Status of Perinatal HIV Prevention in the United States
CDC Statement Following the Release of the Institute of Medicine Report
October 14, 1998
In 1996, as part of the authorization of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, Congress requested that the Institute of Medicine (IOM) evaluate state efforts to reduce mother-to-infant (perinatal) HIV transmission and to analyze barriers to further reductions. IOM has completed its report and has concluded that states have made substantial progress in reducing perinatal HIV transmission, but that even more can be done to "meet the goal of ensuring that all pregnant women be tested for HIV as early in pregnancy as possible, and those who are positive remain in care so that they can receive optimal treatment for themselves and their children." The report's central recommendation is "for the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care."
The Centers for Disease Control and Prevention (CDC) strongly supports increased national emphasis on the prevention of perinatal HIV transmission in the United States. Despite dramatic progress in recent years in decreasing perinatal HIV transmission, far too many HIV-infected women are not provided the opportunity to get care for themselves and to reduce their child's risk of infection. Not all pregnant women are being offered HIV-testing as part of prenatal care, and not all HIV-infected women are being reached with early prenatal care. Further reductions in perinatal HIV transmission in the U.S. will require that we address both of these critical gaps in care.
CDC agrees with the Institute of Medicine's conclusion that mandatory newborn testing would not further the goals of perinatal HIV prevention. Providing HIV-infected pregnant women the best chance for a healthy baby requires that they be reached early in prenatal care with the opportunity to learn their HIV status and, if infected, to benefit from therapy for their own health and for reducing the risk of transmitting HIV to their infant. To help achieve this goal, CDC has recommended since 1994 that all pregnant women be offered HIV testing as part of early prenatal care, and if infected, be offered the AZT regimen proven most effective in reducing perinatal HIV transmission.
As health care providers across the country have incorporated these guidelines into clinical practice, perinatal HIV transmission has dropped dramatically. On a national level, the number of children reported to CDC with perinatally acquired AIDS declined 43% between 1992 and 1996. Declines have been observed for all races in all regions and areas of the country.
CDC concurs with IOM's conclusion that even more can be done and applauds their efforts to further decrease the number of children born with HIV. IOM concludes that while prenatal care providers are more likely now than in the past to offer HIV tests, many physicians are not offering their patients testing because of the burden of providing extensive pre-test counseling and because they may incorrectly believe that a woman is not at risk for HIV infection. IOM therefore recommends that testing be universal - offered to all patients - and routine - added to the standard battery of prenatal tests, without pre-test counseling, but with notification to the woman that she will be tested and the option for the woman to refuse testing.
CDC strongly supports the goal of increasing physicians' education and willingness to provide testing. At the same time, as these recommendations are considered, it will be critical to consider the needs of HIV-infected women and women at high risk of HIV-infection. In many settings and situations, these women may require more extensive counseling. It is important for a pregnant woman, particularly if she is at high risk for infection, to understand why she should be tested and what a positive result might mean for her and her baby. If she is infected with HIV, she will have to make complex decisions about treatment for herself and her baby and must be provided quality counseling about the benefits and risks of available treatments. As we work to increase the number of women in care that are offered testing, it is also paramount that we work to get more women at risk for HIV into prenatal care.
One of our highest priorities must be to ensure all women have access to quality care early in pregnancy and beyond. In order for HIV-infected women and their children to benefit from treatment advances they must be reached with the opportunity for care. Recent CDC studies show that while the proportion of HIV-infected women offered HIV testing during pregnancy has greatly increased, a significant number of HIV-infected women are not receiving prenatal care. CDC data suggest that at least 15% of HIV-infected women do not receive prenatal care, and over one-third of HIV-infected women who use illicit drugs receive no prenatal care. Strategies to bring these high-risk women into care could have a profound impact on future HIV prevention.
Finally, we must always remember that the best way to prevent infection in babies is to prevent infection in women in the first place. We have made significant gains in the U.S. in translating science into life-saving prevention. While the remaining challenges will not be easy to address, the strides we are making clearly document the benefits.
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