The diagram of the analytic framework begins at the left with "Screening" and "Risk Factor Assessment." From "Screening," the arrow proceeds to key question (KQ) 1: "Does screening for HIV in pregnant women reduce mother-to-child transmission or premature death and disability?" From there it proceeds to "Reduced premature death and disability for women and children and reduced mother-to-child transmission."
Under "Risk Factor Assessment" is KQ 2 with the note: "Asymptomatic Pregnant Women including Adolescents" KQ 2 is "Can clinical or demographic characteristics (including specific settings) identify subgroups of asymptomatic pregnant women at increased risk for HIV infection compared to the general population of pregnant women?" Two arrows proceed from KQ 2. One goes to "Low Risk" and the other to "High Risk."
The arrows both proceed to KQ 3. "What are the test characteristics of HIV antibody (HIV ab) test strategies in pregnant women?" One arrow proceeds from KQ 3 to KQ 4: What are the harms (including labeling and anxiety) associated with screening? Is screening acceptable to pregnant women?" Another arrow from KQ 3 splits and goes to "HIV Ab Positive" and "HIV Ab Negative."
From "HIV Ab Positive," an arrow proceeds to KQ 5: "How many HIV-infected pregnant women who meet criteria for interventions receive them?" Then the arrow splits in two. One prong goes to KQ 6: "What are the harms associated with the work-up for HIV infection in pregnant women?" The second prong splits in two and goes to "Low CD4 cell count or high viral load" and "High CD4 cell count and low viral load." The prongs reunite then split and proceed either to "Interventions," KQ 7a and KQ 7b, or to KQ 7c.
KQ 7a is "How effective are interventions (antiretroviral prophylaxis [to prevent mother-to-child transmission] or treatment [to improve maternal outcomes]; avoidance of breastfeeding, elective cesarean section [in selected patients], or other labor management practices; counseling on risky behaviors; immunizations; routine monitoring and follow-up; or prophylaxis against opportunistic infections) in reducing mother-to-child transmission rates or improving clinical outcomes (mortality, functional status, quality of life, symptoms, or opportunistic infections) in pregnant women with HIV infection?" KQ 7b is:"Does immediate antiretroviral treatment in HIV-infected pregnant women result in improvements in clinical outcomes compared to delayed treatment until the infected woman becomes symptomatic?" That arrow continues to "Reduced premature death and disability for women and children, and reduced mother-to-child transmission" and ends there.
KQ 7c is "How well do interventions reduce the rate of viremia, improve CD4 cell counts, or reduce risky behaviors? How does identification of HIV infection in pregnant women affect future reproductive choices?" The arrow splits from KQ 7a and one prong goes to KQ 8, "What are the harms (including adverse effects from in utero exposure) associated with antiretroviral drugs and elective cesarean section?" The other prong goes to KQ 9: "Have improvements in intermediate outcomes (CD4 cell counts, viremia, or risky behaviors) in HIV-infected pregnant women been shown to improve clinical outcomes or reduce mother-to-child transmission?" That arrow continues as a dotted line to "Reduced premature death and disability for women and children and reduced mother-to-child transmission."
The authors note that a separate report17 reviews KQs 6, 7c, 9, and portions of 7a (immunizations, routine monitoring and followup, and more frequent Papanicolaou testing).