Human Immunodeficiency Virus Screening

The problem of perinatal transmission of human immunodeficiency virus (HIV) infection was first appreciated in 1982. In 1991, the Institute of Medicine (IOM) recommended a policy of routine counseling and offering testing (with specific informed consent) for HIV infection to all pregnant women. Since 1991, there have been major advances in the treatment of HIV infection, including demonstration in 1994 of the efficacy of zidovudine to reduce perinatal transmission. The US Public Health Service subsequently issued guidelines for use of zidovudine to reduce perinatal transmission and for counseling and voluntary testing for pregnant women. Dramatic declines in reported pediatric acquired immunodeficiency syndrome (AIDS) cases have been observed as a consequence of implementation of these guidelines. However, for a variety of reasons, screening pregnant women in the United States has been far from universal and infected infants continue to be born to undiagnosed infected women. Further reduction in the rate of perinatal HIV infection will require wider application of both screening to identify infected women, and treatments that have demonstrated efficacy in reducing vertical transmission.

The IOM recently completed a study of interventions that would be helpful to further reduce the rate of perinatal HIV infection in the United States (Reducing the Odds). They have recommended that “the United States adopt a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care.” Early diagnosis of HIV infection in pregnant women allows them to institute effective antiretroviral therapy for their own health and to reduce the risk of HIV transmission to their infants. The use of “patient notification” provides women the opportunity to decline to be tested but eliminates the obligation to provide extensive pretest counseling, which has been a barrier to testing in many settings. Care providers would be charged with responsibility for the details of how the notification would take place. The IOM has recommended universal testing for two reasons. First, attempts to identify those “at risk” for infection inevitably fail to identify some infected individuals. Second, universal testing of all pregnant women avoids stereotyping and stigmatizing any social or ethnic group. The IOM recognizes in its report that many states now have laws requiring a formal, and in many cases written, informed consent process before testing. They recommend that the federal government adopt policies that will encourage these states to change their laws.

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) strongly support efforts to further reduce the rate of perinatal transmission of HIV in the United States. We therefore support the recommendation of the IOM for universal HIV testing with patient notification as a routine component of prenatal care. If a patient declines testing, this should be noted in the medical record. We recognize that current laws in some states may prevent implementation of this recommendation at this time. We encourage our members and Fellows to include counseling as a routine part of care, but not as a prerequisite for and barrier to prenatal HIV testing.

• Copyright © 1999 American Academy of Pediatrics