July 2005 CCC Corner > Abstract of the Month
Abstract of the Month
USPSTF recommends that clinicians screen all pregnant women for HIV
Rating: A
Recommendation.
Rationale: The USPSTF found good evidence that both standard and FDA-approved
rapid screening tests accurately detect HIV infection in pregnant women and fair
evidence that introduction of universal prenatal counseling and voluntary testing
increases the proportion of HIV-infected women who are diagnosed and are treated
before delivery. There is good evidence that recommended regimens of HAART are
acceptable to pregnant women and lead to significantly reduced rates of mother-to-child
transmission. Early detection of maternal HIV infection also allows for discussion
of elective cesarean section and avoidance of breastfeeding, both of which are
associated with lower HIV transmission rates. There is no evidence of an increase
in fetal anomalies or other fetal harm associated with currently recommended
antiretroviral regimens (with the exception of efavirenz). Serious or fatal maternal
events are rare using currently recommended combination therapies. The USPSTF
concluded that the benefits of screening all pregnant women substantially outweigh
potential harms.
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that
clinicians screen for human immunodeficiency virus (HIV) all adolescents and
adults at increased risk for HIV infection (go to Clinical
Considerations* for discussion of risk factors).
Rating: A
Recommendation.
Rationale: The USPSTF found good evidence that both standard and U.S. Food
and Drug Administration (FDA)-approved rapid screening tests accurately detect
HIV infection. The USPSTF also found good evidence that appropriately timed interventions,
particularly highly active antiretroviral therapy (HAART), lead to improved health
outcomes for many of those screened, including reduced risk for clinical progression
and reduced mortality. Since false-positive test results are rare, harms associated
with HIV screening are minimal. Potential harms of true-positive test results
include increased anxiety, labeling, and effects on close relationships. Most
adverse events associated with HAART, including metabolic disturbances associated
with an increased risk for cardiovascular events, may be ameliorated by changes
in regimen or appropriate treatment. The USPSTF concluded that the benefits of
screening individuals at increased risk substantially outweigh potential harms.
The USPSTF makes no recommendation for or against routinely screening for
HIV adolescents and adults who are not at increased risk for HIV infection (go
to Clinical
Considerations* for discussion of risk factors).
Rating: C
Recommendation.
Rationale: The USPSTF found fair evidence that screening adolescents and adults
not known to be at increased risk for HIV can detect additional individuals with
HIV, and good evidence that appropriately timed interventions, especially HAART,
lead to improved health outcomes for some of these individuals. However, the
yield of screening persons without risk factors would be low, and potential harms
associated with screening have been noted (above). The USPSTF concluded that
the benefit of screening adolescents and adults without risk factors for HIV
is too small relative to potential harms to justify a general recommendation.
http://www.ahrq.gov/clinic/uspstf/uspshivi.htm
*Clinical Recommendations, USPSTF
http://www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm#clinical
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OB/GYN CCC Editorial Comment
#1 This decision by the USPSTF reinforces several recent CCC Corner Indian
Health items on this topic.
The U.S. Preventive Services Task Force issued a new recommendation calling
for all pregnant women, to be screened for HIV. This recommendation is based
on evidence that currently available tests accurately identify pregnant women
who are HIV infected and that recommended treatment strategies can dramatically
reduce the chances that an infected mother will transmit HIV to her infant.
The Task Force also reaffirmed its 1996 recommendation that all adolescents
and adults at increased risk for HIV infection be screened and has broadened
its definition of high risk. In addition to patients who report high-risk
behaviors, all patients receiving care in high-risk settings such as homeless
shelters or clinics dedicated to the treatment of sexually transmitted diseases
should be tested.
The Task Force found at least fair evidence that screening adolescents and
adults who are not at increased risk can improve health outcomes, but concluded
that the balance of benefits and harms is too close to justify a general recommendation.
Other recent Indian Health HIV screening items
Use ‘Opt out’ HIV
screening methods during pregnancy in Indian Country
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0305_AOM.cfm
Have you had your ‘morning after’ antiretroviral
cocktail yet?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605_AOM.cfm
#2
In addition, HIV testing and education are Indian Health GPRA Indicators,
so there are significant clinical and administrative reasons to improve HIV screening
in pregnancy and its documentation. As you see the GPRA system gives you credit
for HIV counseling and education as well as testing (as well as refusals).
GPRA # 33
HIV Screening:
Support screening for HIV infections in appropriate
population groups. [outcome]
Prenatal HIV Screening:
In FY 2005, establish the baseline
number of women screened for HIV in pregnancy.
Prenatal HIV Screening:
In FY 2006, increase the proportion
of pregnant female patients screened for HIV.
In FY 2006, assure that the proportion of pregnant female patients screened
for HIV does not decrease more than 1% from the FY 2006 level.
Contact: Jim Cheek, DPHS/Epi, 505-248-4226
Background
Q. What is the Indian Health procedure for HIV screening in pregnancy?
http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=9808&app_dir_id=4&doc_file=HIV_Consent_Procedures-revised.pdf
Q. Does it have to be a separate specific consent in writing during pregnancy?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/HIVscreen52005.doc
PRENATAL HIV TESTING AND EDUCATION
Changes for Version 5.1, as noted below.
Denominator: GPRA: All pregnant patients with no documented miscarriage or
abortion during the past 20 months and NO recorded HIV diagnosis ever.
Numerators: 1) Patients who received counseling and/or patient education about
HIV and testing during the past 20 months.
2) GPRA: Patients who received HIV test during the past 20 months, including
refusals.
2A) Number of documented refusals.
Definitions: 1) Pregnancy: At least 2 visits with POV: V22.0-V23.9, 640.*-648.*,
651.*-676.* during the past 20 months, with one diagnosis occurring during the
reporting period.
2) Miscarriage: Occurring after the second pregnancy POV and during the past
20 months. POV: 630, 631, 632, 633*, 634*, CPT: 59812, 59820, 59821, 59830
3) Abortion: Occurring after the second pregnancy POV and during the past
20 months. POV: 635*, 636*, 637*, CPT: 59840, 59841, 59850, 59851, 59852, 59855,
59856, 59857
4) HIV: V POV or Problem List: 042.0-044.9, V08, 795.71
5) HIV Counseling/Patient Education: POV: V65.44, Patient Education codes
containing “HIV-” or "-HIV" or HIV diagnosis 042.0-044.9,
V08, 795.71
6) HIV Test: CPT: 86689, 86701-86703, 87390, 87391; LOINC taxonomy; site-defined
taxonomy BGP GPRA HIV TESTS
7) Refusal of HIV Test: Lab Test HIV
GPRA Description: In FY 2005, establish baseline screening rates for
HIV in pregnancy.
Patient List: Patients not screened.
http://www.ihs.gov/cio/crs/
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