This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: The American College of Obstetricians and Gynecologists recommends routine human immunodeficiency virus (HIV) screening for women aged 19–64 years and targeted screening for women with risk factors outside of that age range. Ideally, opt-out HIV screening should be performed, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care, unless the patient declines testing (1). The American College of Obstetricians and Gynecologists recommends that obstetrician–gynecologists annually review patients' risk factors for HIV and assess the need for retesting.
An estimated one quarter of all individuals infected with the human immunodeficiency virus (HIV) in the United States are unaware of their HIV status. In order to identify individuals with undiagnosed HIV infection, the U.S. Centers for Disease Control and Prevention (CDC) recommends HIV screening for all patients aged 13–64 years in health care settings (1). Because obstetrician–gynecologists provide primary and preventive care for women, they are ideally suited to play an important role in promoting HIV screening for their patients. Although most obstetrician–gynecologists are familiar with routine HIV testing of their pregnant patients, physicians should incorporate routine HIV testing into their gynecologic practices as well.
There are a number of reasons why it is critical that women, who represent an increasing proportion of overall HIV and acquired immunodeficiency syndrome (AIDS) cases, know their HIV status. Early diagnosis and treatment of HIV can improve survival and reduce morbidity (2). In addition, women who are infected with HIV can take steps to avoid unintended pregnancy, protect their sexual partners, and reduce the likelihood of mother-to-child transmission should pregnancy occur (3). Therefore, the American College of Obstetricians and Gynecologists (ACOG) recommends routine HIV screening for women aged 19–64 years and targeted screening for women with risk factors outside of that age range, for example, sexually active adolescents younger than 19 years.
Ideally, opt-out HIV screening should be performed, in which the patient is notified that HIV testing will be performed as a routine part of gynecologic and obstetric care, unless the patient declines testing (1). In opt-out screening, neither specific signed consent nor prevention counseling is required. However, women should be provided with oral or written information about HIV and the meaning of positive and negative test results and given the opportunity to ask questions and decline testing. If a patient declines HIV testing, this should be documented in the medical record and should not affect access to care (4). Although ACOG recommends opt-out screening where legally possible, state and local laws may have specific requirements for HIV testing that are not consistent with such an approach. Therefore, obstetrician–gynecologists should be aware of and comply with legal requirements regarding HIV testing in their jurisdictions. Legal requirements for HIV testing may be verified by contacting state or local health departments. The National HIV/AIDS Clinicians' Consultation Center at the University of California San Francisco maintains an online compendium of state HIV testing laws that can be a useful resource (www. nccc.ucsf.edu).
The use of rapid HIV tests may provide test results to women in a more timely manner and may reduce the resources necessary to follow-up with patients regarding their test results. Although a positive rapid test result is preliminary and must be confirmed with additional testing, a negative rapid test result does not require any additional testing. Therefore, rapid testing may be a feasible and acceptable approach for an HIV screening program in an obstetric–gynecologic practice (5). To code for rapid testing, the modifier 92 is added to the basic HIV testing Current Procedural Terminology* (CPT‚) codes (86701–86703).
Although CDC and ACOG both recommend that reproductive-aged women be tested at least once in their lifetime, there is no consensus regarding how often women should be retested. The American College of Obstetricians and Gynecologist recommends that obstetrician–gynecologists annually review patients' risk factors for HIV and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who:
- Are injection drug users
- Have sex partners who are injection drug users or are infected with HIV
- Exchange sex for drugs or money
- Have received a diagnosis of another sexually transmitted disease in the past year
- Have had more than one sex partner since their most recent HIV test
Obstetrician–gynecologists also should encourage women and their prospective sex partners to be tested before initiating a new sexual relationship. In addition, periodic retesting could be considered even in the absence of risk factors depending on clinical judgment and the patient's wishes because patients may be concerned about their status but not know about or want to disclose risk-taking behavior to their physicians.
Although HIV-negative test results may be conveyed without direct personal contact, HIV-positive test results should be communicated confidentially and in person by a physician, nurse, or other skilled staff member. Women who are infected with HIV should receive or be referred for appropriate clinical and supportive care.
Rapid test results usually will be available during the same clinical visit that the specimen (eg, blood or oral swab sample) is collected. Obstetrician–gynecologists who use these tests must be prepared to provide counseling to women who receive positive rapid test results the same day that the specimen is collected (ie, women with positive rapid test results should be counseled regarding the meaning of these preliminarily positive test results and the need for confirmatory testing) (4). Obstetrician–gynecologists should develop links with individuals who can provide these counseling services on an emergent basis or train their own staff to handle the initial encounter and, thereafter, transition infected individuals to professionals who can serve as ongoing resources to them. Women whose confirmatory testing yields positive results and, therefore, are infected with HIV should receive or be referred to appropriate clinical and supportive care.
American College of Obstetricians and Gynecologists
409 12th Street SW, PO Box 96920
Washington, DC 20090-6920
ACOG HIV resources: http://www.acog.org/goto/HIV
National HIV/AIDS Clinicians' Consultation Center
UCSF Department of Family and Community Medicine at San Francisco General Hospital
1001 Potrero Ave., Bldg. 20, Ward 22
San Francisco, CA 94110
National HIV Telephone Consultation Service:
1-800-933-3413 (M–F, 8 am–8 pm [EST])
American Academy of HIV Medicine, American Medical Association. Coding guidelines for routine HIV testing in health care settings. Washington, DC: AAHIVM; Chicago (IL): AMA; 2008. Available at: http://aahivm.org/images/stories/ pdfs/brochure_reimburse_guide_routinehivtest.pdf. Retrieved May 6, 2008.
- Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2006;55(RR-14):1–17; quiz CE1–4.
- Palella FJ Jr, Deloria-Knoll M, Chmiel JS, Moorman AC, Wood KC, Greenberg AE, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. HIV Outpatient Study Investigators. Ann Intern Med 2003;138:620–6.
- U.S. Public Health Service Task Force. Recommendations for use of antiretroviral drugs in pregnant HIV-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Rockville (MD): USPHSTF; 2007. Available at: http://www.aidsinfo. nih.gov/contentfiles/PerinatalGL.pdf. Retrieved March 7, 2008.
- Human immunodeficiency virus. ACOG Committee Opinion No. 389. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1473–8.
- Jamieson DJ, Cohen MH, Maupin R, Nesheim S, Danner SP, Lampe MA, et al. Rapid human immunodeficiency virus-1 testing on labor and delivery in 17 US hospitals: the MIRIAD experience. Am J Obstet Gynecol 2007;197(suppl 1):S72–S82.
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Routine Human Immunodeficiency Virus Screening. ACOG Committee Opinion No.411. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:1495–502.