ACOG Pushes for Routine Prenatal HIV Screening.
SAN FRANCISCO -- The American College of Obstetricians and Gynecologists is attempting to make it easier for physicians to fold HIV screening into the standard battery of tests for pregnant women--regardless of the individual's apparent risk for the disease.
In turn, experts at the college are hoping that such action will influence national policies on HIV resting in pregnancy.
The primary tools in a packet of materials recently mailed to ACOG's 40,000 members are tear sheets in English and Spanish. Each patient handout briefly describes standard tests for pregnant women--including hepatitis B, rubella, blood type, Rh factor, and syphilis--and devotes three-quarters of the text to information regarding HIV.
Physicians may use these handouts in lieu of more extensive counseling. In addition, such a "routine testing with notification" policy means that physicians aren't obligated to get the patient's explicit consent. Rather, the patient just needs to be informed that this is one of many tests that will be done unless she refuses
It seems easy, but laws or regulations in a majority of states still require more in-depth counseling and informed consent prior to HIV testing, ACOG leaders acknowledged in interviews.
Specifically, 12 states require voluntary testing of pregnant women with informed consent, 5 states require HIV testing of pregnant women unless the woman refuses, and 43 have informed consent and/or pretest counseling laws that are applicable to pregnant women.
An unspoken goal of the campaign is to spur the national government into using its leverage--such as allocation of Ryan White Care Act funds--to loosen state requirements around prenatal HIV testing.
Also in the packet: educational brochures and a poster of a group of women with the caption: "Which woman should get an HIV test? All of them."
A new ACOG committee opinion recommends that physicians counsel any pregnant woman with a high HIV viral load (more than 1,000 copies/mL) about the risks and benefits of cesarean delivery before the onset of labor and the rupture of membranes. Scheduled C-sections lower the likelihood of vertical transmission but carry increased risks for HIV infected mothers.
The Institute of Medicine first advocated a national policy of routine perinatal HIV testing in 1998. In a report, the IOM advised that patients be tested unless they refused. ACOG, the American Academy of Pediatrics, and the American Academy of Family Physicians backed the IOM recommendations in 1999 statements.
The current ACOG drive takes the issue to another level.
The earlier, more stringent policies regarding counseling and patient approval before HIV testing were enacted when the stigma and discrimination associated with HIV were a greater problem than today, said Dr. Stanley Zinberg, vice president of ACOG's practice activities division. The IOM experts found that the burden of counseling kept many physicians from incorporating prenatal HIV testing into their practices.
The new ACOG tear sheet approach suggests that extensive counseling isn't necessary because it doesn't necessarily improve the quality of care. And if physicians end up avoiding HIV resting altogether because they can't do the required counseling, it may even hinder good care.
Previous policies also tended to focus on "high-risk" patients, missing many HIV infections. An estimated 91% of children with AIDS are born to mothers infected with or at risk for HIV; one-third of these mothers do not report a risk for HIV, the ACOG leaders noted.
Advances in treatment and in the prevention of vertical transmission make it more advantageous for pregnant women to learn their HIV status as early as possible, Dr. Zinberg added.
The rate of new pediatric AIDS cases has plunged 43% since the discovery in the early 1990s that maternal treatment with zidovudine lowers the risk of vertical transmission of HIV infection from 25% to 8% overall.
Antiretroviral therapy alone cuts the risk of vertical transmission to 2% in women with low viral loads ([less than] 1,000 copies/mL), a rate that does not improve with cesarean delivery Women with higher viral loads can achieve the same 2% risk of vertical transmission if they receive antiretroviral therapy and deliver by C-section, according to the ACOG committee opinion.
The college advises delivery at 38 weeks' gestation for women with HIV infection to avoid the onset of labor or rupture of membranes before delivery, factors that increase the risk of neonatal infection.
Prophylactic antibiotics should be considered because women with HIV have higher morbidity rates associated with C-sections, the statement said. Amniocentesis to determine fetal lung maturity is discouraged.
ACOG sent packets to leaders of the AAFP and to organizations of nurse-midwives, but funding did not allow mailings to all family physicians and midwives, Dr. Zinberg said.
Obstetricians deliver approximately 85% of U.S. babies, family physicians deliver about 13%, and midwives deliver 2% of newborns, he said.