July 2000
SAN FRANCISCO - All pregnant women, regardless of apparent risk, should be tested for HIV as a routine part of prenatal care, according to the American College of Obstetricians and Gynecologists (ACOG). The measure is the first step to reducing overall mother-to-child transmission rates to between zero to 2%.
ACOG also recommended HIV-infected pregnant women with a viral load of >1,000 copies/mL receive counseling about the benefits and risks of elective cesarean delivery to further reduce perinatal transmission rates.
The recommendations were announced at the ACOG 48th Annual Clinical Meeting held here. The education initiative is funded in large part through a grant by the Centers for Disease Control and Prevention (CDC).
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"The hope is that by making (HIV testing) routine, physicians will identify the women who otherwise would not have been identified during pregnancy," said Laura Riley, MD, director, obstetrics/gynecology, infectious disease unit, Massachusetts General Hospital in Boston.
According to Riley, women should be tested as early in pregnancy as possible. ACOG suggests testing occur during the first prenatal visit, when a woman is already receiving a battery of tests. If a woman declines testing at that point, there is still time to test during later stages of pregnancy.
Under the ACOG initiative, physicians would be able to transition from time-consuming pretest procedures to treating HIV testing like any other prenatal test - similar to the "universal testing with notification" recommendation advocated by the Institute of Medicine.
Many states however, have different laws requiring different procedures for HIV testing.
"In some states, like Massachusetts, you have to sign a consent form and provide an element of counseling," said Riley at a press briefing during the meeting. "You're not just checking off a box. In other states they have laws which prohibit physicians from embracing ACOG guidelines altogether.
"ACOG is not saying you should throw out the laws in your own state. We don't want obstetricians to be liable. We're saying what they need to do is adapt a more routine approach to (testing) so they end up testing almost everyone."
According to Stanley Zinberg, MD, vice president of ACOG practice activities division, physicians "can't afford any mistaken assumptions or stereotypes about who is really at risk for HIV."
Michael Greene, MD, chair of ACOG's Committee on Obstetric Practice, added, "The aim is to make HIV testing as commonplace as urinalysis during the first prenatal office visit."
Counseling can be a burdensome, time-consuming task, especially for patients that physicians consider not at risk, according to Riley. Physician- and patient-directed bilingual educational materials provided by ACOG pare down information and streamline the testing procedure.
"There's literally a tear-off sheet physicians can give their patients with all the information they need," said Riley. "This should make it easier for physicians. Hopefully it will make it better for their patients also because they'll be better educated so there won't be situations where people are tested for HIV and didn't know it was going to happen. That's not good medicine."
ACOG's educational material packet has a policy statement and cover letter from Zinberg; important news for pregnant women about blood tests and HIV; a fact sheet for physicians on HIV testing with phone numbers for questions about test results; and posters for physicians to post in the waiting room or clinic. One poster shows different women with the caption, "Which women should get an HIV test? Answer? All of them."
"Pediatricians have been waiting for us to do this for a long time," said Riley. "This means babies will be identified earlier and treated earlier so they don't ever become HIV positive. That's our goal."
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