The effectiveness of a verbal opt-out system for human immunodeficiency virus screening during pregnancy

OBJECTIVE: We sought to evaluate the use of human immunodeficiency virus (HIV) screening during pregnancy in a health care system using the verbal opt-out method, in which HIV screening was recommended during all pregnancies and women were given an opportunity to refuse testing. METHODS: This was a retrospective cohort study of pregnancies resulting in delivery from 1998 through 2001 at Denver Health Medical Center, an urban public hospital. The main outcome measure was the proportion of documented HIV screening within 9 months before the delivery date. RESULTS: Of 12,221 pregnancies resulting in delivery, HIV screening was completed in 12,000 (98.2%, 95% confidence interval 97.9-98.4%). Of the 221 women not screened for HIV, only 24 (10.9% of those not screened, 0.2% of all women in the study) were documented as refusing HIV testing. Patients not screened for HIV presented late in pregnancy, a median of 1 day before delivery, compared with a median of 176 days for those who were screened (P <.001). CONCLUSION: A verbal opt-out system was very effective in promoting HIV screening during pregnancy. Late presentation in pregnancy was associated with not having HIV screening performed.     

Mother-to-Child Transmission of HIV in Canada: A Population Health Risk Management Perspective

The standard of prenatal care in Canada for preventing transmission of the human immunodeficiency virus (HIV) from mother to infant is universal counselling and voluntary testing of pregnant women for the virus. Appropriate treatmentof HIV-positive women reduces the risk of viral transmission to the infant to less than 1%. Despite this, too many children in Canada are born with HIV because their mothers were not tested. The barriers to screening include lack of appropriate resources and lack of training in this area. As a result, physicians find HIV test-counselling too time-consuming or believe that testing is not relevant to their patient population. Risk management strategies to improve screening rates and decrease transmission, including community action and technological strategies such as vaccines and rapid testing kits, are reviewed. The "advisory" option, the process of risk communication between health-care providers, the government, and the public, for the purpose of making recommendations, is a key component toward the success of universal screening. A shift to simplified screening and "opt-out" testing procedures is recommended.     

Testing for HIV during pregnancy: 5 years after changing German pregnancy guidelines

Objective

A known HIV status is the most important step in preventing mother-to-child transmission of HIV and screening for HIV is recommended by German prenatal guidelines. In our study, we wanted to ascertain the prevalence of HIV-testing in a pregnant inner-city cohort.

Methods

Prenatal records of 279 women were prospectively studied, and the testing confirmed with the prenatal care providers.

Results

82.4 % of the patients had been tested for HIV during pregnancy. The test was refused by 4.0 % of the women. Contrary to current guidelines, in more than half of the cases documentation of the test or the result was found in the women’s prenatal care papers.

Conclusions

Even though a large majority of pregnant women are screened for HIV, the rates of testing need to be increased. Education of patients and providers as well as changing to the “opt-out” approach used in other countries may prevent unnecessary mother-to-child transmission of HIV.     

Uptake of HIV screening in an antenatal clinic

OBJECTIVE: To assess the uptake of HIV screening in pregnant women attending a tertiary hospital antenatal clinic. METHODS: An audit was undertaken in an antenatal clinic where HIV screening was routinely offered to all women following counselling. For the women offered HIV testing, note was taken whether the woman agreed to testing or refused, and if so, the reason for refusal. RESULTS: Sixty eight percent of women who were offered testing opted to have the test performed. Thirty two percent of women decided against testing, with half of these reporting a recent (negative) HIV test result. CONCLUSIONS: Over 80% of pregnant women were willing to have HIV testing. IMPLICATIONS: With the introduction of recommendations that all pregnant women be given the opportunity for HIV screening, a high participation rate can be expected from women who are offered testing, with the potential for minimisation of vertical transmission by identification of HIV positive women.     

Obstetrician gynecologists' knowledge and practice regarding human immunodeficiency virus screening

OBJECTIVE: To gather more information regarding prenatal human immunodeficiency virus (HIV) testing by examining the practice patterns of obstetrician-gynecologists. METHODS: Survey questionnaires were sent to 1,032 American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in practice. Questionnaires included inquiries about obstetrician-gynecologist characteristics, testing practices, and knowledge regarding HIV screening. RESULTS: A total of 582 surveys (56%) were returned. We found that 1) most (97%) obstetrician-gynecologists reported recommending HIV testing to all of their pregnant patients, 2) almost half (48%) of the physicians reported using the opt-out approach to prenatal HIV testing, and 3) respondents were sometimes unaware of whether their state requires recommending HIV testing during pregnancy. CONCLUSION: The finding that some obstetrician-gynecologists are unaware of their state regulations regarding prenatal HIV testing suggests that they would benefit from an increased awareness of state laws and regulations and having timely access to these requirements. The finding that most obstetrician-gynecologists offer HIV testing to all of their pregnant patients is consistent with the literature regarding prenatal HIV screening and with federal and national recommendations. However, study results also suggest that obstetrician-gynecologists may benefit from additional information to increase knowledge and strengthen perinatal HIV testing practice patterns. LEVEL OF EVIDENCE: III.     

HIV and Pregnancy: Mandatory Counselling,Not Mandatory Screening

Objective: to review the evidence in support of universal prenatal human immunodeficiency virus (HIV) counselling and screening, and to review current clinical guidelines and practice patterns.Methods: a Medline search was conducted and the relevant articles reviewed. The issues involved in offering HIV counselling and screening routinely to all pregnant women were explored.Results: clinical guidelines recommend that HIV counselling be offered to all pregnant women and that screening be voluntary and confidential. One evaluation of current practice patters in a Canadian academic centre indicated that few general practitioners counselled and offered screening to all their pregnant patients.Conclusion: in order for universal prenatal HIV counselling to become the standard of care in Canada, a national strategy needs to be implemented. This review supports the need for further evaluation of practice patterns among Canadian obstetricians, family physicians and midwives.     

Maternal and neonatal seroprevalence of human immunodeficiency virus antibodies in Benin City, Nigeria.

The prevalence of human immunodeficiency virus antibodies in mothers and their neonates was determined through unlinked anonymous HIV testing at delivery. Two hundred and forty-six apparently healthy volunteer anonymous parturients at the University of Benin Teaching Hospital, Nigeria, and their neonates were recruited for the study. Blood samples were collected from the mothers and cord blood from their neonates at delivery. The blood samples were coded and assayed for HIV antibodies using ImmunoComb HIV 1 and 2 bispot test and ImmunoComb II HIV-1 and 2 CombFirm, both from PBS Orgenics, France. The results for maternal and neonatal blood sample pairs were matched. The maternal seroprevalence for HIV antibodies was 2.4% (6/246) while only two infants had HIV antibodies. The mother-to-child transmission of HIV antibodies was 33.3%. The study highlights the increasing HIV infection among pregnant women in this hospital. The risk of vertical transmission is therefore high. Universal antenatal HIV testing with an opt-out system is suggested. The need for our maternity centres and special care baby units to establish management protocols and anti-retroviral therapy for HIV infected women and their neonates is recommended.     

Influence of an "opt-out" test strategy and patient factors on human immunodeficiency virus screening in pregnancy

OBJECTIVE: To estimate both human immunodeficiency virus (HIV) testing acceptance rates in pregnancy using an opt-out policy and patient characteristics influencing acceptance. METHODS: At the first prenatal visit, HIV testing was offered using an opt-out approach. Reasons for refusing testing were explored. Demographic information was collected on all study subjects. RESULTS: In the prospective portion of the study, 1,140 of 1,233 women (92.5%) accepted testing. Race was predictive of accepting HIV testing, with Asian women significantly less likely (odds ratio [OR] 0.4; 95% confidence interval [CI] 0.3-0.6; P<.001) and Hispanic women significantly more likely (OR 6.9; 95% CI 2.2-22.0; P=.001) to be tested. Although English as a first language, country of birth, and insurance status were not significantly associated with acceptance, women who were fluent in English were more likely to be tested (OR 2.0; 95% CI 1.2-3.3; P=.01). Our testing rates were significantly higher than the provincial average. CONCLUSION: Using an opt-out strategy, HIV testing rates in our clinic were significantly higher than the provincial average. Rates were influenced by race and fluency in English.     

Cost-effectiveness of HIV screening of pregnant women in hospitals of the Paris area. The Paris-Tours study group of antenatal transmission of HIV, Group '9 maternites'

In the context of an epidemiologic multicentric study about perinatal transmission of HIV, screening was systematically proposed to all pregnant women attending nine maternities clinics of the Paris region (n = 7600, between August 1987 and July 1988) at their first prenatal visit. Among them, 2145 had already been tested and 45 were known to be HIV positive. So, 5660 tests were performed during the first 6 months (period 1), and 17 pregnant women were discovered to be positive. The total cost of screening has been estimated between FF. 720,000 and 775,000, resulting in a mean cost per pregnant woman found to be HIV positive of about FF. 42,000 to 45,000. A similar calculation over the following 5 months (period 2) gave a mean cost of between FF. 165,000 and 178,000. Since the women, before being screened, had to answer a short questionnaire about risk factors; cost and effectiveness of a selective screening strategy could be simulated. The preference of systematic screening to selective screening enabled the discovery of two HIV positive cases in each period, the marginal cost, i.e., cost per extra pregnant woman found to be HIV positive was thus FF. 303,320 to 327,540 for period 1, and FF. 572,240 to 619,000 for period 2. Although these figures seem high, an estimation of the cost-effectiveness does not allow us to conclude whether it is in society's interest to devote the funds necessary to move away from selective screening towards systematic screening.(ABSTRACT TRUNCATED AT 250 WORDS)     

中国部分地区HIV阳性孕产妇的调查分析

目的:了解我国部分地区育龄妇女感染人类免疫缺陷病毒(HIV)的情况;调查研究各种阻断方式的效果,探讨适合我国国情的HIV母婴阻断措施。方法:2004年至2007年间,选择我国部分地区为调查地点,对来院进行孕检的妇女及孕期未曾检测HIV住院分娩的产妇进行HIV抗体筛查检测;对HIV阳性孕产妇采取相应阻断措施,此后追踪检测HIV母婴传播状况,综合分析各阻断方案的效果。结果:共筛查119616例孕产妇,检测HIV阳性65例,阳性率0.05%。65例阳性孕产妇中终止妊娠24例,分娩40例,待产1例;孕期、产时及产后发现的HIV阳性孕产妇分别占60.0%、15.4%及24.6%;性途径感染44例(67.7%),血途径感染21例(32.3%),以性传播途径为主;采取完全阻断措施20例(50.0%),1例HIV(+);不完全阻断措施15例(37.5%),1岁内死亡3例,失访2例;未实施阻断5例(12.5%),3例死产,1例HIV(+)。结论:孕产期做好HIV的自愿检测,有利于预防艾滋病母婴传播及阻断工作的开展,根据疫情不同,筛检措施应因地制宜;目前我国部分地区艾滋病流行以性传播为主;HIV母婴阻断应提倡早期发现早期预防,以免错过接受阻断传播的最佳时机;当前预防HIV母婴传播的策略降低了传播率,但也存在一些问题。     

Tuberculosis in pregnancy

Tuberculosis (TB) remains an important infection in women globally. It is responsible for 700 000 deaths annually and is a major contributor to maternal mortality. Mycobacterium tuberculosis/HIV co-infection is common in areas of high HIV prevalence, and may be associated with significant perinatal and maternal morbidity. Improved diagnosis and treatment of TB in pregnant women are important interventions for both maternal and child health. Controlling TB in pregnancy in high-prevalence areas requires a range of interventions, including active TB screening in pregnant women, TB preventative therapy for HIV-infected pregnant women, treatment of active TB and linking mothers and children to TB care services.     

Maternal views and acceptance of antenatal HIV screening in a university teaching hospital in Hong Kong

OBJECTIVE: To assess maternal acceptance, knowledge, attitude, perceived risks and barriers toward antenatal HIV screening. STUDY DESIGN: Prospective anonymous survey of 1,519 pregnant women recruited in a university teaching hospital RESULTS: Women demonstrated fairly good knowledge of and a positive attitude toward HIV screening. Condom usage was 61.4%, and 25.3% of women had at least 1 risk factor for HIV infection. Support for mandatory and universal screening was 31.4% and 48.8%, respectively. A total of 82.6% women agreed to HIV testing. The major reason for declining the test was that women considered themselves to be at low risk (84.3%). Women with risk factors tended to prefer more aggressive methods of antenatal testing (P < .001) and more readily accepted HIV screening (89.8% vs. 73.1%, P < .001). CONCLUSION: Given the high acceptance rate in our local population, universal offering but voluntary testing is the optimal mode of antenatal HIV screening in Hong Kong.     

Mandatory prenatal screening for the human immunodeficiency virus: the experience in south-eastern France of a national policy, 1992–1994

Objective To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test.
Design Successive surveys in April 1992 and May 1994 in south-eastern France. Logistic regressions were performed to identify factors which affected access to HIV testing for women who gave birth and those who terminated their pregnancy, and for each year of study.
Main outcome measures Attitudes and access to HIV testing among pregnant women, irrespective of pregnancy outcome.
Setting All obstetrics and gynaecology departments and abortion clinics in the region.
Population 3497 women in 1992 (2775 who were delivered and 722 who chose termination) and 3407 in 1994 (2701 who were delivered and 766 who chose termination). The response rates were 82% and 88%, respectively.
Results In 1994 of women who were delivered, 73% had an HIV test, compared with 63% in 1992 (   P < 0.001  ); however of women who terminated their pregnancy, only 28% had an HIV test, compared with 245% in 1992 ( P not significant), although they were more at risk for HIV infection. Socioeconomic differences affecting access to testing were reduced between 1992 and 1994, but only among women who gave birth.
Conclusion Introduction of a policy which makes it mandatory to offer HIV screening to all women who intended to have their baby improved access to screening but did not improve the rate of preventative counselling. A mandatory requirement to offer HIV screening should be extended to women who request termination of pregnancy.     

Changes in HIV testing policies and the implications for women

The US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) together with the Joint United Nations Programme on HIV/AIDS (UNAIDS) recently released new guidelines for HIV testing in health care settings. Both sets of guidelines recommend eliminating individual informed consent in favor of an opt-out approach that requires clients to actively decline the HIV test after a pretest information session. The revised guidelines also recommend reducing the amount of counseling that accompanies the HIV test. Women are more likely than men to be affected by efforts to expand access to HIV testing in health care settings because of women's increased vulnerability to HIV and greater contact with the health care system. Women may also be more susceptible to changes to the consent and counseling process for HIV testing because of their marginalized social status in many settings. More research is needed to document women's experiences with provider-initiated, opt-out HIV testing. Understanding women's experiences will help to formulate feasible and effective strategies to support women and ensure they gain access to HIV treatment services.     

Human immunodeficiency virus infection, women, and pregnancy. Ethical issues

Should women of childbearing age be screened for the presence of infection with the human immunodeficiency virus? If infected, should they be instructed not to become pregnant or not to bear children? Should pregnant women and their offspring be included in research protocols that explore ways to prevent or treat perinatally acquired HIV disease? This article examines ethical controversies related to HIV screening, counseling, and research and suggests that resolutions may come from achieving greater clarity about the ultimate goals of obstetric and gynecologic care.     

ACOG Committee Opinion No. 389, December 2007. Human immunodeficiency virus

Because human immunodeficiency virus (HIV) infection often is detected through prenatal and sexually transmitted disease testing, an obstetrician-gynecologist may be the first health professional to provide care for a woman infected with HIV. Universal testing with patient notification and right of refusal ("opt-out" testing) is recommended by most national organizations and federal agencies . Although opt-out and opt-in testing (but not mandatory testing) are both ethically acceptable, the former approach may identify more women who are eligible for therapy and may have public health advantages . It is unethical for an obstetrician-gynecologist to refuse to continue providing health care for a patient solely because she is , or is thought to be, seropositive for HIV. Health care professionals who are infected with HIV should adhere to the fundamental professional obligation to avoid harm to patients. Physicians who believe that they have been at significant risk of being infected should be tested voluntarily for HIV.     

Women's attitudes to HIV screening in pregnancy in an area of low prevalence

Objectives To identify factors that influence acceptance of the human immunodeficiency virus (HIV) screening test by pregnant women.
Design Prospective survey using questionnaires.
Setting An antenatal clinic at a tertiary referral hospital.
Population 200 pregnant women of multiethic origin residing in a low prevalence area.
Methods Two hundred consecutive women attending the antenatal booking clinic were interviewed. We collected data on reasons for opting in or out and factors that could influence the rate of acceptance, such as ethnicity, age, parity, level of education, first language and marital or relationship status.
Main outcome measure Attitudes of pregnant women to HIV screening.
Results The rate of acceptance of HIV screening was 160/200(80%). The most frequent reasons for opting in were the perceived benefits of screening (92/160, 58%) and the fact that the test is now routinely offered (87/160, 54%). The most frequent reason for refusal of screening was perceived low risk of HIV (27/40, 68%). Logistic regression analysis showed that ethnicity, age, parity and level of formal education did not play a role in influencing uptake of the test. However, women whose first language was English were more likely to opt in compared with those whose first language was not English (   P = 0.016  ) and those who were married or in a stable relationship were more likely to opt in than those who were not (   P < 0.001  ).
Conclusion We have not reached the national target of 90% in our region. This appears to be due to a combination of factors, the main one being a perception of low risk. Greater knowledge of the ease of transmission of HIV may alter this perception, which may improve acceptance of the test.     

Testing women for human immunodeficiency virus infection: who, when, and how?

Obstetrician-gynecologists provide comprehensive primary and preventive care for women and are ideally suited to provide human immunodeficiency virus (HIV) screening for their patients. This paper provides a summary and rationale for the current recommendations for HIV testing among women in the United States, emphasizing recommendations from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists [corrected] Who should receive HIV testing, when and how often testing should be conducted, and how testing should be offered are discussed. These recommendations are described separately for general populations (including nonpregnant women) and for pregnant women and their infants.     

The role of the rapid HIV test in women with no prenatal care

The purpose of this study was to evaluate the cost effectiveness of rapid HIV screening tests in laboring women presenting with no prenatal care. Ninety-seven charts were reviewed of women with no prenatal care presenting in active labor at our institution from December, 1996 to April, 1998. All of these women had an HIV test drawn as part of the prenatal tests ordered upon admission. The cost of employing the rapid HIV screening test in these women was calculated using: 1. The prevalence of HIV in this population; 2. The false positive rate of the test; 3. The cost of the test; and 4. The cost of treating women with iv Zidovudine for an average of 5 hrs intrapartum at our institution.The background HIV seroprevalence for Norfolk, VA is 0.17%. None of the 97 women presenting in active labor with no prenatal care were found to be HIV positive. The cost of screening these women with the rapid HIV screen would have been $970.00 ($10.00/kit) compared to $388.00 using the ELISA ($4.00/kit). In addition, the CDC found the rapid screen to have a higher false positive rate in populations with a low HIV prevalence rate. Based on the seroprevalence rate among childbearing women in Norfolk, VA, the positive predictive value of the screen in our population, the cost of iv Zidovudine for 5 hrs intrapartum at our institution, and the cost of the screen, it will cost at least $6,450.00 to treat each pregnant woman infected with HIV detected with the SUDS rapid screen.The HIV prevalence rate in this high-risk population was very low (0%). Based on these data, the HIV rapid screening test would not have been cost effective in this population. In addition to the monetary costs of employing this screening test, other issues such as a significant number of patients receiving false positive results and unnecessary exposure to Zidovudine must be considered.