Academy of Pediatrics recommends documented, routine HIV testing for all pregnant women in the United States after notifying the patient that testing will be performed, unless the patient declines HIV testing (“opt-out” consent or “right of refusal”). For women in labor with undocumented HIV-infection status during the current pregnancy, immediate maternal HIV testing with opt-out consent, using a rapid HIV antibody test, is recommended. Positive HIV antibody screening test results should be confirmed with immunofluorescent antibody or Western blot assay. For women with a positive rapid HIV antibody test result, antiretroviral prophylaxis should be administered promptly to the mother and newborn infant on the basis of the positive result of the rapid antibody test without waiting for results of confirmatory HIV testing. If the confirmatory test result is negative, then prophylaxis should be discontinued. For a newborn infant whose mother's HIV serostatus is unknown, the health care professional should perform rapid HIV antibody testing on the mother or on the newborn infant, with results reported to the health care professional no later than 12 hours after the infant's birth. If the rapid HIV antibody test result is positive, antiretroviral prophylaxis should be instituted as soon as possible after birth but certainly by 12 hours after delivery, pending completion of confirmatory HIV testing. The mother should be counseled not to breastfeed the infant. Assistance with immediate initiation of hand and pump expression to stimulate milk production should be offered to the mother, given the possibility that the confirmatory test result may be negative. If the confirmatory test result is negative, then prophylaxis should be stopped and breastfeeding may be initiated. If the confirmatory test result is positive, infants should receive antiretroviral prophylaxis for 6 weeks after birth, and the mother should not breastfeed the infant.

Women’s willingness to be tested for human immunodeficiency virus during pregnancy: A review

“…Proper therapy for HIV in pregnancy is crucial to prevent MTCT [14] . The most important advantage of testing women for HIV during pregnancy is that timely identification of a pregnant woman infected with HIV allows planning and initiation of care, which may significantly lower the risks of MTCT of HIV, and, consequently, lead to healthier populations [15] . In high-income countries, MTCT rates have decreased dramatically following the introduction of recommendations for routine HIV testing for all pregnant women [16][17][18] .…”

“…Programs promoting Prevention of MotherTo-Child Transmission (PMTCT) of HIV, including routine testing for HIV, have also led to a substantial decrease in MTCT rates in Sub-Saharan Africa, by around 50% since 2009 [9] . Identification of the HIV-status of a pregnant woman allows establishment of three interventions for PMTCT of HIV: (1) administration of antiretroviral prophylaxis to mothers during pregnancy and delivery, and to newborn infants following delivery; (2) delivery of infants by scheduled cesarean section; and (3) avoidance of breastfeeding in favor of appropriate replacement feeding [15] . These interventions have been shown to be both effective and cost-effective in lowering MTCT of HIV [19][20][21] .…”

“…Willingness to be tested for HIV Early identification of HIV infected pregnant women enables health care providers to test infants for HIV infection following delivery, as well as for the early administration of prophylaxis to protect HIVinfected infants and those whose HIV status remains unknown from opportunistic infections. It also allows an opportunity for counseling women on the risks of infant infection via breastfeeding and proper initiation of appropriate replacement feeding [15,26] . Testing early in the pregnancy has several advantages over testing in late stages of pregnancy.…”

“…Testing early in the pregnancy has several advantages over testing in late stages of pregnancy. Testing and identification of HIV status during pregnancy allows health care providers to use the three known effective interventions for prevention of MTCT of HIV (maternal antiretroviral treatment during pregnancy and delivery and postpartum infant prophylaxis; delivery by scheduled cesarean section; and avoidance of breastfeeding) [15] . When HIV infection is not detected during pregnancy, it is not possible to administer antiretroviral treatment during the course of the pregnancy itself.…”

“…In such cases, the only remaining strategy for health care providers is to administer antiretroviral therapy during delivery and to the infant immediately following birth, and to instruct the mother to avoid breastfeeding and to begin replacement feeding. However, it is known that antiretroviral prophylaxis is more effective in preventing MCTC when begun during pregnancy [15] . In a study by Wade et al [27] , maternal prophylaxis treatment during delivery with intravenous zidovudine, together with a six-week course of zidovudine administered to the newborn following delivery reduced the rate of MCTC by 60%.…”