Clinician's Guide to Routine Human Immunodeficiency Virus (HIV) Testing During Pregnancy
2014

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Maternal HIV antibody testing, with patient consent, is a routine component of prenatal care. An HIV test is recommended for all women who are pregnant, or planning a pregnancy regardless of their risk factors or the prevalence rates where they live. Proper diagnosis and treatment can improve the health of the mother and dramatically reduce the transmission of HIV from mother to infant.

Implementation Steps

At the first OB visit, discuss the following with the patient:

  • An HIV antibody test is recommended as a routine part of prenatal care. It will be routinely offered to all patients for the following reasons:
    • HIV can be transmitted from the mother to the fetus or newborn during the pregnancy, the birth process or breast feeding.
    • Treatment is available that will significantly reduce the transmission rate.
    • A risk assessment will not identify all HIV-infected pregnant women.
  • Before HIV testing, provide the following minimum information: (although a face-to-face counseling session is ideal, other methods can be used (e.g., brochure, pamphlet, or video) if they are culturally and linguistically appropriate. A possible source of materials is the American College of Obstetricians and Gynecologists.
      • HIV is the virus that causes AIDS. HIV is spread through unprotected sexual contact and injection-drug use. Approximately 25% of HIV-infected pregnant women who are not treated during pregnancy can transmit HIV to their infants during pregnancy, during labor and delivery, or through breast-feeding.
      • A woman might be at risk for HIV infection and not know it, even if she has had only one sex partner.
      • Effective interventions (e.g., antiretroviral medication combinations) for HIV-infected pregnant women can protect their infants from acquiring HIV and can prolong the survival and improve the health of these mothers and their children.
      • For these reasons, HIV testing is recommended for all pregnant women.
      • Services are available to help women reduce their risk of acquiring HIV and to provide medical care and other assistance to those who are infected.
      • Women who decline testing will not be denied care for themselves or their infants.
    • Obtain informed consent prior to testing; women should not be tested without their knowledge.
    • Inform the patient that a positive HIV test will be reported by name to MDH, as are other STD’s.

HIV Screening for Pregnant Women and Their Infants

Universal Opt-Out Screening (Minnesota is an Opt-Out state)

  • All pregnant women in the United States should be screened for HIV infection.
  • Screening should occur after a woman is notified that HIV screening is recommended for all pregnant patients and that she will receive an HIV test as part of the routine panel of prenatal tests unless she declines (opt-out screening).
  • HIV testing must be voluntary and free from coercion. No woman should be tested without her knowledge.
  • Pregnant women should receive oral or written information that includes an explanation of HIV infection, a description of interventions that can reduce HIV transmission from mother to infant, and the meanings of positive and negative test results and should be offered an opportunity to ask questions and to decline testing. One patient education fact sheet is ACOG's Patient Education Fact Sheet on Testing for HIV.
  • No additional process or written documentation of informed consent beyond what is required for other routine prenatal tests should be required for HIV testing.
  • If a patient declines an HIV test, this decision should be documented in the medical record.

Addressing Reasons for Declining Testing

  • Providers should discuss and address reasons for declining an HIV test (e.g., lack of perceived risk; fear of the disease; and concerns regarding partner violence or potential stigma or discrimination).
  • Women who decline an HIV test because they have had a previous negative test result should be informed of the importance of retesting during each pregnancy.
  • Logistical reasons for not testing (e.g., scheduling) should be resolved.
  • Certain women who initially decline an HIV test might accept at a later date, especially if their concerns are discussed. Certain women will continue to decline testing, and their decisions should be respected and documented in the medical record.

Timing of HIV Testing

  • Health-care providers should test women for HIV as early as possible during each pregnancy. Women who decline the test early in prenatal care should be encouraged to be tested at a subsequent visit.
  • A second HIV test during the third trimester, preferably <36 weeks of gestation, is cost-effective even in areas of low HIV prevalence and may be considered for all pregnant women. A second HIV test during the third trimester is recommended for women who meet one or more of the following criteria:
      • Women who receive health care in facilities in which prenatal screening identifies at least one HIV-infected pregnant woman per 1,000 women screened.
      • Women who are known to be at high risk for acquiring HIV (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy).
      • Women who have signs or symptoms consistent with acute HIV infection. When acute retroviral syndrome is a possibility, a plasma RNA test should be used in conjunction with an HIV antibody test to diagnose acute HIV infection.

Documentation

  • Document in the medical record information discussed with patient about HIV and testing as well as whether the patient accepts or declines an HIV antibody test.
  • Include the HIV antibody test in the prenatal lab panel.

If Patient Declines an HIV Test

  • Continue to recommend an HIV test as a routine component of prenatal care at subsequent visits.
  • Refusing to be tested must not have detrimental consequences to the quality of prenatal care.

Testing During Labor

  • Any woman with undocumented HIV status at the time of labor should be screened with a rapid HIV test unless she declines the test.
  • MN Perinatal HIV Nurse Coordinator is available to coordinate and support intrapartum and newborn care. This service is available free of charge to any provider or hospital in MN. (612) 387-2989 (cell)
  • Immediate initiation of appropriate antiretroviral prophylaxis should be recommended to women on the basis of a reactive rapid test result without waiting for the result of a confirmatory test.

Algorithm for HIV Testing During Pregnancy

Algorithm for HIV Testing During Pregnancy

Rapid Testing

Women admitted for labor and delivery with unknown or undocumented HIV status should be assessed promptly for HIV infection to allow for timely prophylactic treatment. The use of Rapid Testing (with confirmation by a second licensed test when available) is an option. There are currently seven rapid HIV tests approved by the U.S. Food and Drug Administration (FDA) and commercially available in the U.S.:

Test kit name

Manufacturer

Specimen type

CLIA Category

Equipment Required

OraQuick ADVANCE Rapid HIV-1 Antibody
Ora Quick Rapid HIV-1 Antibody Test

OraSure Technologies

Whole Blood

Waived-Whole blood

Timer

Uni-Gold Recombigen HIV-1

Trinity Biotech

Whole Blood

Waived-Whole blood

Timer

Reveal G3 Rapid HIV-1 Antibody Test

MedMira Inc.

Serum or Plasma

CLIA-moderate complexity

Centifuge

Multispot HIV-1/HIV-2 Rapid Test

Bio-Rad Laboratories

Plasma or Serum

CLIA-moderate complexity

Timer

Clearview HIV 1/2Stat-Pack and COMPLETE 1/2Test Kits

Alere

Serum or Plasma Whole Blood

Waived-Whole blood

Timer

INSTI HIV-1 Antibody Test

BioLytical Laboratories

Whole blood Serum or Plasma

Waived

Timer

Alere Determine HIV-1/2AF/Ab Combo

Alere

Serum or Plasma
Whole Blood

CLIA-moderate complexity

Timer

 

Test Results:

For Negative Test Results, discuss the following:

  • Window period, particularly if risk behaviors are present.
  • Negative test result does not imply immunity to future infection.
  • Reinforce ways to prevent transmission of HIV.
  • Retest in the future, including the third trimester-before 36 weeks gestation, if evidence of risk (e.g. STD diagnosis, multiple partners).

For Positive Test Results, discuss the following:

  • The meaning of an HIV positive test, HIV and AIDS.
  • Medical care, including treatment for the mother’s health and to reduce the risk of transmission.
  • Notify MDH of positive test result.
  • Notification of partners and explore risk of any domestic violence. *
  • Recommend testing of partners and children. *
  • Consult or refer to an HIV specialist for treatment, and a Pediatric HIV Specialist for baby’s follow up care.

* MDH Partner Services Program contacts all newly diagnosed HIV positive individuals

If test is being done in the presence of active labor, a positive Rapid test result warrants the initiation of IV Retrovir prophylaxis.  A confirmatory test is still sent.

Resources

Information on Care Coordination for Pregnant HIV+ Women and Training and Education on Perinatal HIV:

Susan Dicker, RN, MS, MPH
Perinatal HIV Nurse Coordinator
Children’s Hospital and Clinics of MN
347 North Smith Avenue, Suite 504
St. Paul, Minnesota 55102
(612) 387-2989 (cell)
(651) 220-6444 (office)
(651) 220-7233 (fax)
Susan.Dicker@childrensmn.org

Tamara Harvanko R.N.
High Risk OB Clinical Care Coordinator
Hennepin County Medical Center
701 Park Ave SL 120
Minneapolis, MN 55415
Direct: 612-873-6552
Pager: 612-336-0327
tamara.harvanko@hcmed.org

Information for Care of Newborns Perinatally Exposed to HIV:

Laura Hoyt, MD
Susan Kline, MD
Tim Schacker, MD
Fairview-University Medical Center
Box 88 Mayo, 420 Delaware St. S.E.
Minneapolis, Minnesota 55455
(612) 625-4680

Frank Rhame, MD
The Doctors, Allina Medical Clinic
1300 Lagoon Avenue
Minneapolis, Minnesota 55408

Keith Henry, MD
Ron Schut, MD
Kay Schwebke, MD
Margaret Simpson, MD
Virginia Lupo, MD (OB/GYN)
Hennepin County Medical Center
701 Park Avenue South
Minneapolis, Minnesota 55415
(612) 873-6963

mn-tel: HIV Consultation Network

HIV/AIDS clinical support & consultation services for
healthcare providers

Call MATEC at 612-626-3609 for more information

Information about Disease Reporting:

Adriana DiStaolo
Sue Bedard-Johnson
Minnesota Department of Health
STD and HIV Section
625 Robert Street North
Minneapolis, MN 55107
(651) 201-5414

Assistance with HIV Partner Notification:

MDH STD/MDH Partner Services Program
Call the Partner Services Program at 651-201-5414

HIV Perinatal Clinical Resources:

UCSF Clinical Consultation Center

UCSF Clinical Consultation Center
“Frequently Asked Questions about HIV Testing”

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Updated Monday, December 01, 2014 at 01:09PM