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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OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.