Recommendations for human immunodeficiency virus screening, prophylaxis, and treatment for pregnant women in the United States

Article Outline

• Abstract
• The Evolution of the Centers for Disease Control and Prevention (CDC) HIV Screening Guidelines for Pregnant Women
• US Public Health Service Guidelines for Prophylaxis and Treatment of HIV-Infected Pregnant Women
• Comment
• References
• Copyright

In the United States, current human immunodeficiency virus (HIV) testing guidelines recommend an opt-out approach for pregnant women, whereby HIV testing is incorporated routinely into the standard panel of prenatal tests with the option to decline. Current recommendations for the initiation of treatment of HIV infection in pregnant women are the same as those for nonpregnant women. However, the special circumstances of pregnancy raise additional issues that are related to potential drug toxicity to the mother and fetus, which affect the choice of antiretroviral drugs to be used. For HIV-infected pregnant women who do not require therapy for their own health, antiretroviral drugs are recommended for prevention of mother-to-child transmission. Highly active antiretroviral therapy is recommended for all women with HIV RNA levels of ≥1000 copies/mL, along with consideration of elective cesarean delivery. For women with HIV RNA levels of <1000 copies/mL, a 3-part zidovudine prophylaxis regimen (prenatal, intrapartum, and neonatal) should be used alone or in combination with other antiretroviral drugs.

Key words: HIV testing and treatment, pregnancy

Recommendations regarding human immunodeficiency virus (HIV) screening, prophylaxis, and treatment of pregnant women have evolved considerably in the United States over the last 25 years, reflecting changes in the epidemic and the science of prevention. Not long after acquired immunodeficiency syndrome (AIDS) was first described in 1981, the possibility of mother-to-child transmission of the new syndrome was proposed.¹ Scientific consensus that gathered to support this theory included reports of infants with AIDS who had not had significant contact with their mothers after delivery, which suggested that infection had occurred before or during birth.² Even though significant gaps still exist in our knowledge of the exact timing and mechanisms of mother-to-child transmission of HIV, substantial evidence has accumulated to document the risk of mother-to-child transmission, and concerted research efforts have brought about a dramatic decrease in such transmission, at least in the industrialized world, with interventions such as combination antiretroviral prophylaxis, cesarean delivery, and avoidance of breastfeeding.³ In addition, the treatment of HIV disease during pregnancy has changed considerably, with an increasing proportion of women receiving highly active antiretroviral therapy throughout pregnancy.³ This article describes the evolution of US recommendations for HIV screening, prophylaxis, and treatment of HIV-infected women that have contributed to this remarkable public health success in the arena of mother-to-child HIV transmission.

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The Evolution of the Centers for Disease Control and Prevention (CDC) HIV Screening Guidelines for Pregnant Women 

The CDC released its first set of recommendations for HIV testing of pregnant women in 1985.⁴ These recommendations acknowledged that the only available strategy for reducing the risk of perinatal transmission was pregnancy prevention and that the benefits of knowing one’s HIV status were few, given the lack of treatment options. The 1985 recommendations identified certain groups of women who were at high risk for HIV infection who should be counseled regarding HIV and offered testing. These groups included women with signs and symptoms of infection, intravenous drug users, women who were born in countries with a higher burden of heterosexual transmission of HIV, sex workers, and sex partners of men at increased risk. Nonpregnant women with positive test results could be encouraged to delay pregnancy. However, women who were already pregnant could be offered only additional medical and support services to manage opportunistic infections and psychologic concerns and be advised not to breastfeed their infant because of the potential for transmission of HIV through breastfeeding. These guidelines did not endorse routine testing of all women or counseling and testing among women who were considered not at high risk. This recommendation was motivated by concern about the interpretation of test results in low prevalence populations (ie, the repercussions of false positive results in an environment in which considerable stigma and fear surrounded a diagnosis of HIV infection).

Only a few years passed, however, before it became apparent that risk-based screening was failing to identify substantial numbers of infected women.⁵, ⁶ Many physicians and public health officials believed that being able to notify a woman of her HIV status was important enough to justify expanded screening beyond defined risk groups, despite the few options for treatment of a woman’s own disease or prevention of perinatal transmission.

In 1994, 1 of the most significant breakthroughs in the history of the HIV/AIDS epidemic was announced. On February 21, 1994, the Pediatric AIDS Clinical Trials Group (PACTG) announced results of a randomized, double-blinded clinical trial, PACTG 076, that had demonstrated that a 3-part regimen of zidovudine (starting in the second trimester of gestation and continuing in labor and to the infant for 6 weeks after birth) was effective in lowering the risk of perinatal HIV transmission by approximately two-thirds. In addition to being effective, zidovudine was found to be safe in this setting, with no serious or short-term side effects of zidovudine therapy detected for women or their infants when compared with placebo.⁷, ⁸ The announcement of an intervention that offered significant protection against HIV infection for infants was a turning point for perinatal HIV prevention strategies. Although stigma and discrimination against persons with HIV and AIDS were still present, there were now real benefits to learning one’s HIV status. Treatments for the protection of an individual’s health had been available for several years, and now prophylaxis could be provided to pregnant women to lower the risk that they would pass the virus to their children.

In response to this development, the CDC developed new recommendations for HIV testing among pregnant women in 1995. For the first time, the US Public Health Service recommended routine HIV counseling and voluntary testing for all pregnant women.⁹ Increasing scientific data on the safety and effectiveness of zidovudine for prevention of mother-to-child HIV transmission and some advances in advocacy and protections for persons who were infected with HIV had shifted the balance of benefits and risks. However, these guidelines maintained a strong emphasis on the provision of counseling before and after testing, specific informed consent, and the voluntary nature of testing. The recommendations stated that pretest counseling should include information on HIV risk behaviors, the risk of mother-to-child transmission if the woman were infected, and the availability of therapy to reduce this risk. Provisions were also included to ensure that women who declined testing, or declined treatment if positive, were not denied care or subjected to discrimination. After the receipt of positive HIV test results, the guidelines stated that women should receive posttest counseling that included an explanation of the clinical implications of a positive test result, information about HIV-related medical and other intervention services, the risk for mother-to-child HIV transmission and ways to reduce this risk, the prognosis for infants who become infected, reproductive options, recommendations to abstain from breastfeeding, and an assessment of the potential for negative psychologic and social effects that result from HIV infection.⁹

In 1996, Congress passed the Ryan White CARE Act, which provided funding for testing and treatment and additional strategies to combat the HIV/AIDS epidemic. A provision of this legislation called on the Institute of Medicine to conduct an evaluation of state efforts to reduce mother-to-child HIV transmission and an analysis of the existing barriers to further reductions in transmission in the United States.¹⁰ The committee found that, despite considerable efforts to implement the US Public Health Service recommendations, the number of children who were born with HIV remained too high, often because of lack of timely diagnosis of maternal HIV infection. Their central recommendation was to implement universal HIV testing with patient notification as a routine component of prenatal care, a strategy referred to as “opt-out” testing. They stressed that extensive pretest counseling had proved to be a barrier to providing testing for many providers. Incorporating HIV testing into the standard panel of prenatal tests could increase the number of women who were offered testing, while still ensuring notification to the patient that testing would be done and preserving her option to decline. Associated recommendations that were designed to increase the proportion of pregnant women who were tested for HIV included educating prenatal providers on the value of HIV testing, adoption of professional recommendations and performance measures to encourage testing, improvement of care for HIV-infected persons, maintenance of federal funding for perinatal prevention of HIV, and collection of appropriate surveillance data.

As a result of the Institute of Medicine report, several professional groups, including the American College of Obstetricians and Gynecologists and American Academy of Pediatrics, issued new guidelines that supported the recommendations of the Institute of Medicine and endorsed universal HIV testing with patient notification as a routine component of prenatal care.¹¹ The CDC convened consultations to discuss these recommendations and published revised recommendations for HIV screening of pregnant women in 2001 that replaced the 1995 recommendations. The revised recommendations emphasized that HIV testing should be a routine part of prenatal care and recommended simplification of the testing process to reduce barriers to testing but maintained a strong commitment to the voluntary approach to HIV testing.¹² These guidelines also recommended the provision of pretest counseling, with a preference for face-to-face counseling, but allowed for the possibility of written or electronic formats.

In 2002, a CDC assessment of prenatal HIV screening rates was published that found that testing rates were generally lower in jurisdictions with laws that mandated pretest counseling and specific written consent before an HIV test (the “opt-in” approach) and were generally higher in areas with opt-out testing.¹³ After the publication of this study, the CDC issued a “Dear Colleague” letter that endorsed the practice of routinely incorporating HIV testing in the standard panel of tests for all pregnant women with the option to decline.¹⁴ In 2006, the most recent CDC recommendations for HIV testing were published. Recommendations regarding HIV screening for pregnant women were incorporated into general recommendations for all adults and adolescents, and opt-out HIV screening was recommended for all adults aged 13-64 years who seek care in healthcare settings, including pregnant women. The 2006 guidelines codified and strengthened the recommendation for opt-out screening in pregnant women.¹⁵

The 2006 recommendations also strengthened the CDC’s recommendation for rescreening during pregnancy. A second HIV test during pregnancy was first mentioned in the 1995 guidelines, which recommended that women who test negative early in pregnancy and continue to practice high-risk behavior should be retested during the third trimester.⁹ The recommendations for a second test during pregnancy were repeated in the 2001 guidelines, which again recommended retesting in the third trimester (before 36 weeks of gestation) for women who had tested negative but remained at high risk for acquiring HIV. This recommendation was also strengthened by adding a caveat that routine universal retesting could be considered in healthcare facilities with high HIV prevalence among women of childbearing age.¹² After the publication of these recommendations, new analyses demonstrated that a second HIV test during the third trimester is as cost-effective as other commonly accepted health interventions, even in populations with relatively low HIV prevalence.¹⁶ In addition, emerging research from New York has suggested an increasing proportion of infants with perinatal HIV infection are born to women who acquire HIV infection during pregnancy.¹⁷ These findings support expanded recommendations for a second HIV test in the third trimester. Although the latest recommendations continue to note that a second screen may be considered in all areas, a second test is recommended specifically for all women in 22 states with elevated HIV incidence, for women who are served in facilities in which prenatal screening reveals a prevalence of at least 1 per 1000, and for women who are at high risk of acquiring HIV infection.¹⁸

Before the release of the 2001 recommendations, new research demonstrated reductions in the risk of mother-to-child HIV transmission, even if antiretroviral prophylaxis was not given during pregnancy and could only be given during labor and/or to the newborn infant.¹⁹ Therefore, the 2001 guidelines also recommended that women with unknown status at labor and delivery should be tested promptly to allow for intrapartum and neonatal antiretroviral prophylaxis, if positive.¹² Testing could be accomplished either by expedited standard testing (with return of results within 12 hours) or preferably with rapid testing, which could be done at the bedside, to allow the prompt initiation of antiretroviral prophylaxis in women with a positive HIV test while still in labor. However, at the time the guidelines were published, only 1 rapid test was available commercially in the United States.

Since 2001, several additional rapid tests have been approved by the Food and Drug Administration (FDA) for use in the United States, and additional research has described the acceptability and accuracy of rapid testing during labor and delivery. The Mother-Infant Rapid Intervention at Delivery study found that rapid testing is feasible and accurate and delivers timely results for women in labor.²⁰ The 2006 recommendations specifically recommend the use of a rapid HIV test for screening women who arrive in labor with unknown or undocumented HIV status and reiterate recommendations to initiate antiretroviral prophylaxis to prevent mother-to-child HIV transmission based on the rapid test result, without waiting for confirmatory results.¹⁸ These recommendations are also reflected in the most recent guidance from the American College of Obstetricians and Gynecologists.²¹

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US Public Health Service Guidelines for Prophylaxis and Treatment of HIV-Infected Pregnant Women 

Within 2 months of the release of the results from the PACTG 076 trial, interim guidance was issued by the US Public Health Service that supported the use of zidovudine as described in the PACTG 076 protocol.²² On June 6-7, 1994, the US Public Health Service convened a workshop of invited guests that included representatives from the medical, scientific, public health, and legal communities to develop recommendations for the use of zidovudine to reduce perinatal HIV transmission and to provide guidance for clinicians and public health professionals in interpreting the results of the PACTG 076 trial. Based on feedback from this workshop, the US Public Health Service Task Force, which was composed of obstetric and pediatric HIV experts and federal agency representatives, issued more extensive guidance for the use of zidovudine to reduce perinatal HIV transmission.⁷ These guidelines, which are now more than a decade old, were notable for several features that are still reflected in the current 2006 guidelines²³ such as (1) the inclusion of clinical situations, later termed clinical scenarios, that present hypothetic clinical scenarios with discussion and recommendations to help clinicians with decision-making and (2) the clear distinction between prophylaxis to prevent perinatal transmission as opposed to treatment for the benefit of the woman’s own health. The guidelines emphasize that pregnancy should not be a reason to defer antiretroviral therapy when it is needed. Although there is a need for antiretroviral prophylaxis for the prevention of transmission to the infant and although issues that are related to potential drug toxicity to mother and fetus affect the choice of antiretroviral drugs that are used for treatment, these concerns should be dealt with in the context of assuring optimal treatment to preserve the mother’s health.

In January 1998, updated guidelines were issued that included more general recommendations for the use of antiretroviral drugs in pregnancy, expanding the previous guidelines’ focus on zidovudine. By this time, there were 11 FDA-approved antiretroviral drugs, and these powerful new drugs were being used in highly active drug combinations. The title of the document now included “maternal health”, which reflected further emphasis on considerations beyond mother-to-child HIV transmission to address issues for the pregnant woman’s own health.²⁴ After publication of these guidelines, the Public Health Service Task Force began meeting by monthly conference calls to review new evidence and regularly update the recommendations. The guidelines, which are now updated several times a year, are posted on a website²³ so that revised guidelines can be disseminated more rapidly. Each time the guidelines are posted, the changes that are new since the last revision are highlighted so that the reader can quickly review the most recent changes. The guidelines also contain hyperlinks that link the reader to other parts of the guidelines and supplemental information.

The current Public Health Service guidelines have evolved considerably over time. They now contain information on >20 antiretroviral drugs, the FDA pregnancy category and information on placental passage, dosing and pharmacokinetics during pregnancy, and animal carcinogenicity and teratogenicity studies. Most of the approved antiretroviral drugs are FDA pregnancy category B or C. However, efavirenz is category D, which indicates that there is evidence of human fetal risk. Severe central nervous system defects, which were consistent with abnormalities that have been seen in animal studies, have been reported in 4 infants after first trimester exposure of efavirenz-containing regimens. Therefore, efavirenz should be avoided during the first trimester. Because efavirenz is a relatively popular choice for combination regimens and because more than one-half of pregnancies in the United States are unintended, it is critical that women who take efavirenz be counseled regarding the risks. Women who are planning to become pregnant should strongly consider the use of regimens that do not contain efavirenz or other drugs with teratogenic potential.

Current recommendations for treatment of HIV infection in pregnant women are the same as those for the initiation of treatment in nonpregnant individuals; in the United States, treatment is recommended for all individuals with a CD4 cell count of <200/mm³ or an AIDS-defining illness and should be considered for individuals with a CD4 cell count of <350/mm³.²⁵ Standard treatment for nonpregnant and pregnant women is highly active antiretroviral therapy with ≥3 drugs.²³ For HIV-infected pregnant women who do not require therapy for their own health, antiretroviral drugs are recommended for the prevention of mother-to-child transmission. In the United States, combination therapy with highly active antiretroviral therapy is also recommended for all pregnant women with HIV RNA levels of >1000 copies/mL. For women with HIV RNA levels of <1000 copies/mL, the 3-part PACTG 076 zidovudine prophylaxis regimen can be used alone or in combination with other antiretroviral drugs. Table 1 provides a summary of recommendations for the treatment and prevention of mother-to-child HIV transmission for pregnant HIV-infected women in different clinical scenarios.

TABLE. Recommendations for antiretroviral drug use and prevention of mother to child HIV transmission in pregnant HIV-infected women in the United States

Variable	Recommendations
Clinical scenario
HIV-1–infected woman of childbearing potential but not pregnant who has indications for the initiation of antiretroviral therapy	HAART as per US treatment guidelines Avoid drugs with teratogenic potential (eg, efavirenz) in women of child-bearing age, unless adequate contraception ensured; exclude pregnancy before starting treatment with efavirenz
HIV-1–infected woman who receives HAART and becomes pregnant
Woman	Continue current HAART regimen; discontinue drugs with teratogenic potential (eg, efavirenz) or with known adverse potential for the pregnant mother (eg, combination stavudine [d4T] + didanosine [ddI]) In general, if woman requires treatment, antiretroviral drugs should not be stopped during the first trimester If it is decided to discontinue antiretroviral drugs during the first trimester, stop all drugs (if regimen includes drug with long half-life such as NNRTI, consider stopping NRTIs 3-7 days after stopping NNRTI although limited data exist) Continue HAART regimen during intrapartum (zidovudine given as continuous infusion⁎ during labor) and postpartum period Elective cesarean delivery if plasma HIV-1 RNA remains >1000 copies/mL at 34-36 weeks of gestation
Infant	Zidovudine for 6 weeks
HIV-1–infected pregnant woman with antenatal plasma HIV-1 RNA of ≥1000 copies/mL who does not currently receive antiretroviral therapy
Woman	HAART (ideally contains zidovudine) consider delaying initiation until after the first trimester Because of risk of severe hepatic toxicity with nevirapine in women with CD4 of >250/mm3, use nevirapine in this situation only if benefit clearly outweighs risk and alternatives are not available Continue HAART regimen during intrapartum period (zidovudine given as continuous infusion⁎ during labor) Evaluate need for continued therapy after delivery; discontinue HAART, unless there are indications for continued therapy (if regimen includes drug with long half-life such as NNRTI, consider stopping NRTIs 3-7 days after stopping NNRTI, although limited data exist) Elective cesarean delivery if plasma HIV-1 RNA remains >1000 copies/mL at 34-36 weeks of gestation
Infant	Zidovudine for 6 weeks
Clinical situation
HIV-1–infected pregnant woman with antenatal maternal plasma HIV-1 RNA of <1000 copies/mL who does not currently receive antiretroviral therapy
Woman	Zidovudine given antepartum after the first trimester and as continuous infusion⁎ during labor OR HAART (ideally contains zidovudine) consider delaying initiation until after the first trimester plus zidovudine given as continuous infusion⁎ intrapartum; discontinue HAART after delivery (if regimen includes drug with long half-life such as NNRTI, consider stopping NRTIs 3-7 days after stopping NNRTI, although limited data exists)
Infant	Zidovudine for 6 weeks
HIV-1–infected woman who has received no antiretroviral therapy before labor	Several effective regimens are available to choose from: (1) Woman: zidovudine given as continuous infusion⁎ during labor; infant: zidovudine for 6 weeks OR (2) Woman: zidovudine + lamivudine every 12 hours during labor; infant: zidovudine + lamivudine for 1 week OR (3) Woman: single-dose nevirapine (Note: If delivery is imminent (<1 hour), do not give the maternal intrapartum nevirapine because of insufficient time to reach adequate level in the infant; infant: single-dose nevirapine at 48-72 hours of age (Note: If mother did not receive intrapartum nevirapine, then give infant nevirapine at birth and 48-72 hours) OR (4) Combination zidovudine + nevirapine: woman: zidovudine given as continuous infusion⁎ during labor, plus single-dose nevirapine at onset labor; infant: single-dose nevirapine plus zidovudine for 6 weeks.
Infant born to HIV-1–infected woman who has received no antiretroviral therapy before or during labor	Zidovudine given for 6 weeks to the infant (started within 6-12 hours of birth) OR Some clinicians may choose to use zidovudine in combination with additional drugs, but appropriate dosing for neonates is defined incompletely and the additional efficacy of this approach in reducing transmission is not known

(Adapted from Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. Last accessed: October 23, 2006. Available at: http://AIDSInfo.nih.gov.)

HAART, highly active antiretroviral therapy; NRTI, nucleoside analogue reverse transcriptase inhibitor; NNRTI, nonnucleoside analogue reverse transcriptase inhibitor.

After pregnancy, it is recommended that, if the woman does not meet criteria for treatment in nonpregnant women, consideration should be given to discontinuing therapy after delivery. In most cases, all drugs should be stopped simultaneously. One exception is when drugs with long half-lives (such as nonnucleoside drugs like nevirapine) are used in combination with drugs with considerably shorter half-lives (such as nucleoside analogue drugs [eg, zidovudine or lamivudine]). In the case of a nevirapine-containing regimen, consideration should be given to continuing the dual nucleoside analogue drug component of the regimen for a period of time (ie, 3-7 days) after discontinuation of nevirapine to reduce the risk of the development of nevirapine resistance, although the optimal duration of time to continue the dual nucleosides is not known.

As noted earlier, highly active combination therapy is now the norm for both nonpregnant and pregnant women, and because of the complex nature of the management of HIV infection, it is recommended that a specialist with experience in the treatment of pregnant women with HIV infection be involved in their care. The guidelines now also include a table that summarizes the pharmacokinetic data and general concerns in pregnancy and makes recommendations about the suitability of each antiretroviral drug in pregnancy by categorizing each agent as (1) a recommended agent, (2) an alternate agent, (3) insufficient data to recommend use, and (4) not recommended. Although antiretroviral prophylaxis and treatment regimens have evolved rapidly and have become increasingly complicated, it is interesting to note that zidovudine is still the mainstay of perinatal prevention efforts, >10 years after the results of PACTG protocol 076 were released. It is still recommended that zidovudine be included in antiretroviral regimens for pregnant women whenever possible.

Antiretroviral drug resistance is another topic that has received considerable attention in the pregnancy guidelines in recent years, with sections specifically addressing incidence, prevalence, impact, management, and prevention of drug resistance in pregnancy and indications for and the significance of resistance testing. Resistance testing is recommended for all pregnant women who are not currently receiving antiretroviral drugs before the initiation of therapy or prophylaxis and for those women with persistent viral replication while receiving antiretroviral treatment to optimize antiretroviral drug choice and to provide the most effective and durable regimen in women who need treatment and greater preservation of future treatment options in women receive antiretroviral prophylaxis. The development of resistance during pregnancy may have clinical importance for both the pregnant woman and her infant. The development of drug resistance is a problem for drugs for which a single mutation may be associated with resistance (eg, nonnucleoside drugs such as nevirapine and efavirenz and lamivudine or emtricitabine), when the drug is used in the context of a nonsuppressive antiretroviral regimen. In contrast, for drugs in which multiple mutations are required before resistance occurs (such as zidovudine), prolonged use as single-drug prophylaxis is generally required before resistance occurs; the development of zidovudine resistance was rare in PACTG 076.²⁶ Because the development of drug resistance is 1 of the major factors that leads to HIV therapy failure, resistance that develops during pregnancy may have life-long implications for the woman. In addition, if the woman transmits resistant virus to her infant, future treatment options for the infant may be limited. Because there are few drugs with adequate safety data in pregnancy, a general principle in obstetrics is to minimize fetal exposure to drugs. Therefore, early on, monotherapy and dual therapy were used extensively for prophylaxis in pregnant women with the aim of reducing the mother-to-child transmission risk without exposing the fetus to multiple drugs. However, the use of antiretroviral regimens that do not fully suppress viral replication can be associated with the development of resistance. Thus, current recommendations in the United States are for the use of highly active combination therapy with ≥3 drugs for pregnant women with ongoing viral replication (HIV RNA, ≥1000 copies/mL) who do not require therapy for their own health.

In addition to summarizing information about antiretroviral drugs, the guidelines also include extensive discussion of the preferred mode of delivery for HIV-infected women.²⁷ This expanded scope of the recommendations is reflected in the current phrase, interventions to reduce perinatal HIV-1 transmission, which replaced the phrase antiretroviral drugs in pregnant women in the older title of the guidelines. In addition to the 4 clinical scenarios that summarize the recommendations for use of antiretroviral drugs, the guidelines also include 4 scenarios regarding the mode of delivery. Other recent revisions to the guidelines include an expanded section on preconception counseling, which refers to the CDC guidance on preconception counseling for all women and then addresses issues that are specific to HIV-infected women. In addition, the new guidelines summarize whatever pregnancy information is available for recently approved antiretrovirals, such as tipranavir and darunavir.

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Comment 

Throughout the HIV epidemic in the United States, the Public Health Service and its agencies such as the CDC and the National Institutes of Health have worked to translate rapidly the latest scientific findings into usable guidance for clinicians on the frontline who take care of HIV-infected patients. In the case of HIV screening of pregnant women, the autonomy of the woman must be balanced against the benefits of identifying HIV-infected pregnant women so that preventive measures may be offered. In addition, when prophylaxis and treatment are administered to HIV-infected pregnant women, the risks and benefits to the woman must be balanced with those of the infant. Although a great deal of research in this area has resulted in dramatic progress, the prophylactic and treatment regimens for HIV-infected pregnant women and their infants have become increasingly complex. Current Public Health Service guidance regarding HIV screening of pregnant women has been published recently¹⁸ and up-to-date recommendations regarding prophylaxis and treatment are posted on the internet (www.AIDSinfo.nih.gov) and are updated regularly. A major revision to the prophylaxis and treatment guidelines is anticipated in 2008. These HIV screening and treatment guidelines are designed as a resource for clinicians and are recommendations only. Clinicians should be aware that they are subject to the laws and statutes in their states, which may differ somewhat from these federal guidelines.

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