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SPECIAL ARTICLES: Guidelines Section


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Infectious Diseases in Clinical Practice: January 2002 - Volume 11 - Issue 1 - p 33
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[CDC MMWR 2001;50: RR-19:59]:

The revised guidelines represent the recommendations of an expert panel of 48 consultants who met in April, 1999. Highlights include the following:

  • Frequency of perinatal transmission: The transmission rate in the period 1985–94 was reported at 16–25%; this decreased to less than 11% with the ACTG 076 report [NEJM 1994;331:1173]. During the period from 1996 to 2000, the transmission rate decreased to 5–6%, reflecting the effects of AZT and HAART, and the most recent data, for 2000–01, shows that rates are now less than 2%. With no detectable virus, the rate is less than 1% [NEJM 1999;341:385; JAMA 1999;282:531; JID 2001;183:539].
  • Dynamics of perinatal transmission: For women who do not breast feed, intrauterine transmission accounts for 25–40%, and transmission during labor and delivery accounts for 60–75%. For women who breast-feed, intrauterine transmission accounts for 20–25%; this or early breast feeding accounts for 60–70%, and later postpartum transmission through breast feeding accounts for 10–15% [JID 1996;174:722].
  • Counseling recommendations are summarized as follows:
    • Who: All pregnant women
    • How: Standard assay with informed consent. Rapid assay if presents in labor.
    • When: As early as possible. High-risk patients: Repeat in 3rd trimester preferably before week 36
    • Information to be provided in counseling (the bare minimum):
      1. HIV is the virus that causes AIDS and is spread primarily by sex and injection drug use.
      2. Women may be infected and not know it.
      3. There are effective interventions that can protect the infant and reduce morbidity and mortality in the mother.
      4. HIV serology is recommended for all pregnant women.
      5. Services are available to help pregnant women prevent HIV transmission.
      6. Women who refuse the test will receive their care and their infants will also receive care.
  • Legal considerations: The PHS guidelines endorse counseling all pregnant women on the risk of HIV infection, the benefits of HIV testing, and the need for voluntary testing. These have been endorsed “by most professional organizations” and these have been implemented by states, “but with substantial variability in strategy.” Most states have policies for HIV counseling and testing, and 50% have laws or regulations requiring this. New York and Connecticut are the only states that mandate testing of newborns and no states require testing of pregnant women without informed consent. This issue has been reviewed by the Institute of Medicine, which resulted in a 1999 recommendation that the U.S. adopt a policy of universal HIV testing of pregnant women with patient notification as a routine component of prenatal care. This recommendation for universal HIV testing and patient notification is under consideration by some states.
© 2002 Lippincott Williams & Wilkins, Inc.