Universal HIV testing during pregnancy has been strongly recommended as the standard of care by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, Institutes of Medicine and the Center for Disease Control and Prevention to facilitate life-saving treatments for HIV infected women and prevent perinatal HIV transmission to the newborn. As of January 1, 2006, Oregon law changed prenatal HIV testing from ‘opt-in’ (special informed consent required prior to testing) to ‘opt-out’ (notification of testing and the option to decline). Confidentiality protections are maintained with this transition and results obtained during pregnancy should be readily available to both the maternal and newborn providers at the time of delivery. Thus, HIV is included in the standard battery of prenatal tests and results should be included in the prenatal record along with the Hepatitis B, Syphilis, Gonorrhea, and Chlamydia status. Third party payers must still obtain written authorization prior to obtaining HIV test results.
If HIV infection is diagnosed in pregnancy, vertical, or perinatal transmission of HIV can be reduced to ~1% with aggressive treatment of the mother and newborn at the time of delivery. New rapid tests offer excellent sensitivity and specificity for women presenting in labor without prior HIV testing or without available test results. Because the prevalence of HIV among pregnant women in Oregon and the United States is low, some false-positive test results will occur. All positive tests should be considered true positives until confirmatory test results are known. Thus, the communication of testing results obtained during pregnancy is vital to reducing unnecessary rapid testing in labor with potential false positive results, subsequent psychological stress and antiretroviral exposure.
The goal is to document HIV status in all pregnant women early in gestation. If the prenatal HIV status is not available, maternal rapid testing should be performed on admission to labor and delivery. If maternal status is not tested during labor, rapid testing should be performed on the newborn following delivery. Parental verbal consent is required for neonatal testing.
The HIV Initiative Change Package incorporates a position paper, educational materials for the different staffs & departments, order sets, a Parent Information Sheet, Treatment Algorithm, Nursing Staff Algorithm, resources for counseling, etc.
There have been challenges & issues typical of any large clinical change implementation and several more unique aspects involving individual staff responses from conflicts with their values & beliefs as well as legal considerations around confidentiality issues.
At the time of this presentation we will have two years of process & outcome data.