ACOG Updates Recommendations for Prenatal HIV Testing

New guidelines for HIV testing in pregnancy recognize that early detection and treatment can benefit the mother and her sexual partners, as well as the infant. The American College of Obstetricians and Gynecologists published the updated guidelines, which replace a 2008 committee opinion, in the June issue of Obstetrics & Gynecology.

“There are more reasons than ever to identify pregnant women who have HIV,” said author Denise Jamieson, MD, chief of the Women’s Health and Fertility Branch at the Centers for Disease Control and Prevention, Atlanta, Georgia. Previously, HIV prophylaxis was focused on preventing transmission to the baby, and women would often be treated with antiretrovirals during pregnancy, but taken off the drugs after birth. “Now, with the emphasis on earlier treatment [for all HIV patients], the vast majority of women who are identified during pregnancy will stay on antiretrovirals after their pregnancy.”

That said, “the basics of who should be screened, and how often, have not changed,” Dr Jamieson told Medscape Medical News.

Those basics are:

  Women should be tested for HIV during routine prenatal testing, on an opt-out basis where possible.

  Women at high risk for HIV, including injection drug users and women with multiple sex partners during their pregnancy, should be tested again in their third trimester.

  Women who have not been tested should be offered rapid screening when in labor, and if the rapid test is positive, they should start antiretroviral therapy while waiting for results from a confirmatory test.

Antiretrovirals can prevent the chance of an HIV-positive woman passing the virus to an uninfected partner, so treatment is now understood to benefit the mother, baby, and the mother’s partner, rather than just the baby.


Given the enormous advances in the prevention of perinatal transmission of human immunodeficiency virus (HIV), it is clear that early identification and treatment of all pregnant women with HIV is the best way to prevent neonatal infection and also improve women’s health. Therefore, the American College of Obstetricians and Gynecologists makes the following recommendations:

* All pregnant women should be screened for HIV infection as early as possible during each pregnancy using the opt-out approach where allowed.

* Repeat HIV testing in the third trimester is recommended for women in areas with high HIV incidence or prevalence and women known to be at risk of acquiring HIV infection.

* Women who were not tested earlier in pregnancy or whose HIV status is otherwise undocumented should be offered rapid screening on labor and delivery using the opt-out approach where allowed.

* If a rapid HIV test result in labor is reactive, antiretroviral prophylaxis should be immediately initiated while waiting for supplemental test results.

* If the diagnosis of HIV infection is established, the woman should be linked into ongoing care with a specialist in HIV care for comanagement.

Testing technology has also changed since the guidelines were last issued. Previous testing relied on antibody screening, but current screening uses combined antibody and antigen tests, as well as testing for viral RNA. As a result, tests can detect infections earlier, within weeks rather than months.

The Centers for Disease Control and Prevention (CDC) estimates that nearly 50,000 individuals become infected with HIV annually in the United States. From 2009 through 2013, the annual estimated number of diagnoses and rate of diagnoses of HIV infection in the United States remained stable. These new HIV infections include approximately 150 infants infected by mother-to-child (vertical) transmission. Antiretroviral medications given to women with HIV during pregnancy and delivery and to their newborns in the first weeks of life reduce the vertical transmission rate from 25% to 2% or less. Even instituting maternal prophylaxis during labor and delivery, neonatal prophylaxis within 24–48 hours of delivery, or both, can substantially decrease rates of infection in infants. Furthermore, new evidence suggests that early initiation of antiretroviral therapy in the course of infection is beneficial for individuals infected with HIV and reduces the rate of sexual transmission to partners who are not infected. Therefore, it is critical that pregnant women infected with HIV be accurately identified in a timely manner so that measures can be taken to decrease the risk of mother-to-child transmission of HIV as well as to optimize their own health. This would require that all pregnant women be screened for HIV infection as early as possible during each pregnancy. Those women who present late in pregnancy or in labor with undocumented HIV status should be tested using an HIV test that provides preliminary results in less than 1 hour. Women who were not tested earlier in pregnancy or whose HIV status is otherwise undocumented should be offered rapid screening on labor and delivery using the opt-out approach where allowed.

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2015;125:1544-1547

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