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Routine HIV Screening Recommended for All Women, Regardless of Individual Risk Factors; ACOG Pushes Routine Prenatal HIV Testing - American College of Obstetricians and Gynecologists
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Washington, DC -- Ob-gyns should routinely screen all women between the ages of 19 and 64 for HIV, regardless of their risk factors, according to a Committee Opinion, Routine Human Immunodeficiency Virus Screening, issued today by The American College of Obstetricians and Gynecologists (ACOG). Implementation of this screening recommendation will be a dramatic shift for some ob-gyn practices, especially those that are currently testing only pregnant patients, patients at high risk, and/or upon patient request.
"Women represent the fastest growing population of persons infected with HIV in this country, and heterosexual transmission has become a much bigger factor," according to Denise J. Jamieson, MD, MPH, chair of ACOG's Committee on Gynecologic Practice. "There are two basic messages for patients: Every woman should know her HIV status, and it's a simple test."
It is estimated that one-quarter of all Americans with HIV are unaware of their status. Women continue to represent a growing proportion of HIV and AIDS cases, and it's critical that they know their status. According to ACOG, this knowledge can improve women's chances of survival, reduce associated illnesses, help them take steps to avoid unintended pregnancy, protect their sexual partners, and reduce the likelihood of mother-to-child transmission should pregnancy occur.
"ACOG recommends routine HIV screening for all women ages 19 to 64, regardless of pregnancy status or what their risk factors might be," Dr. Jamieson said. "ACOG also recommends targeted screening for women outside this age range who are at high risk. For example, all sexually active teenagers under 19 should be tested, as well as women older than 64 who have had multiple partners in recent years."
Today's recommendation on HIV screening emphasizes 'opt-out' testing as the preferred approach. Opt-out testing is when the patient is notified that HIV testing will be performed as a routine part of her gynecologic and obstetric care unless she declines testing. Neither specific signed consent nor prevention counseling is required with opt-out testing. However, many state and local laws are not consistent with opt-out testing and may require informed consent or counseling.
Committee Opinion #411, "Routine Human Immunodeficiency Virus Screening," is published in the August 2008 issue of Obstetrics & Gynecology.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 52,000 members who provide health care for women.
ACOG Pushes Routine Prenatal HIV Testing - American College of Obstetricians and Gynecologists
Family Pratice News, July 1, 2000 by Sherry Boschert
SAN FRANCISCO -- A new initiative by the American College of Obstetricians and Gynecologists is aimed at making it easier for physicians to fold HIV screening into the standard battery of tests for pregnant women--regardless of the individual's apparent risk for the disease.
In turn, experts at the college are hoping that such action will influence national policies on HIV testing in pregnancy
The primary tools in a packet of materials mailed to AGOG's 40,000 members-- and available for sale to other physicians--are patient handouts that briefly describe standard tests for pregnant women--including hepatitis B, rubella, blood type, Rh factor, and syphilis--and devote three-quarters of the text to HIV information.
Also in the packet: educational brochures and a poster of a group of women with the caption: "Which woman should get an HIM test? All of them."
Physicians may use the handouts in lieu of more extensive counseling. This "routine testing with notification" policy means physicians aren't obligated to get the explicit consent--the patient just needs to be informed that this is one of many tests that will be done unless she refuses.
It seems easy, but laws or regulations in most states still require more in-depth counseling and informed consent prior to HIV testing, ACOG leaders noted.
Specifically, 12 states require voluntary testing of pregnant women with informed consent, 5 states require HIV testing of pregnant women unless the woman refuses, and 43 have informed consent and/or pretest counseling laws that are applicable to pregnant women.
An unspoken goal of the campaign is to spur the national government into using its leverage--such as allocation of Ryan White Care Act funds--to loosen state requirements around prenatal HIV testing.
A new ACOG committee opinion recommends that physicians counsel any pregnant woman with a high HIV viral load (more than 1,000 copies/mL) about the risks and benefits of cesarean delivery before onset of labor and rupture of membranes. Scheduled C-sections lower the likelihood of vertical transmission but carry increased risks for HIV-infected mothers.
The Institute of Medicine first advocated a national policy of routine perinatal HIV testing in 1998. In a report, the IOM recommended that patients be tested for HIV unless they refused.
In 1999 statements, ACOG, the American Academy of Family Physicians, and the American Academy of Pediatrics backed the IOM recommendations. The new ACOG drive takes the issue to another level.
More stringent requirements in many states require that patients be counseled and that their approval be obtained before being tested. These earlier policies were enacted when stigma and discrimination associated with HIV were a greater problem than today, said Dr. Stanley Zinberg, vice president of ACOG's practice activities division.
The IOM experts found that the burden of counseling kept many physicians from providing prenatal HIV testing.
The new ACOG approach--using patient handouts--suggests that extensive counseling isn't needed because it doesn't necessarily improve the quality of care. And if physicians end up avoiding HIV testing altogether because they can't do the required counseling, it may even hinder good care.
Previous policies also tended to focus on "high-risk" patients, missing many HIV infections. An estimated 91% of children with AIDS are born to mothers infected with or at risk for HIV; one-third of these mothers do not report a risk for HIV
Advances in treatment and prevention of vertical transmission make it more advantageous for pregnant women to learn their HIV status as early as possible, Dr. Zinberg added. The issue is important in many practice settings: Obstetricians deliver about 85% of U.S. babies, he noted, but family physicians deliver about 13% and midwives deliver 2% of newborns.
The rate of new pediatric AIDS cases has plunged 43% since the discovery in the early 1990s that maternal treatment with zidovudine lowers the risk of vertical transmission from 25% to 8% overall.
Antiretroviral therapy alone lowers the risk of vertical transmission to 2% in women with low viral loads ([less than]1,000 copies/mL), a rate that does not improve with cesarean delivery. Women with higher viral loads can achieve the same 2% risk of vertical transmission if they receive antiretroviral therapy and deliver by C-section, according to the committee opinion.
The college advises delivery at 38 weeks' gestation for women with HIV infection to avoid the onset of labor or rupture of membranes before delivery, factors that increase the risk of neonatal infection.
Prophylactic antibiotics should be considered because women with HIV have higher morbidity rates associated with C-sections. Amniocentesis to determine fetal lung maturity is discouraged.
The Centers for Disease Control and Prevention funded the creation and distribution of the ACOG materials. They can be ordered by calling 800-762-2264, ext. 115, and requesting patient handouts (item AA349, $15 for pack of 210) or brochures (AP113 for English or SP113 for Spanish, $17.50 for pack of 50).
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