Last week I was asked to represent our hospital system at a conference sponsored by the Centers for Disease Control (CDC) regarding “Implementation of HIV Screening in Acute Care Settings.” Several of the larger hospitals in the southeast were represented and HIV/AIDS has been an interest of mine, particularly as it relates to women and their pregnancies, since before we knew what caused the problem, so I was glad to be invited.
HIV seems not to get much press in the U.S. anymore, but the problem is NOT going away. Indeed, the southeast, where I practice, seems to be leading the epidemic in the U.S., and most folks here either are unaware, or are in denial, of that fact. There are now more than 1.2 million (1 in 300) Americans infected with HIV, 50-55,000 new cases per year, and more than 300,000 individuals unaware that they have the infection. It is estimated that since the epidemic began, more than 560,000 individuals have died from AIDS-related complications and 17,000 per year continue to do so, despite the advances that have been made in therapy. Since 1994, there has been a steady rise in AIDS cases among blacks and other ethnic minorities, women, and persons exposed through heterosexual contact. Perhaps the shifting demographics of HIV/AIDS have contributed to the decrease in its political visibility and the social activism that seemed to characterize the early stages of the epidemic in this country.
One of the bright spots in the HIV story has been in the care of pregnant women. As quoted in the CDC Morbidity and Mortality Weekly Report of September 22, 2006 (MMWR 2006;55(RR-14):1): “The number of children reported with AIDS, attributed to perinatal HIV transmission, peaked at 945 in 1992 and declined 95% to 48 in 2004, primarily because of the identification of HIV-infected pregnant women and the effectiveness of antiretroviral prophylaxis in reducing mother-to-child transmission of HIV.” During the same time period, the total number of babies born infected with HIV also declined more than 90% from a peak of about 1650 in 1991 to 138 in 2004. The success in pregnant women illustrates the value of a routine screening program, not only in the reduction of transmission, but in the identification of HIV in individuals, previously, unaware of their infections, who can then be offered ongoing care that might dramatically improve the length and quality of their lives. (Recent studies have shown that a significant percentage (more than 2/3) of individuals also reduce their ‘high risk behaviors’ once they are identified as being HIV-positive, thereby, further reducing transmission rates).
Today, with current therapies, HIV is a disease that can be managed as a ‘chronic’ condition, allowing a relatively long, uncomplicated, and productive life, but this is only true among those who have a diagnosis made early in the course of their infection so that appropriate counseling, follow-up, and therapy can be implemented. The tragedy is more than one-quarter of those who have HIV are still unaware of that fact and more than 40% will not have their positive HIV status identified until late in the course of their infection (<12 months before developing AIDS) despite multiple opportunities to identify their status during encounters with the health care system. (It is also from this group of individuals that 50-75% of all new cases of HIV infection will be transmitted).
These points were brought closer to home in another recent CDC report that focused on South Carolina (MMWR 2006;55:47). In this report, it was noted that among the 4315 cases of HIV reported in South Carolina between 2001 and 2005, 3157 of these individuals made 20,271 health care visits prior to their first positive HIV test. Forty-two percent of these HIV-infected individuals developed AIDS within 12 months of diagnosis and among these, 73% had made 7988 health care visits (median of 4 per patient) but were not tested for HIV. The bulk (79%) of these visits were to emergency departments. When the diagnostic codes for these visits were reviewed, more than 99% would not have prompted an HIV test! The point emphasized by these observations is that, even though identifying individuals with HIV is important in terms of prognosis, we often miss opportunities to do so at the portals in which they do enter the health care system such as emergency rooms, labor and delivery units, private doctors offices, and even community clinics when they are being seen for ‘other medical indications.’
With regard to pregnancy, women should be informed that HIV affects ALL socioeconomic and ethnic groups and can be carried for years without any signs or symptoms related to the infection. Even without signs or symptoms, the disease can be transmitted to the baby before, during and, even after labor and delivery (by breastfeeding in those who are unaware of their infections). In 2002, for example, it was estimated that 6000 to 7000 HIV-infected women gave birth to infected babies (about 280); 40% of the infected babies were born to women who did not know their HIV status. The clinical course of HIV in babies who contract the virus in the peripartum period is often associated with an accelerated progression to AIDS, even if HIV infection is recognized relatively early. Indeed, an AIDS-defining illness during the first 12-24 months of life is often the only indication that a baby has contracted HIV from an undiagnosed and ‘unaware’ mother.
If HIV is identified, prophylactic therapy should be initiated during pregnancy and intrapartum to reduce risks of perinatal transmission. Transmission rates in the absence of prophylactic therapy are about 25%; this can be reduced to 9-13% if prophylactic therapy is initiated during labor in women previously not treated or not identified as having HIV before their delivery admission; and, they are < 2% in women treated prophylactically both during pregnancy and labor. With these points in mind, the updated recommendations for pregnant women can be summarized as follows:
• Opt-out testing is now recommended for ALL women by the CDC and ACOG as part of the routine screening strategies during prenatal care. Opt-out testing implies that the routine ‘consent to care’ that all women are asked to sign at intake includes an understanding that HIV screening will be performed, unless it specifically requested that this is not done.
• Extensive counseling prior to having an HIV screen is not necessary (although, may be warranted, perhaps, with the patient who is expressing the desire to ‘opt-out’ of screening).
• Testing should be performed, not only as a routine during the New OB evaluation, but again in third trimester in areas where HIV incidence is > 17 cases per 100,000 person-years (as is the case in South Carolina).
• All women having no prenatal care, having previously declined testing, or having no documented test results available should have rapid screening done on admission to L&D and, if this is declined, or if the mother’s status is unknown at delivery, the baby should be screened after delivery.
• Screening should be performed in the ‘acute care setting’ using a rapid diagnostic test. The tests currently available have virtually 100% sensitivity and 100% specificity and can provide results within 10-30 minutes (recommended turn-around time).
• If the rapid test is positive, appropriate prophylactic therapy, such as AZT, should be started based on the test results, even without having results of confirmatory testing.
It is hoped (and the most recent data would support the fact) that destigmatizing HIV screening by bringing it into the realm of the ‘routine’ will improve acceptance among all persons and, eventually, improve our management of the current epidemic. This approach would have seemed the most logical for many years, not only in pregnant women who, generally, want what’s best for their babies. I have said for years “If you don’t know who has the problem, how can you treat the epidemic” and this is clearly one situation in which “If you don’t take a temperature, you can’t find a fever” has been demonstrated not to be the most prudent approach to care.