Washington, DC -- Reflecting a growing emphasis on the importance of preventive care for women, the American College of Obstetricians and Gynecologists (the College) today released two Committee Opinions on human immunodeficiency virus (HIV) in women: One lowering the recommended age for HIV screening and one addressing prevention of HIV transmission through use of prophylaxis. Because ob-gyns often provide primary and preventive care to their patients, they are ideally suited to play an important role in promoting HIV screening and prevention for women. Notably, the College released the new recommendations during the Centers for Disease Control and Prevention’s STD Awareness Month.
In 2010 and 2011, approximately 10,000 women in the United States were diagnosed with HIV. Unfortunately, almost one in five people with HIV are unaware of their infection. Lack of diagnosis can lead to delays in treatment, increased risk of infecting others, and other health care challenges.
The College mirrors the Centers for Disease Control and Prevention’s recommendation that all females ages 13 to 64 be tested at least once in their lifetime; previous guidelines recommended that testing begin at age 19. Annual re-testing is recommended, based on individual risk factors.
For example, the College recommends that repeat HIV testing be offered at least annually to women who:
- Are injection-drug users or partners of injection-drug users,
- Exchange sex for money or drugs,
- Have had sex with men who have sex with men since their most recent HIV test, or
- Have had more than one sex partner since their most recent HIV test.
“As physicians, our role does not end with HIV testing,” said Ruth Morgan Farrell, MD, MA, a member of The Colleges Committee on Gynecologic Practice, which developed the Committee Opinion. “If a patient has a positive HIV test, the ob-gyn should continue counseling the patient, referring her for appropriate clinical and supportive care.”
For women who are at highest risk of HIV infection, pre-exposure prophylaxis (PrEP) may be a useful tool in combination with other HIV prevention methods, according to the second Committee Opinion, “Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus.” PrEP is the once-daily dose of antiretroviral medications to HIV-negative individuals who are a high risk of becoming infected. PrEP has been shown to be effective in decreasing transmission rates, with reportedly mild adverse effects.
The new guideline clarifies that potential candidates for PrEP are women not infected with HIV who have a male sexual partner who is HIV positive and/or women who engage in sexual activity within a high HIV-prevalence area or social network, and who have one or more of the following risk factors:
- Inconsistent or no condom use,
- Diagnosis of sexually transmitted infections,
- Exchange of sex for commodities,
- Use of intravenous drugs or alcohol dependence or both, and/or
- Partners of unknown HIV status with any of the factors previously listed.
In discussing the new guidelines about PrEP, Kevin A. Ault, MD, a member of the College’s Committee on Gynecologic Practice, which developed the Committee Opinion, emphasized the importance of physician counseling to reduce the patient’s risk: “Although PrEP may be an excellent option for women who are at the highest risk of acquiring HIV, as ob-gyns, we should continue to stress the importance of risk reduction, like safe-sex practices, especially consistent condom use.”
For example, risk reduction conversations should also include education, counseling about testing, discussions about increased condom use, and other behavioral interventions. Ob-gyns involved in the care of women using PrEP must also reinforce the importance of adhering to the daily medication regimen.
The CDC’s guidance for PrEP is likely to evolve in the coming years, and ob-gyns should remain aware of new developments in this area.
Committee Opinion #595 “Preexposure Prophylaxis for the Prevention of Human Immunodeficiency Virus” and Committee Opinion #596 “Routine Human Immunodeficiency Virus Screening” will be published in the May issue of Obstetrics & Gynecology.
CDC STD Awareness Month
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Other recommendations issued in this month’s Obstetrics & Gynecology:
Committee Opinion #597 "Labor Induction or Augmentation and Autism" (NEW!)
ABSTRACT: Functional oxytocin deficiency and a faulty oxytocin signaling pathway have been observed in conjunction with autism spectrum disorder (ASD). Because exogenous synthetic oxytocin commonly is administered for labor induction and augmentation, some have hypothesized that synthetic oxytocin used for these purposes may alter fetal oxytocin receptors and predispose exposed offspring to ASD. However, current evidence does not identify a causal relationship between labor induction or augmentation in general, or oxytocin labor induction specifically, and autism or ASD. Recognizing the limitations of available study design, conflicting data, and the potential consequences of limiting labor induction and augmentation, the Committee on Obstetric Practice recommends against a change in current guidance regarding counseling and indications for and methods of labor induction and augmentation.
Committee Opinion #598 "The Initial Reproductive Health Visit" (Revised)
ABSTRACT: The initial visit for screening and the provision of reproductive preventive health care services and guidance should take place between the ages of 13 years and 15 years. The initial reproductive health visit provides an excellent opportunity for the obstetrician–gynecologist to start a patient–physician relationship, build trust, and counsel patients and parents regarding healthy behavior while dispelling myths and fears. The scope of the initial reproductive health visit will depend on the individual’s need, medical history, physical and emotional development, and the level of care she is receiving from other health care providers. A general exam, a visual breast exam, and external pelvic examination may be indicated. However, an internal pelvic examination generally is unnecessary during the initial reproductive health visit, but may be appropriate if issues or problems are discovered in the medical history. Health care providers and office staff should be familiar with state and local statutes regarding the rights of minors to consent to health care services and the federal and state laws that affect confidentiality.
Committee Opinion #599 "Adolescent Confidentiality and Electronic Health Records" (NEW!)
ABSTRACT: Confidentiality concerns are heightened during adolescence, and these concerns can be a critical barrier to adolescents in receiving appropriate health care. Health care providers caring for minors should be aware of federal and state laws that affect confidentiality. State statutes on the rights of minors to consent to health care services vary by state, and health care providers should be familiar with the regulations that apply to their practice. Parents and adolescents should be informed, both separately and together, that the information each of them shares with the health care provider will be treated as confidential, and of any restrictions to the confidential nature of the relationship. Health care providers and institutions establishing an electronic health record (EHR) system should consider systems with adolescent-specific modules that can be customized to accommodate the confidentiality needs related to minor adolescents and comply with the requirements of state and federal laws. If the EHR system does not allow for procedures to maintain adolescent confidentiality, the health care provider or staff should inform the patient that parents will have access to the records, and the patient should be given the option for referral to a health care provider who is required to provide confidential care, such as one who participates in the Title X family planning program.
Practice Bulletin #144 "Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies" (Revised)
ABSTRACT: The incidence of multifetal gestations in the United States has increased dramatically over the past several decades. The rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (1). The rate of triplet and higher-order multifetal gestations increased more than 400% during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per 100,000 births by 2009 (2). The increased incidence in multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted reproductive technology (ART), which is more likely to result in a multifetal gestation (3).