Recommendations for HIV Counseling of Pregnant

The following recommendations have been developed to provide guidanceto healthcare workers when educating women about HIV infectionand the importance of early diagnosis of HIV. The recommendationsare based on the advances made in treatment and prevention ofHIV infection and stress the need for a universal counseling andvoluntary testing program for pregnant women. These recommendationsaddress a) HIV-related information needed by infected and uninfectedpregnant women for their own health and that of their infants,b) laboratory considerations involved in HIV testing of this population,and c) the importance of follow-up services for HIV-infected women,their infants, and other family members.

HIV Counseling and Voluntary Testing of Pregnant Women andTheir Infants

• Healthcare providers should ensure that all pregnant womenare counseled and encouraged to be tested for HIV infection toallow women to know their infection status, both for their ownhealth and to reduce the risk for perinatal HIV transmission.Pretest HIV counseling of pregnant women should be done in accordancewith previous guidelines for HIV counseling. Such counseling shouldinclude information regarding the risk for HIV infection associatedwith sexual activity and injecting-drug use, the risk for transmissionto the woman's infant if she is infected, and the availabilityof therapy to reduce this risk. HIV counseling, including anywritten materials, should be linguistically, culturally, educationally,and age appropriate for individual patients.
• HIV testing of pregnant women and their infants should bevoluntary. Consent for testing should be obtained in accordancewith prevailing legal requirements. Women who test positive forHIV or who refuse testing should not be a) denied prenatal orother healthcare services, b) reported to child protective serviceagencies because of refusal to be tested or because of their HIVstatus, or c) discriminated against in any other way.
• Healthcare providers should counsel and offer HIV testingto women as early in pregnancy as possible so that informed andtimely therapeutic and reproductive decisions can be made. Specificstrategies and resources will be needed to communicate with womenwho may not obtain prenatal care because of homelessness, incarceration,undocumented citizenship status, drug or alcohol abuse, or otherreasons.
• Uninfected pregnant women who continue to practice high-riskbehaviors (eg, injecting-drug use and unprotected sexual contactwith an HIV-infected or high-risk partner) should be encouragedto avoid further exposure to HIV and to be retested for HIV inthe third trimester of pregnancy.
• The prevalence of HIV infection may be higher in women whohave not received prenatal care. These women should be assessedpromptly for HIV infection. Such an assessment should includeinformation regarding prior HIV testing, test results, and riskhistory. For women who are first identified as being HIV infectedduring labor and delivery, healthcare providers should consideroffering intrapartum and neonatal ZDV according to published recommendations.For women whose HIV infection status has not been determined,HIV counseling should be provided and HIV testing offered as soonas the mother's medical condition permits. However, involuntaryHIV testing should never be substituted for counseling and voluntarytesting.
• Some HIV-infected women do not receive prenatal care, choosenot to be tested for HIV, or do not retain custody of their children.If a woman has not been tested for HIV, she should be informedof the benefits to her child's health of knowing her child's infectionstatus, and should be encouraged to allow the child to be tested.Counselors should ensure that the mother provides consent withthe understanding that a positive HIV test for her child is indicativeof infection in herself. For infants whose HIV infection statusis unknown and who are in foster care, the person legally authorizedto provide consent should be encouraged to allow the infant tobe tested (with the consent of the biologic mother, when possible)in accordance with the policies of the organization legally responsiblefor the child and with prevailing legal requirements for HIV testing.
• Pregnant women should be provided access to other HIV preventionand treatment services (eg, drug-treatment and partner-notificationservices) as needed.

Interpretation of HIV Test Results

• HIV antibody testing should be performed according to therecommended algorithm, which includes the use of an EIA to testfor antibody to HIV and confirmatory testing with an additional,more specific assay (eg, Western blot or IFA). All assays shouldbe performed and conducted according to manufacturers' instructionsand applicable state and federal laboratory guidelines.
• HIV infection (as indicated by the presence of antibody toHIV) is defined as a repeatedly reactive EIA and a positive confirmatorysupplemental test. Confirmation or exclusion of HIV infectionin a person with indeterminate test results should be made notonly on the basis of HIV antibody test results, but with considerationof a) the person's medical and behavioral history, b) resultsfrom additional virologic and immunologic tests when performed,and c) clinical follow-up. Uncertainties regarding HIV infectionstatus, including laboratory test results, should be resolvedbefore final decisions are made concerning pregnancy termination,ZDV therapy, or other interventions.
• Pregnant women who have repeatedly reactive EIA and indeterminatesupplemental tests should be retested immediately for HIV antibodyto distinguish between recent seroconversion and a negative testresult. Additional tests (eg, viral culture, PCR, or p24 antigentest) to diagnose or exclude HIV infection may be required forwomen whose test results remain indeterminate-especially womenwho have behavioral risk factors for HIV, have had recent exposureto HIV, or have clinical symptoms compatible with acute retroviralillness. In such situations, confirmation by an FDA-licensed IFAkit may be helpful because IFA is less likely to yield indeterminateresults than Western blot.
• Women who have negative EIAs and those who have repeatedlyreactive EIAs but negative supplemental tests should be considereduninfected.

Recommendations for HIV-Infected Pregnant Women

• HIV-infected pregnant women should receive counseling as previouslyrecommended. Post-test HIV counseling should include an explanationof the clinical implications of a positive HIV antibody test resultand the need for, benefit of, and means of access to HIV-relatedmedical and other early intervention services. Such counselingshould also include a discussion of the interaction between pregnancyand HIV infection, the risk for perinatal HIV transmission andways to reduce this risk, and the prognosis for infants who becomeinfected.
• HIV-infected pregnant women should be evaluated accordingto published recommendations to assess their need for antiretroviraltherapy, antimicrobial prophylaxis, and treatment of other conditions.Although medical management of HIV infection is essentially thesame for pregnant and nonpregnant women, recommendations for treatinga patient who has tuberculosis have been modified for pregnantwomen because of potential teratogenic effects of specific medications(eg, streptomycin and pyrazinamide). HIV-infected pregnant womenshould be evaluated to determine their need for psychologicaland social services.
• HIV-infected pregnant women should be provided informationconcerning ZDV therapy to reduce the risk for perinatal HIV transmission.This information should address the potential benefit and short-termsafety of ZDV and the uncertainties regarding a) long-term risksof such therapy and b) effectiveness in women who have differentclinical characteristics (eg, CD4+ T-lymphocyte count and previousZDV use) than women who participated in the trial. HIV-infectedpregnant women should not be coerced into making decisions aboutZDV therapy. These decisions should be made after considerationof both the benefits and potential risks of the regimen to thewoman and her child. Therapy should be offered according to theappropriate regimen in published recommendations. A woman's decisionnot to accept treatment should not result in punitive action ordenial of care.
• HIV-infected pregnant women should receive information aboutall reproductive options. Reproductive counseling should be nondirective.Healthcare providers should be aware of the complex issues thatHIV-infected women must consider when making decisions about theirreproductive options and should be supportive of any decision.
• To reduce the risk for HIV transmission to their infants,HIV-infected women should be advised against breast- feeding.Support services should be provided when necessary for use ofappropriate breast-milk substitutes.
• To optimize medical management, positive and negative HIVtest results should be available to a woman's healthcare providerand included on both her and her infant's confidential medicalrecords. After obtaining consent, maternal healthcare providersshould notify the pediatric-care providers of the impending birthof an HIV-exposed child, any anticipated complications, and whetherZDV should be administered after birth. If HIV is first diagnosedin the child, the child's healthcare providers should discussthe implication of the child's diagnosis for the woman's healthand assist the mother in obtaining care for herself. Providersare encouraged to build supportive healthcare relationships thatcan facilitate the discussion of pertinent health information.Confidential HIV-related information should be disclosed or sharedonly in accordance with prevailing legal requirements.
• Counseling for HIV-infected pregnant women should includean assessment of the potential for negative affects resultingfrom HIV infection (eg, discrimination, domestic violence, andpsychological difficulties). For women who anticipate or experiencesuch effects, counseling also should include a) information onhow to minimize these potential consequences, b) assistance inidentifying supportive persons within their own social network,and c) referral to appropriate psychological, social, and legalservices. In addition, HIV-infected women should be informed thatdiscrimination based on HIV status or AIDS regarding matters suchas housing, employment, state programs, and public accommodations(including physicians' offices and hospitals) is illegal.
• HIV-infected women should be encouraged to obtain HIV testingfor any of their children born after they became infected or,if they do not know when they became infected, for children bornafter 1977. Older children (ie, children more than12 years ofage) should be tested with informed consent of the parent andassent of the child. Women should be informed that the lack ofsigns and symptoms suggestive of HIV infection in older childrenmay not indicate lack of HIV infection; some perinatally infectedchildren can remain asymptomatic for several years.

Recommendations for Follow-Up of Infected Women and PerinatallyExposed Children

• Following pregnancy, HIV-infected women should be providedongoing HIV-related medical care, including immune-function monitoring,antiretroviral therapy, and prophylaxis for, and treatment of,opportunistic infections and other HIV-related conditions. HIV-infectedwomen should receive gynecologic care, including regular Pap smears,reproductive counseling, information on how to prevent sexualtransmission of HIV, and treatment of gynecologic conditions accordingto published recommendations.
• HIV-infected women (or the guardians of their children) shouldbe informed of the importance of follow-up for their children.These children should receive follow-up care to determine theirinfection status, to initiate prophylactic therapy to preventPCP, and, if infected, to determine the need for antiretroviraland other prophylactic therapy and to monitor disorders in growthand development, which often occur before 24 months of age. HIV-infectedchildren and other children living in households with HIV-infectedpersons should be vaccinated according to published recommendationsfor altered schedules.
• Because the identification of an HIV-infected mother alsoidentifies a family that needs or will need medical and socialservices as her disease progresses, healthcare providers shouldensure that referrals to these services focus on the needs ofthe entire family.