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Detecting and treating HIV infection early can make a big difference in the health of the baby.

• Perinatal transmission accounts for 91% of all AIDS cases reported among children in the United States—and an estimated 17,000 HIV infections among children since the epidemic began.¹
• Approximately 40% of the mothers of the HIV-infected infants born in the United States in 2000 were not known to have HIV before delivery.^2,3
• Perinatal HIV transmission rates are 2% or less when antiretroviral therapy is initiated and adhered to during pregnancy.^4,5 The figure is 25% for women who receive no preventive treatment.^4,6
• When antiretroviral therapy is begun intrapartum, the rate of transmission is approximately 10%.^7,8

Determine the cause of your patient's reluctance to be tested, so you can address it appropriately.

Encouraging screening after an initial refusal can be uncomfortable, but it is in line with current recommendations. Following are possible responses to common reasons for refusal.

• If your patient doesn't think she has HIV, perhaps because she's in a monogamous relationship, she could be right. But remind her that the only way to be sure is to be tested.
• If she's worried that someone will find out about her HIV status, assure her that her medical records are confidential, in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
• If she thinks nothing can be done for her or her baby if her test is positive, discuss the highly effective drug therapies now available. Explain that these drug regimens can prolong the lives of people with HIV—and help keep unborn babies from contracting HIV from their mothers. It also may be appropriate to discuss surgical options that can help prevent vertical transmission.
• If she thinks she doesn't need retesting because she had a negative result in the past, point out that it's best for her—and her baby—to be certain of her current status early in her pregnancy. If the test results are positive, antiretroviral therapy can be initiated.
• If she has a fear of needles, consider offering to draw blood for the HIV screening and other prenatal tests at the same time, so she won't have to be “stuck” more than necessary. Or, you may offer your patient an oral fluid test.
• If she's concerned about job loss, the loss of personal relationships, or even domestic violence, talk through the relevant issues with her; then, if necessary, direct her to the appropriate services for additional assistance.
• If she thinks testing won't be covered by her health plan, assure her that most plans do cover HIV screening during pregnancy. Also let her know that in most states, the AIDS Drug Assistance Program facilitates access to early treatment of HIV for people without health insurance.

Your patients trust your judgment.

If you actively encourage HIV screening, your patients are likely to accept it. In a study of 1,362 parturient women:^9,10

• Nearly 90% were offered prenatal HIV screening. About 75% of those who were offered testing accepted it.
• Most notably, 93% of the women who felt that their providers strongly recommended HIV screening accepted the test.

It's never too late to test.

If your patient refuses screening at early prenatal visits, be sure to readdress the issue throughout the pregnancy. CDC recommends routine, rapid HIV testing, with patient notification and right of refusal (opt-out), for women who arrive at labor and delivery without a documented prenatal HIV test.²

Several organizations recommend routine prenatal HIV screening.^9,11-14

• Centers for Disease Control and Prevention (CDC)
• American College of Obstetricians and Gynecologists (ACOG)
• American College of Nurse-Midwives (ACNM)
• American Academy of Pediatrics (AAP)
• Institute of Medicine (IOM)
• U.S. Preventive Services Task Force (USPSTF)

Sources

1. CDC. Eliminating perinatal HIV transmission. Program in Brief August 2004.
2. CDC. Rapid HIV-1 antibody testing during labor and delivery for women of unknown HIV status: a practical guide and protocol. January 30, 2004.
3. Office of the Inspector General. Reducing obstetrician barriers to offering HIV testing.
4. CDC. HIV testing among pregnant women—United States and Canada, 1998-2001. MMWR 2002;51:1013-1016.
5. Dorenbaum A, Cunningham CK, Gelber RD, et al. Two-dose intrapartum/newborn nevirapine and standard antiretroviral therapy to reduce perinatal HIV transmission: a randomized trial. JAMA 2002;288:189-198.
6. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. New England Journal of Medicine 1994;331:1173-1180.
7. American College of Obstetricians and Gynecologists (ACOG). Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. ACOG Committee on Obstetric Practice Committee Opinion No. 304. November 2004.
8. Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of human immunodeficiency virus. New England Journal of Medicine 1998;339:1409-1414.
9. CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50(RR-19):59-85.
10. Royce RA, Walter EB, Fernandez MI, et al., for the Perinatal Guidelines Evaluation Project. Barriers to universal prenatal HIV testing in 4 US locations in 1997. American Journal of Public Health 2001;91:727-733.
11. American College of Obstetricians and Gynecologists (ACOG). Joint statement of ACOG/AAP on human immunodeficiency virus screening. ACOG Statement of Policy May 1999.
12. American College of Nurse-Midwives. Position statement: Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS).
13. Institute of Medicine, National Research Council. Reducing the odds: preventing perinatal transmission of HIV in the United States. Washington, DC: National Academy Press, 1999.
14. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Annals of Internal Medicine 2005;143:38-54.