HIV Screening for Pregnant Women and Infants
This Position Statement has been retired. The AWHONN Board of Directors retired this statement June 2015.
All pregnant women should be offered an HIV screening test. The Centers for Disease Control and Prevention (CDC) (2011) recommend HIV screening for all women as a routine part of prenatal care. Pregnant women should receive education about HIV, its consequences for the mother and infant, its transmission, and its treatment, and they should have the opportunity to decline screening (Branson et al., 2006). In circumstances where a new mother's HIV status is unknown, the newborn should be tested as soon as possible after birth with a rapid test (Association of Maternal and Child Health Programs, 2007).
It is estimated that 6,000 women living with HIV give birth in the United States every year (March of Dimes, 2011). HIV transmission rates from mother to newborn can be decreased to less than 2% with universal HIV screening of pregnant women in combination with the following strategies:
- prophylactic administration of antiretroviral drugs,
- scheduled cesarean birth when indicated, and
- avoidance of breast feeding (Branson et al., 2006).
Without screening and the above listed strategies, the transmission rate is approximately 25% (Pahwa et al., 2008).
The CDC has determined that voluntary HIV screening is cost-effective, even in healthcare settings where there are low rates of HIV (Branson et al., 2006). Early identification and diagnosis is a key public health strategy in the reduction of HIV transmission (Branson et al.). It is important to identify women who are unaware of their HIV-positive status.
Ideally, HIV testing would be offered at the preconception visit. If not, HIV testing should occur as early in the pregnancy as possible in order to provide treatment and decrease the likelihood of transmission of the virus to the fetus or newborn. Additionally, a second HIV test during the third trimester, ideally before 36 weeks gestation, may be considered for all pregnant women and is recommended for women in settings with elevated HIV incidence (Branson et al., 2006).
In circumstances where a woman presents in labor and her HIV status is unknown, screening with a rapid HIV test is recommended unless the woman declines. If the rapid test is reactive, immediate antiretroviral prophylaxis should be recommended to the woman without waiting for confirmatory test results (Branson et al., 2006).
If a woman's status is unknown postpartum then rapid testing for the newborn as soon as possible after birth is recommended. This will allow for timely initiation of antiretroviral therapy for the newborn. The CDC reports that neonatal antiretroviral prophylaxis is best achieved within 12 hours after birth. If a newborn screens positive for HIV, the mother should be informed and be made aware that she is also infected (Branson et al., 2006).
Some pregnant women may decline HIV testing even after counseling and discussion. The woman's informed choice should be respected and documented in her health record (National Institutes of Health, Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, 2010). Testing should not be forced, and a woman should not be tested without her knowledge. Women who initially decline testing may change their minds as their pregnancies progress. Those who have had a negative test result previously should be informed of the importance of retesting with each pregnancy (American College of Obstetricians and Gynecologists, 2008). If a woman declines testing, the health care provider should offer other opportunities for testing throughout the course of care. Health care providers must be aware that some states have requirements for HIV screening, testing, and counseling, and they must abide by the laws in their states (Branson et al., 2006).
The Role of the Nurse
Most women are likely to accept HIV testing if they perceive that their healthcare providers strongly recommend it. It is helpful for women to know that HIV screening is recommended for all pregnant women as part of routine prenatal screening (Branson et al., 2006). Some women may initially decline HIV screening because of lack of perceived risk; concerns about stigma or discrimination; fear of the disease; and/or concerns regarding intimate partner violence as a result of the test results. These are real concerns and should be discussed with the woman in a private setting and in a culturally sensitive and age-appropriate manner.
A woman with a positive HIV test result should receive non-judgmental, comprehensive education regarding the impact of her HIV status on herself, her children or future children, and any current or future sexual partners. Appropriate follow-up care is essential and should be planned for the woman and newborn, including information on how to obtain breast milk from human milk banks and instructions on safe formula preparation and feeding (Branson et al., 2006). In the United States, breastfeeding is contraindicated for HIV positive women to eliminate the risk of postnatal transmission (Branson et al.; March of Dimes, 2011).
Healthcare providers and facilities should strive to link women and infants who screen HIV positive to specific community resources for further education and support. Referral and follow up of the woman and her family to counseling and other support services in her community are essential.