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Cover of Screening for HIV Infection in Pregnant Women: A Systematic Review for the U.S. Preventive Services Task Force

Screening for HIV Infection in Pregnant Women: A Systematic Review for the U.S. Preventive Services Task Force

Evidence Synthesis, No. 177

Investigators: , MD, MPH, , MPH, , MLS, , BA, and , MD.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 18-05246-EF-2

Structured Abstract

Background:

A 2012 systematic review on HIV screening for the U.S. Preventive Services Task Force (USPSTF) found strong evidence that antiretroviral therapy (ART) greatly decreases the risk of mother-to-child HIV transmission but that use of ART may be associated with increased risk of preterm delivery. The USPSTF previously found HIV screening tests to be highly accurate.

Purpose:

To systematically update the 2012 USPSTF review on HIV screening in pregnancy, focusing on research gaps identified in the prior review.

Data Sources:

We searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and MEDLINE (2012 to June 2018) and manually reviewed reference lists, with surveillance through January 25, 2019.

Study Selection:

We selected randomized, controlled trials (RCTs) and cohort studies of pregnant women that reported risk of mother-to-child transmission or maternal or infant harms associated with prenatal HIV screening or ART during pregnancy.

Data Extraction:

One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF.

Data Synthesis (Results):

We identified no studies on the benefits or harms of prenatal HIV screening versus no screening, or on the yield of repeat versus one-time screening or screening at different intervals. One new RCT and five new cohort studies were consistent with the 2012 USPSTF review in finding combination ART highly effective at reducing the risk of mother-to-child transmission of HIV infection, especially if started early in pregnancy (rate of mother-to-child transmission <1%). As in the prior USPSTF review, one new RCT and several observational studies found certain ART regimens associated with increased risk of preterm delivery without increased risk of low birth weight. One RCT conducted in Africa found prenatal tenofovir-based ART associated with very preterm delivery and early infant death versus zidovudine-based ART, but the trial had methodological limitations. Prenatal exposure to most currently recommended ART drugs was not associated with increased risk of overall birth defects, but limited evidence found certain ART agents and regimens associated with increased risk of congenital abnormalities, cardiac anomalies, and echocardiographic changes, with no association with adverse neurodevelopmental outcomes. Evidence on long-term maternal harms associated with short-term exposure to ART during pregnancy remains limited, with some evidence of short-term harms.

Limitations:

Only English-language articles were included. Observational studies were included. Studies conducted in resource-poor settings were included, which might limit applicability to screening in the United States.

Conclusions:

Combination ART is highly effective at reducing risk of mother-to-child HIV transmission. The USPSTF previously determined that avoidance of breastfeeding and Caesarean delivery in women with HIV ribonucleic acid levels greater than 1,000 copies/mL near the time of delivery is also effective at reducing mother-to-child transmission, and that prenatal screening is accurate at diagnosing HIV infection. Use of certain ART regimens during pregnancy is associated with increased risk of preterm delivery and may be associated with other adverse pregnancy outcomes. Although more evidence is required to better understand short- and long-term maternal and infant harms, selection of ART regimens may help mitigate or reduce harms.

Contents

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 5600 Fishers Lane, Rockville, MD 20857; www.ahrq.gov Contract No. HHSA-290-2015-00009-I, Task Order No. 7 Prepared by: Pacific Northwest Evidence-Based Practice Center, Oregon Health & Science University, Mail Code: BICC, 3181 SW Sam Jackson Park Road, Portland, OR 97239; www.ohsu.edu/epc

Suggested citation:

Selph S, Bougatsos C, Dana T, Grusing S, Chou R. Screening for HIV Infection in Pregnant Women: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 177. AHRQ Publication No. 18-05246-EF-2. Rockville, MD: Agency for Healthcare Research and Quality; 2019.

This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA-209-2015-00009-I, Task Order No. 7). The findings and conclusions in this document are those of the authors, who are responsible for its contents, and do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information (i.e., in the context of available resources and circumstances presented by individual patients).

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.

Bookshelf ID: NBK542898PMID: 31233298

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