For HIV-infected women who have not received antiretroviral treatment or transmission prophylaxis in pregnancy, starting antiretrovirals in labor or soon after birth can still decrease the risk of perinatal transmission. There is, therefore, potential benefit in conducting rapid HIV testing in labor, but hospitals are seldom prepared to conduct such testing. We compared protocols for rapid HIV testing at 2 hospitals to determine what proportion of women had results back early enough to intervene if results had been positive. Hospital A initially used HIV enzyme-linked immunosorbent assays (ELISAs) and changed to using rapid tests (eg, Single Use Diagnostic System [SUDS]); hospital B used only the SUDS. With use of the SUDS in hospital A, results were reported more quickly than with the ELISA protocol in the same hospital (P < 0.0001). Comparing use of the SUDS in the 2 hospitals, test results were available more quickly in hospital A than hospital B (P < 0.05), which resulted in hospital A having more results reported prior to delivery (64% vs. 38%, P < 0.05) and within 12 hours postdelivery (94% vs. 73%, P < 0.05). If HIV testing in labor is to have its maximum effect on decreasing the risk of perinatal HIV transmission, hospitals need to institute rapid HIV testing, but protocols must ensure that results are available as quickly as possible.
The success achieved in decreasing transmission of HIV infection from mothers to their children is unparalleled in other areas of HIV prevention. This is largely a result of the initiation of widespread HIV testing of pregnant women and the use of zidovudine transmission prophylaxis or antiretroviral therapy for those found to be infected. With maximum suppression of viremia, the risk of transmission can be as low as 1%1; thus, the majority of children who do become infected represent missed opportunities—instances in which women were not known to be infected either because they did not attend prenatal care or failed to have HIV testing for other reasons. 2
Even if women have not received antiretroviral prophylaxis or therapy earlier in pregnancy, there are still measures that can be taken in labor to decrease the risk of transmission. Starting antiretroviral prophylaxis in labor has been shown to be effective, 3,4 and other interventions, including delivering by cesarean section before membranes are ruptured, decreasing the duration of time membranes are ruptured, 5–7 and possibly decreasing the use of invasive procedures such as scalp probe monitoring, could all potentially decrease the risk of HIV transmission. There is also evidence that even if a woman did not receive antiretrovirals prior to delivery, prophylaxis of the child after birth is effective in decreasing HIV transmission. 8 It is presently unclear, however, how quickly such treatment needs to be initiated, although there are suggestions that it may need to be within the first 12 or 24 hours after birth. 9,10 Knowing that a woman is infected might also enable her to avoid the risk of HIV transmission through breast feeding.
Such evidence has led to the initiation of protocols for offering women who have not been tested earlier in pregnancy the opportunity to have rapid HIV testing when they arrive at a hospital in labor. 11 This, however, requires that there are tests available that can be done rapidly and reliably. Until recently, only 1 rapid test, the Single Use Diagnostic System (SUDS; Murex Diagnostics, Norcross, GA) was approved by the US Food and Drug Administration (FDA) for use in the United States. Use of the test, however, has not been widespread, and hospitals most commonly continue to use the standard enzyme-linked immunosorbent assay (ELISA) test. In November 2002, the FDA approved OraQuick (OraSure Technologies, Bethlehem, PA), a rapid HIV test that is easier to process and more reliable than the SUDS test, thus providing the opportunity for more widespread application of rapid HIV testing in labor. 12 The time taken for a test result to be available, however, does not relate solely to the processing of the test but to the procedures developed for obtaining the sample and reporting the result as soon as possible.
In this observational study, we have examined the effects of the development of different protocols for the rapid return of HIV results for women in labor who have not been tested earlier in pregnancy. A state law introduced in Connecticut in October 1999 mandated offering HIV testing to women in labor if they had not been tested earlier in pregnancy. The law also required that testing should be done on newborn infants if their mothers had not been tested and that the results should be available within 48 hours of delivery. The purpose of the study was to compare the protocols developed in 2 hospitals in Connecticut for the rapid return of results and to determine what proportion of subjects had results available early enough to intervene if the results had been positive.