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 Their Infants
- 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(Drug information on alcohol) abuse, or other reasons.
- 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 testing.
- 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 uninfected.
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 infected.
- 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(Drug information on streptomycin) and pyrazinamide(Drug information on 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 Exposed Children
- 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.