Human immunodeficiency virus testing and counseling: Nuts and bolts

The human immunodeficiency virus poses an increasing health hazard to women. Physicians must recognize this risk and evaluate their patients for human immunodeficiency virus. Because of general increased awareness and the recommendations that all prenatal patients be offered human immunodeficiency virus testing and counseling, more and more women will be tested, yet counseling has not become a routine aspect in the evaluation of patients. This article reviews the key components of human immunodeficiency virus testing and counseling, including test interpretation, risk assessment, risk reduction, and pretest and posttest counseling. Familiarity with these areas should enable the practitioner to feel comfortable in providing this service. (Am J Obstet Gynecol 1996;175:1502-10.)     

Human immunodeficiency virus counseling and testing practices among North Carolina providers

OBJECTIVE: To estimate the percentage of prenatal care providers who offer human immunodeficiency virus (HIV) testing to pregnant women, investigate how strongly testing is encouraged, and explore testing barriers. METHODS: Between January 2001 and March 2001, we sent surveys to 1381 prenatal care providers in North Carolina, comprised of obstetricians, family physicians who practice obstetrics, and nurse-midwives. A total of 653 questionnaires were returned. RESULTS: Overall, 95.5% of providers who responded reported recommending HIV testing to all pregnant patients. Only 69.2% strongly recommend testing, with obstetricians (73.4%) and family physicians (70.1%) doing so at higher rates than nurse-midwives (55.9%). Almost all respondents (96.9%) strongly recommend testing for women they perceive to be high risk, whereas 39.7% strongly recommend testing to women who have had an HIV test in the past 6 months. When women refuse testing, 48.1% of practitioners inquire about the reason, and 28.2% reoffer the test at a future prenatal appointment. The most significant testing barriers were treating an HIV-positive woman (18.4%) and informing a patient she is HIV positive (14.8%). Respondents report that low literacy and culturally appropriate patient education materials would be most helpful to them. CONCLUSION: Among respondents, most prenatal care providers report that they recommend HIV testing to all pregnant women. However, many respondents base their decision about how strongly to recommend HIV testing on an assessment of the woman's risk for HIV exposure. Significant barriers to offering HIV testing were associated with managing an HIV-positive patient. Providers were most in need of patient education materials.     

Human immunodeficiency virus education and screening of prenatal patients

Prenatal HIV education and testing requires access to many resources and is demanding of time and personnel. Properly trained sympathetic on-site counselors are essential. Such personnel may combine this role with other tasks but should have the time necessary to commit to individualized HIV counseling. High-quality laboratory facilities should be available. Ready access to psychiatric professionals, social service supports, clergy, internal medicine, pediatric primary care, and infectious disease consultation or referrals needs to be available and integrated into all prenatal screening programs. Obstetrician/gynecologists at all levels should seek access to and support for these necessary though resource-intensive programs and work toward extension of such programs to all women of childbearing age.     

The case for routinely offering prenatal testing for human immunodeficiency virus

Infections with human immunodeficiency virus are becoming increasingly common among women of reproductive age. The consequences of these infections on maternal and child health are substantial. Evidence has been published that suggests that testing only those women recognized as being at risk through physician-elicited, patient-volunteered testing programs will fail to identify substantial numbers of infected patients. This article develops the arguments that informing infected women of their serologic status is of critical importance and that in clinical practice identification of women with sexually transmitted diseases such as human immunodeficiency virus can only be accomplished with routine testing (with consent, confidentiality, and counseling).     

Human immunodeficiency virus testing and the risk to the surgeon of acquiring HIV

Physicians and other health care workers risk infection with human immunodeficiency virus (HIV), hepatitis B virus and other infectious agents. Most authorities have argued against routine testing of patients preoperatively for HIV infection because it would not prevent or reduce the risk of infection to health care workers. They agree with the policy of the Centers for Disease Control that advocates universal precautions for all patients. Surgeons have not been reassured by these arguments. They claim that their exposure to blood during operation exposes them to increased risk of infection. The risk of acquiring HIV from a single needle-stick injury is low. However, most surgeons are interested in their lifetime risk of infection. In this study, a mathematical model for predicting the risk of acquiring HIV in patients in a given hospital and the total number of needle-stick injuries are given. Using minimal likely HIV seroprevalence, this model predicts that at least 47 of the approximately 18,000 Fellows of the American College of Surgeons would become infected. New data showing early treatment can lead to increased longevity in infected patients with HIV, the fact that many health care workers do not follow universal precautions and other arguments are put forward to support a suggested routine--voluntary testing of all surgical patients for antibody to HIV.     

Results of a prenatal screening program for the human immunodeficiency virus in a cross-sectional population.

A prenatal screening program for antibody to the human immunodeficiency virus (HIV) was examined prospectively in a cross-sectional population. Routine screening was performed on 3,241 women during the first trimester. Serum samples yielding repeatedly positive results on an enzyme-linked immunosorbent assay (ELISA) (n = 6) were subjected to confirmatory Western blot testing. All the specimens were determined to be false positive with atypical banding regions not consistent with HIV-1 infection. This false-positive rate was higher than in previous reports of screening programs in low-risk populations (P less than .005). Since antibody to HIV may not be detectable for several months after infection, we serially tested 984 of the women in different trimesters of pregnancy to determine whether repeat testing would yield seroconversion undetected at the first screening. No patient who initially tested negative on the ELISA tested positive later in gestation. We therefore recommend that routine screening be performed only once during pregnancy, preferably in the first or early second trimester, in the general population.     

Determinants of acceptance of routine voluntary human immunodeficiency virus testing in an inner-city prenatal population

Routine voluntary prenatal human immunodeficiency virus (HIV) counseling and testing offer the opportunity to encourage reduction of high-risk behaviors among uninfected women and to identify those women with asymptomatic HIV infection. To characterize the determinants of acceptance of routinely offered and encouraged HIV testing in inner-city parturients in Atlanta, we identified two groups of women, one that declined HIV testing and another that accepted testing. Each group was asked to complete a questionnaire designed to assess the effectiveness of pre-test counseling. During the 7-month study period, 4731 women registered for prenatal care and 4574 (97%) consented to HIV testing. Nearly all women stated that they were not pressured into having HIV testing performed. Women who accepted HIV testing were more likely to be young, black, and single (P less than .001) and less likely to have received education beyond high school (P less than .05). More accepters than decliners thought the HIV counseling session was valuable (97 versus 91%; P = .04); 55% of accepters agreed to antibody testing because of concern about the risk of transmitting HIV infection to their fetus or infant. More accepters than decliners indicated a willingness to have HIV testing in a future pregnancy (74 versus 33%; P less than .001). These data suggest that most inner-city parturients in our institution view routine voluntary HIV counseling as a valuable component of their prenatal care.     

Human immunodeficiency virus in pregnancy

Most human immunodeficiency virus (HIV) infection in women of childbearing age occurs in resource poor countries. However, increasing numbers of infected women are known to reside in the UK. In developed countries, with appropriate healthcare, HIV infection in adults may be regarded as a chronic manageable condition and mother-to-child transmission (MTCT) can be almost totally prevented.Despite great improvements in antenatal testing in the UK, the greatest single contributor to MTCT is failure to diagnose HIV in pregnancy. Once diagnosed, HIV in pregnancy is best managed by a specialist multidisciplinary team, who can maximise the mother’s health and reduce the risk of MTCT to less than 1%.The British HIV Association has recently published its 2008 guidelines for the management of HIV in pregnancy. Avoidance of breastfeeding and appropriate use of antiretrovirals with or without pre-labour Caesarean section remain the main interventions minimising the risk of MTCT.     

Human immunodeficiency virus in pregnancy

There are already many millions of women and children infected with human immunodeficiency virus across the world, and their numbers are expected to rise. There are effective strategies to reduce the risks of perinatal transmission of the virus and to ensure the long-term health of the mother. These measures include the use of antiretroviral therapy in pregnancy, Caesarean section for delivery and the prevention of breastfeeding.     

Human immunodeficiency virus and pregnancy

Management of infection with human immunodeficiency virus (HIV) dramatically improved during the 1990s. The advent of high-performance quantitative HIV assays and highly active anti-retroviral therapy (HAART) were the two most important developments in HIV medicine. As a result, HIV mortality and morbidity have significantly reduced. This improvement in life quality and expectancy through the use of HAART has led to an increase in the number of HIV-infected patients wishing to have children. The mother-to-child transmission which was of major concern previously can now be significantly reduced by newer management strategies. This review stresses on the management of pregnancy in HIV.     

Human immunodeficiency virus infection in women

Heterosexual transmission is the leading route of transmission worldwide of human immunodeficiency virus (HIV) infection, although the cumulative rate of infection is significantly higher among female partners of infected intravenous drug abusers and men from central African countries than among female partners of bisexual men or blood product recipients. Factors associated with an increased risk of heterosexual transmission are currently under investigation, but number of sexual partners and the presence of genital ulceration appear to be significant. The natural history and clinical manifestations of acquired immunodeficiency syndrome (AIDS) are the same in men and women. Despite initial reports to the contrary, it appears that pregnancy does not have an adverse effect on the course of HIV infection. However, there is clear evidence that HIV is transmitted to the fetus during pregnancy and lactation. A transmission rate of 25-35% has been recorded in follow-up studies of infants born to mothers infected with the AIDS virus. Pregnancy termination should thus be suggested to pregnant AIDS patients, and asymptomatic seropositive women should be advised to delay pregnancy until more is known about the natural history of their infection. The most feasible approach, however, is to identify women at high risk of AIDS before they become pregnant and offer antenatal blood screening.     

Human cytomegalovirus infection and clinical status of infants born to human immunodeficiency virus type 1 infected mothers

Objective.?Human cytomegalovirus (HCMV) is one of the most common congenital infections worldwide and a frequent opportunistic infection that aggravates the condition of human immunodeficiency virus (HIV)-infected patients. The aim of the study was to evaluate the frequency and factors influencing HCMV infection among infants of HIV-positive women.

Methods.?The study included 35 infants born to HIV-1-infected mothers examined for congenital infections. Children were evaluated for human immunodeficiency virus type 1 (HIV-1), HCMV, and HCV infection by serological and molecular methods.

Results.?HIV-1 infection was found in one child whose mother did not receive antiretroviral treatment during pregnancy, and HCV infection in another infant. HCMV-DNA in the urine was present in 13/35 infants (37.14%) on the 10th day and 24/35 infants (68.57%) in the 4th week of life. The majority of HCMV-infected infants were asymptomatic, although they manifested microcephaly and low birth weight significantly more frequently (p = 0.006 and p = 0.02, respectively). Type HIV prophylaxis did not influence HCMV transmission.

Conclusions.?Although often asymptomatic, HCMV infection in infants born to HIV-infected mothers is frequent and may be associated with prematurity, low birth weight, and microcephaly. Diagnostic procedures in children of HIV-infected mothers should involve HCMV.     

Human immunodeficiency virus infection in gynaecology

By the end of 2002, an estimated 40 million people were infected with the human immunodeficiency virus worldwide, the greater proportion of these infections occur in sub-Saharan Africa, where the prevalence is substantially high amongst young women. Females are said to be particularly more susceptible to HIV infection, and it is reported that HIV transmission from men to women is more efficient than from women to men.The presence of a sexually transmitted infection (STI) is known to increase the risk of both acquiring and transmitting the HI virus, whilst the presence of HIV infection, especially advanced disease, may alter the clinical presentation, course and response to conservative treatment for most STIs, as well as pelvic inflammatory disease. Though there are theoretical concerns regarding some methods of fertility control and the risk of HIV acquisition, most contraceptive methods can be used by infected women under close medical surveillance.HIV infection has been associated with an increased prevalence or a more aggressive behavior of certain gynaecological neoplasms. This probably occurs as a result of alterations in the immune response in the lower genital tract to HIV.