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Cover of Screening for Human Immunodeficiency Virus in Pregnant Women

Screening for Human Immunodeficiency Virus in Pregnant Women

Evidence Syntheses, No. 39

Roger Chou, MD, Ariel K Smits, MD, MPH, Laurie Hoyt Huffman, MS, and P Todd Korthuis, MD, MPH.

Oregon Evidence-based Practice Center, Portland, OR
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Structured Abstract

Context:

An estimated 6,000 to 7,000 HIV-infected women give birth each year in the United States. Although the number of cases of perinatally acquired HIV infection has declined sharply in the U.S. since the early 1990's, an estimated 280–370 HIV-infected infants were born each year between 1999 and 2001.

Objective:

To synthesize the evidence on risks and benefits of screening for HIV infection in pregnant women.

Data Sources:

MEDLINE® (through June 30, 2004), Cochrane Clinical Trials Registry (2004, Issue 2), reference lists, and experts.

Study Selection:

Controlled studies of screening and antiretrovirals, elective cesarean section, avoidance of breastfeeding, counseling, prophylaxis for opportunistic infections, immunizations, and routine monitoring and follow-up; observational studies of counseling, risk factors, accuracy of antibody testing, work-up, acceptability of screening and uptake of interventions, harms of interventions and screening, and long-term outcomes.

Data Extraction:

Using preset criteria, the authors assessed the quality of included studies and abstracted information about settings, patients, interventions, and outcomes.

Data Synthesis:

There are no published trials directly linking screening for HIV in pregnant women with clinical outcomes. In developed countries, the rate of mother-to-child transmission from untreated HIV-infected women ranges from 14% to 25%. Targeted screening of pregnant women with risk factor assessment would miss a significant proportion of infected persons. Standard office-based testing is highly (>99%) sensitive and specific, and initial studies of rapid HIV tests in labor and delivery settings found similar diagnostic accuracy. Rapid testing may facilitate timely interventions in those testing positive. HIV testing rates during pregnancy continue to vary widely in the U.S. and appear to be higher in states using ‘opt-out’ testing policies. Recommended interventions (combination antiretrovirals, elective cesarean section in selected patients, and avoidance of breastfeeding) are associated with transmission rates of 1%–2% in clinical trials and large observational studies. Shorter regimens are less effective, but also decrease the rate of transmission. Currently recommended combination antiretroviral regimens appear safe, but long-term follow-up is not yet available. Elective cesarean section is associated with an increased risk of mostly short-term adverse events. There are insufficient data to estimate the effects of interventions during pregnancy on long-term maternal outcomes.

Conclusions:

Identification and treatment of asymptomatic HIV infection in pregnant women can result in major reductions in mother-to-child transmission rates. The estimated benefits from combination antiretrovirals appear to greatly outweigh the risk of short-term complications. In settings with a maternal prevalence of 0.15%, the estimated number needed to screen to prevent one case of maternal-to-child transmission using conservative estimates of intervention effectiveness ranged from 3,500 to 12,170, and in settings with a maternal prevalence of 5%, ranged from 105 to 365. Data are insufficient to accurately estimate the long-term benefits of screening on maternal disease progression or other clinical outcomes (such as horizontal transmission).

Keywords:

HIV, HIV infections, HIV seropositivity, mass screening, pregnancy

Contents

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No. 290-02-0024, Task Order No. 2. Technical Support of the U.S. Preventive Services Task Force. Prepared by: Oregon Evidence-based Practice Center, Portland, OR.

This report may not be used, in whole or in part, as the basis of the development of clinical practice guidelines and other quality enhancement tools, or 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.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmaker—patients and clinicians, health system leaders, and policymakers—make more informed decisions and improve the quality of health care services.

The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

1

540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

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