HIV: Screening - Pregnant Women


General

Grade: A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

Frequency of Service

The evidence is insufficient to determine optimum time intervals for HIV screening. One reasonable approach would be one-time screening of adolescent and adult patients to identify persons who are already HIV-positive, with repeated screening of those who are known to be at risk for HIV infection, those who are actively engaged in risky behaviors, and those who live or receive medical care in a high-prevalence setting. According to the CDC, a high-prevalence setting is a geographic location or community with an HIV seroprevalence of at least 1%. These settings include sexually transmitted disease (STD) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. Patient populations that would more likely benefit from more frequent testing include those who are known to be at higher risk for HIV infection, those who are actively engaged in risky behaviors, and those who live in a high-prevalence setting. Given the paucity of available evidence for specific screening intervals, a reasonable approach may be to rescreen groups at very high risk (see Assessment of Risk) for new HIV infection at least annually and individuals at increased risk at somewhat longer intervals (for example, 3 to 5 years). Routine rescreening may not be necessary for individuals who have not been at increased risk since they were found to be HIV-negative. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.

Risk Factor Information

No information available.


Clinical

Patient Population Under Consideration

These recommendations apply to adolescents, adults, and pregnant women. Screening for HIV infection could begin at age 15 years unless an individual is identified at an earlier age with risk factors for HIV infection. Screening after age 65 years is indicated if there is ongoing risk for HIV infection, as indicated by risk assessment (for example, new sexual partners).

Assessment of Risk

According to estimates from the Centers for Disease Control and Prevention (CDC), men who have sex with men account for about 60% of HIV-positive persons in the United States. Among men living with HIV infection who were diagnosed at age 13 years or older, 68% of infections are attributed to male-to-male sexual contact, 8% are attributed to male-to-male sexual contact and injection drug use, and 11% are attributed to heterosexual contact. Among women living with HIV infection, 74% of infections are attributed to heterosexual contact and the remainder to injection drug use. According to the CDC, heterosexual contact accounted for an estimated 25% of new HIV infections in 2010 and 27% of existing infections in 2009. Data from the CDC on HIV prevalence in different subpopulations are available at www.cdc.gov/hiv/topics/surveillance.On the basis of HIV prevalence data, the USPSTF considers men who have sex with men and active injection drug users to be at very high risk for new HIV infection. Behavioral risk factors for HIV infection include having unprotected vaginal or anal intercourse; having sexual partners who are HIV-infected, bisexual, or injection drug users; or exchanging sex for drugs or money. Other persons at high risk include those who have acquired or request testing for other sexually transmitted infections (STIs). Patients may request HIV testing in the absence of reported risk factors. Individuals not at increased risk for HIV infection include persons who are not sexually active, those who are sexually active in exclusive monogamous relationships with uninfected partners, and those who do not fall into any of the aforementioned categories. The USPSTF recognizes that these categories are not mutually exclusive, the degree of sexual risk is on a continuum, and individuals may not be aware of their sexual partners' risk factors for HIV infection. For patients younger than 15 years and older than 65 years, it would be reasonable for clinicians to consider HIV risk factors among individual patients, especially those with new sexual partners. However, clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having HIV risk factors, even when asked.

Screening Intervals

The evidence is insufficient to determine optimum time intervals for HIV screening. One reasonable approach would be one-time screening of adolescent and adult patients to identify persons who are already HIV-positive, with repeated screening of those who are known to be at risk for HIV infection, those who are actively engaged in risky behaviors, and those who live or receive medical care in a high-prevalence setting. According to the CDC, a high-prevalence setting is a geographic location or community with an HIV seroprevalence of at least 1%. These settings include sexually transmitted disease (STD) clinics, correctional facilities, homeless shelters, tuberculosis clinics, clinics serving men who have sex with men, and adolescent health clinics with a high prevalence of STDs. Patient populations that would more likely benefit from more frequent testing include those who are known to be at higher risk for HIV infection, those who are actively engaged in risky behaviors, and those who live in a high-prevalence setting. Given the paucity of available evidence for specific screening intervals, a reasonable approach may be to rescreen groups at very high risk (see Assessment of Risk) for new HIV infection at least annually and individuals at increased risk at somewhat longer intervals (for example, 3 to 5 years). Routine rescreening may not be necessary for individuals who have not been at increased risk since they were found to be HIV-negative. Women screened during a previous pregnancy should be rescreened in subsequent pregnancies.

Screening Tests

The conventional serum test for diagnosing HIV infection is the repeatedly reactive immunoassay followed by confirmatory Western blot or immunofluorescent assay. The test is highly accurate (sensitivity and specificity, >99.5%), and results are available within 1 to 2 days from most commercial laboratories.Rapid HIV testing may use either blood or oral fluid specimens and can provide results in 5 to 40 minutes. The sensitivity and specificity of the rapid test are also both greater than 99.5%; however, initial positive results require confirmation with conventional methods.Other U.S. Food and Drug Administration–approved tests for detection and confirmation of HIV infection include combination tests (for p24 antigen and HIV antibodies) and qualitative HIV-1 RNA.

Treatment

No cure for chronic HIV infection currently exists. However, appropriately timed interventions in HIV-positive persons can reduce risks for clinical progression, complications or death from the disease, and disease transmission. Effective interventions include ART (specifically, the use of combined ART, defined as ≥3 antiretroviral agents used together, usually from ≥2 classes), immunizations, and prophylaxis for opportunistic infections.

Other Approaches to Prevention

The USPSTF recognizes that the most effective strategy for reducing HIV-related morbidity and mortality in the United States is primary prevention or avoidance of exposure to HIV infection. Condom use can also substantially decrease the risk for transmission of HIV and other STIs. The USPSTF recommends high-intensity behavioral counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for infection. More information can be found at www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm. The Community Preventive Services Task Force has made several recommendations related to the prevention of HIV, AIDS, and other STIs, including person-to-person behavioral interventions (information and skill building to change knowledge, attitudes, beliefs, and self-efficacy) for men who have sex with men that can be implemented at the individual, group, or community level. It also recommends health provider notification and encouragement for HIV testing for sexual or needle-sharing partners of individuals diagnosed with HIV, as well as comprehensive risk reduction interventions in adolescents. More information can be found at www.thecommunityguide.org/hiv/index.html.

Other Resources

More information about HIV and AIDS is available at www.aids.gov and www.cdc.gov/hiv/default.htm. The CDC's recommendations on HIV testing in adults, adolescents, and pregnant women in health care settings are available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. More information on HIV testing is available at www.cdc.gov/hiv/topics/testing/index.htm and www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/HIVandAIDSActivities/ucm117922.htm. Antiretroviral treatment guidelines are regularly updated and available at http://aidsinfo.nih.gov/guidelines. Information about state-based HIV and AIDS hotlines is available at http://hab.hrsa.gov/gethelp/statehotlines.html.  

Other Considerations

Implementation

For populations in which the prevalence of undiagnosed HIV infection is known to be 0.1% or less (that is, ≤1 person in 1,000 is HIV-positive), where the potential benefit per person screened is low, it is reasonable to forgo routine HIV screening and instead screen on the basis of risk assessment. The CDC suggests that for populations in which the prevalence of HIV infection has not been documented, clinicians should initiate voluntary routine screening. If no HIV-infected patients are found after screening of approximately 4,000 patients, the upper limit of the 95% CI for prevalence is less than 0.1% and routine screening may be discontinued and replaced with risk-based screening. The USPSTF concurs with the CDC's recommendation that HIV screening should be voluntary and done only with the patient's knowledge and understanding. Patients should be informed orally or in writing that HIV testing will be performed unless they decline (opt-out screening). The USPSTF further concurs with the CDC's recommendation that before HIV testing, patients should receive an explanation of HIV infection and the meaning of positive and negative test results. Patients should also be offered the opportunity to ask questions and to decline testing. The CDC's recommendations on HIV testing in adults, adolescents, and pregnant women in health care settings are available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

Cost-Effectiveness Analysis

The USPSTF's deliberations on grade recommendations for the effectiveness of clinical preventive services do not include cost or cost-effectiveness considerations. For policy context, however, the USPSTF reviewed some cost-effectiveness analyses published since its previous review. These analyses, which include downstream costs, support the cost-effectiveness of HIV screening in settings with low or average HIV prevalence. No studies directly compared universal versus targeted screening in low-prevalence populations or explicitly considered the potential long-term cardiovascular harms of ART.

Research Needs and Gaps

Individuals who begin ART tend to continue receiving it for an extended length of time. Better evidence is needed about the long-term harms of ART, including risks for cardiovascular and kidney disease. Further follow-up is necessary to better delineate potential long-term harms of ART initiation at higher CD4 cell counts. It would also be helpful to better elucidate the potential risks and long-term outcomes associated with in utero or perinatal exposure to ART. Antiretroviral treatment guidelines are regularly updated and available at http://aidsinfo.nih.gov/guidelines. Direct evidence of the effectiveness of ART and behavioral counseling in reducing HIV transmission among men who have sex with men and other high-risk groups could also guide prevention and treatment strategies. Similarly, additional studies are needed to better define the optimum timing for treatment initiation. More research is needed about the differential effects of various HIV screening strategies on testing acceptability and uptake, linkage to and receipt of care, and harms. Information that could quantify any incremental benefits and harms of repeated HIV screening and identify ideal time intervals for rescreening in different populations would be useful.

Rationale

No information available.


Others

In 2006, the CDC recommended routine voluntary HIV screening in all adolescents and adults aged 13 to 64 years regardless of other recognized risk factors, unless the prevalence of undiagnosed HIV infection has been documented to be less than 0.1%. The CDC also recommended opt-out HIV testing, meaning that all patients should be informed about and undergo testing unless they specifically decline, without a requirement for prevention counseling before screening in order to reduce barriers to testing. In 2009, the American College of Physicians endorsed the CDC's approach. The Infectious Diseases Society of America recommends routine HIV screening for all sexually active adults. The American Congress of Obstetricians and Gynecologists recommends routine opt-out screening in all women aged 19 to 64 years and targeted screening in women with risk factors outside of that age range. The American Academy of Pediatrics recommends offering routine HIV testing to all adolescents at least once by age 16 to 18 years when HIV prevalence is greater than 0.1% in the community, as well as testing of all sexually active adolescents and those with risk factors in low-prevalence settings. The American Academy of Family Physicians recommends that clinicians screen adolescents and adults aged 18 to 65 years for HIV infection, as well as younger adolescents and older adults who are at increased risk.


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