The following recommendations have been developed to provide guidance
to healthcare workers when educating women about HIV infection
and the importance of early diagnosis of HIV. The recommendations
are based on the advances made in treatment and prevention of
HIV infection and stress the need for a universal counseling and
voluntary testing program for pregnant women. These recommendations
address a) HIV-related information needed by infected and uninfected
pregnant women for their own health and that of their infants,
b) laboratory considerations involved in HIV testing of this population,
and c) the importance of follow-up services for HIV-infected women,
their infants, and other family members.
HIV Counseling and Voluntary Testing of Pregnant Women and
- Healthcare providers should ensure that all pregnant women
are counseled and encouraged to be tested for HIV infection to
allow women to know their infection status, both for their own
health and to reduce the risk for perinatal HIV transmission.
Pretest HIV counseling of pregnant women should be done in accordance
with previous guidelines for HIV counseling. Such counseling should
include information regarding the risk for HIV infection associated
with sexual activity and injecting-drug use, the risk for transmission
to the woman's infant if she is infected, and the availability
of therapy to reduce this risk. HIV counseling, including any
written materials, should be linguistically, culturally, educationally,
and age appropriate for individual patients.
- HIV testing of pregnant women and their infants should be
voluntary. Consent for testing should be obtained in accordance
with prevailing legal requirements. Women who test positive for
HIV or who refuse testing should not be a) denied prenatal or
other healthcare services, b) reported to child protective service
agencies because of refusal to be tested or because of their HIV
status, or c) discriminated against in any other way.
- Healthcare providers should counsel and offer HIV testing
to women as early in pregnancy as possible so that informed and
timely therapeutic and reproductive decisions can be made. Specific
strategies and resources will be needed to communicate with women
who may not obtain prenatal care because of homelessness, incarceration,
undocumented citizenship status, drug or alcohol abuse, or other
- Uninfected pregnant women who continue to practice high-risk
behaviors (eg, injecting-drug use and unprotected sexual contact
with an HIV-infected or high-risk partner) should be encouraged
to avoid further exposure to HIV and to be retested for HIV in
the third trimester of pregnancy.
- The prevalence of HIV infection may be higher in women who
have not received prenatal care. These women should be assessed
promptly for HIV infection. Such an assessment should include
information regarding prior HIV testing, test results, and risk
history. For women who are first identified as being HIV infected
during labor and delivery, healthcare providers should consider
offering intrapartum and neonatal ZDV according to published recommendations.
For women whose HIV infection status has not been determined,
HIV counseling should be provided and HIV testing offered as soon
as the mother's medical condition permits. However, involuntary
HIV testing should never be substituted for counseling and voluntary
- Some HIV-infected women do not receive prenatal care, choose
not to be tested for HIV, or do not retain custody of their children.
If a woman has not been tested for HIV, she should be informed
of the benefits to her child's health of knowing her child's infection
status, and should be encouraged to allow the child to be tested.
Counselors should ensure that the mother provides consent with
the understanding that a positive HIV test for her child is indicative
of infection in herself. For infants whose HIV infection status
is unknown and who are in foster care, the person legally authorized
to provide consent should be encouraged to allow the infant to
be tested (with the consent of the biologic mother, when possible)
in accordance with the policies of the organization legally responsible
for the child and with prevailing legal requirements for HIV testing.
- Pregnant women should be provided access to other HIV prevention
and treatment services (eg, drug-treatment and partner-notification
services) as needed.
Interpretation of HIV Test Results
- HIV antibody testing should be performed according to the
recommended algorithm, which includes the use of an EIA to test
for antibody to HIV and confirmatory testing with an additional,
more specific assay (eg, Western blot or IFA). All assays should
be performed and conducted according to manufacturers' instructions
and applicable state and federal laboratory guidelines.
- HIV infection (as indicated by the presence of antibody to
HIV) is defined as a repeatedly reactive EIA and a positive confirmatory
supplemental test. Confirmation or exclusion of HIV infection
in a person with indeterminate test results should be made not
only on the basis of HIV antibody test results, but with consideration
of a) the person's medical and behavioral history, b) results
from additional virologic and immunologic tests when performed,
and c) clinical follow-up. Uncertainties regarding HIV infection
status, including laboratory test results, should be resolved
before final decisions are made concerning pregnancy termination,
ZDV therapy, or other interventions.
- Pregnant women who have repeatedly reactive EIA and indeterminate
supplemental tests should be retested immediately for HIV antibody
to distinguish between recent seroconversion and a negative test
result. Additional tests (eg, viral culture, PCR, or p24 antigen
test) to diagnose or exclude HIV infection may be required for
women whose test results remain indeterminate-especially women
who have behavioral risk factors for HIV, have had recent exposure
to HIV, or have clinical symptoms compatible with acute retroviral
illness. In such situations, confirmation by an FDA-licensed IFA
kit may be helpful because IFA is less likely to yield indeterminate
results than Western blot.
- Women who have negative EIAs and those who have repeatedly
reactive EIAs but negative supplemental tests should be considered
Recommendations for HIV-Infected Pregnant Women
- HIV-infected pregnant women should receive counseling as previously
recommended. Post-test HIV counseling should include an explanation
of the clinical implications of a positive HIV antibody test result
and the need for, benefit of, and means of access to HIV-related
medical and other early intervention services. Such counseling
should also include a discussion of the interaction between pregnancy
and HIV infection, the risk for perinatal HIV transmission and
ways to reduce this risk, and the prognosis for infants who become
- HIV-infected pregnant women should be evaluated according
to published recommendations to assess their need for antiretroviral
therapy, antimicrobial prophylaxis, and treatment of other conditions.
Although medical management of HIV infection is essentially the
same for pregnant and nonpregnant women, recommendations for treating
a patient who has tuberculosis have been modified for pregnant
women because of potential teratogenic effects of specific medications
(eg, streptomycin and pyrazinamide). HIV-infected pregnant women
should be evaluated to determine their need for psychological
and social services.
- HIV-infected pregnant women should be provided information
concerning ZDV therapy to reduce the risk for perinatal HIV transmission.
This information should address the potential benefit and short-term
safety of ZDV and the uncertainties regarding a) long-term risks
of such therapy and b) effectiveness in women who have different
clinical characteristics (eg, CD4+ T-lymphocyte count and previous
ZDV use) than women who participated in the trial. HIV-infected
pregnant women should not be coerced into making decisions about
ZDV therapy. These decisions should be made after consideration
of both the benefits and potential risks of the regimen to the
woman and her child. Therapy should be offered according to the
appropriate regimen in published recommendations. A woman's decision
not to accept treatment should not result in punitive action or
denial of care.
- HIV-infected pregnant women should receive information about
all reproductive options. Reproductive counseling should be nondirective.
Healthcare providers should be aware of the complex issues that
HIV-infected women must consider when making decisions about their
reproductive options and should be supportive of any decision.
- To reduce the risk for HIV transmission to their infants,
HIV-infected women should be advised against breast- feeding.
Support services should be provided when necessary for use of
appropriate breast-milk substitutes.
- To optimize medical management, positive and negative HIV
test results should be available to a woman's healthcare provider
and included on both her and her infant's confidential medical
records. After obtaining consent, maternal healthcare providers
should notify the pediatric-care providers of the impending birth
of an HIV-exposed child, any anticipated complications, and whether
ZDV should be administered after birth. If HIV is first diagnosed
in the child, the child's healthcare providers should discuss
the implication of the child's diagnosis for the woman's health
and assist the mother in obtaining care for herself. Providers
are encouraged to build supportive healthcare relationships that
can facilitate the discussion of pertinent health information.
Confidential HIV-related information should be disclosed or shared
only in accordance with prevailing legal requirements.
- Counseling for HIV-infected pregnant women should include
an assessment of the potential for negative affects resulting
from HIV infection (eg, discrimination, domestic violence, and
psychological difficulties). For women who anticipate or experience
such effects, counseling also should include a) information on
how to minimize these potential consequences, b) assistance in
identifying supportive persons within their own social network,
and c) referral to appropriate psychological, social, and legal
services. In addition, HIV-infected women should be informed that
discrimination based on HIV status or AIDS regarding matters such
as housing, employment, state programs, and public accommodations
(including physicians' offices and hospitals) is illegal.
- HIV-infected women should be encouraged to obtain HIV testing
for any of their children born after they became infected or,
if they do not know when they became infected, for children born
after 1977. Older children (ie, children more than12 years of
age) should be tested with informed consent of the parent and
assent of the child. Women should be informed that the lack of
signs and symptoms suggestive of HIV infection in older children
may not indicate lack of HIV infection; some perinatally infected
children can remain asymptomatic for several years.
Recommendations for Follow-Up of Infected Women and Perinatally
- Following pregnancy, HIV-infected women should be provided
ongoing HIV-related medical care, including immune-function monitoring,
antiretroviral therapy, and prophylaxis for, and treatment of,
opportunistic infections and other HIV-related conditions. HIV-infected
women should receive gynecologic care, including regular Pap smears,
reproductive counseling, information on how to prevent sexual
transmission of HIV, and treatment of gynecologic conditions according
to published recommendations.
- HIV-infected women (or the guardians of their children) should
be informed of the importance of follow-up for their children.
These children should receive follow-up care to determine their
infection status, to initiate prophylactic therapy to prevent
PCP, and, if infected, to determine the need for antiretroviral
and other prophylactic therapy and to monitor disorders in growth
and development, which often occur before 24 months of age. HIV-infected
children and other children living in households with HIV-infected
persons should be vaccinated according to published recommendations
for altered schedules.
- Because the identification of an HIV-infected mother also
identifies a family that needs or will need medical and social
services as her disease progresses, healthcare providers should
ensure that referrals to these services focus on the needs of
the entire family.