Make HIV Testing Routine in Prenatal Care, IOM Panel Urges

WASHINGTON—HIV testing should be made a routine but voluntary part of prenatal care for all women in the United States, an Institute of Medicine (IOM) committee has recommended.

“We believe that health care providers should notify pregnant women that HIV is part of the usual array of tests they will receive, and women should have the opportunity to refuse the test,” said panel chair Marie McCormick, MD, ScD, professor of maternal and child health, Harvard School of Public Health. “This subtle yet important shift in policy would help reduce the number of pediatric AIDS cases and, as long as it happens in parallel with good medical care, would also improve treatment for mothers with AIDS.”

Women now account for 21% of adult AIDS cases in the United States. The IOM report noted that the use of zidovudine (AZT, Retrovir) in HIV-infected pregnant women had a major role in helping reduce the number of new pediatric AIDS cases by 43% between 1992 and 1996.

Clinical trials have shown that zidovudine can reduce mother-to-child HIV transmission rates to below 5%. About 500 babies will be born this year with full-blown AIDS and as many as 1,500 more with HIV infection.

Making HIV testing routine would reduce the need to provide extensive pre-test counseling required by current guidelines, Dr. McCormick said. It would also end the need for doctors to assess whether a women is at high risk of infection and make extra efforts to encourage high-risk women to be tested.

“By recognizing that HIV is a communicable disease without inherent geographic or human barriers, routine testing would lessen the stigmatization of groups in which perinatal HIV transmission is now more prevalent,” she added.

An analysis showed that the cost of this policy recommendation compares favorably with the cost of treating HIV-infected children.

The panel also urged that the federal government establish a regional system of perinatal HIV prevention and treatment centers. “These centers would help ensure optimal HIV care for all pregnant women and newborns, and would help develop and implement strategies to promote prenatal HIV screening,” she said.

The IOM report, “Reducing The Odds: Preventing Perinatal Transmission of HIV in the United States,” proposed six actions needed to make its testing recommendation a reality:

Health care plans should implement policies to facilitate routine prenatal testing, and should track their success in conducting HIV screening.

•  Businesses and other organizations that purchase health care should support routine prenatal testing in their contracts with providers.
  
•  Professional medical organizations should update their guidelines to recommend routine prenatal screening.
  
•  Providers need to be educated about the value of prenatal HIV screening and how to deal appropriately with those who test positive.
  
•  Health officials need to improve their outreach to pregnant women, to address their concerns about testing and treatment.
  
•  Testing should be seamlessly linked to treatment for women found to be infected, and this care must be coordinated before, during, and after delivery. Providers must take steps to ensure their patients’ confidentiality is protected, and that a patient is not forced to take a test.

“We are saying that the process for identifying HIV should be so routine, with informed consent, that it is likely to be universally available,” said panel vice chair Ezra Davidson, Jr., MD, professor of ob/gyn, Charles R. Drew University of Medicine and Science, Los Angeles.