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HIV Testing & Reproductive Health. Treatment of TB , STDs, HIV, Hepatitis C, Family Planning and Substance Abuse: Focus on TESTING June 21 , 2014 El Centro California. Mary Caffery RN MSN UCSD Mother Child Adolescent HIV Program 858-534-9202

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Hiv testing reproductive health

HIV Testing & Reproductive Health

Treatment of TB, STDs, HIV, Hepatitis C,

Family Planning and Substance Abuse:

Focus on TESTING

June 21, 2014 El Centro California

Mary Caffery RN MSN

UCSD Mother Child Adolescent HIV Program


Financial disclosure

Financial Disclosure

I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter.



At the end of this session, participants will be able to:

  • Discuss current guidelines and recommendations for HIV testing of pregnant women and women of reproductive age.

  • Review opportunities for routine HIV screening of pregnant women, including at labor and delivery

  • Reflect on local HIV screening experiences with pregnant women

Have you ever had an hiv test

Have you ever had an HIV test?

  • Yes, I have been tested for HIV

  • No, I have NEVER had an HIV test

  • I’m not sure

Hiv testing reproductive health

Why should we integrate HIV

in reproductive health care settings?

Hiv testing reproductive health

The AIDS epidemic is integrally linked to sexual and reproductive health

  • Most persons with HIV in the U.S./Mexico acquired HIV through sexual exposure during their reproductive years, and most continue sexual activity after their diagnosis

  • The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding.

Hiv testing reproductive health

Percentages of HIV Cases Diagnosed Among Female Adults and Adolescents, by Transmission Category 46 States and 5 US-Dependent Areas 2010

The condom broke

“The condom broke”


  • Testing patient and partner

  • PREP

  • Plan B/ Emergency contraception

Health benefits of stronger linkages hiv r eproductive h ealth s ettings

Health Benefits of Stronger Linkages:HIV & Reproductive Health Settings

  • Public health benefits

  • Economic efficiency

  • Greater support for dual protection against unintended pregnancy and sexually transmitted infections, including HIV, for those in need, especially young people

Hiv testing reproductive health

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care SettingsSeptember 22, 2006 / 55(RR14);1-17

  • These revised CDC recommendations advocate routine voluntary HIV screening as a normal part of medical practice, similar to screening for other treatable conditions

Is hiv testing routinely offered to all sexually active adults in your community

Is HIV testing routinely offered to all sexually active adults in your community?

  • Yes

  • Somewhat

  • No

  • Not sure

Screening guidelines are clear

Screening Guidelines are Clear

  • Inallhealth-care settings, screening for HIV infection should be performed routinely for all patients, 13-64

  • Allpatients initiating treatment for TB should be screened routinely for HIV infection

  • Allpatients seeking treatment for STDs should be screened for HIV during eachvisit, regardless of whether the patient is known or suspected to have specific behavior risks

Effective screening guidelines

Effective Screening Guidelines

  • Voluntary

  • Informed

  • Consent in general consent for care

  • Information/materials should be made available

  • If a patient declines, document in the record

Routine testing results in more testing

Routine testing results in more testing!

  • Routine prenatal HIV testing with streamlined counseling and consent procedures has substantially increased the number of pregnant women testing

  • Opt-Out prenatal HIV testing led to more care and fewer infected children

Hiv testing reproductive health


Hiv testing reproductive health

1 Test 2 LivesCDC /ACOG Recommendations for HIV Screening for Pregnant Women

  • All pregnant women should be tested for HIV infection

  • All health care providers should recommend HIV testing to all of their pregnant patients, as early as possible

  • If a patient refuses an HIV test, it should be re-offered at regular intervals throughout the pregnancy

Screening protection

Screening => Protection

  • Without ARVs during pregnancy, risk of transmission from mother to infant is 1 in 4

  • The risk of perinatal transmission <2%

  • Increased screening

    • Highly effective antiretroviral

    • Elective Cesarean section as appropriate

    • Formula feeding

Hiv testing reproductive health

Estimated Numbers of Perinatally Acquired AIDS Cases by Year of Diagnosis, 1985–2010 — United States and Dependent Areas

CDC, 2013

Should pregnant women get a second hiv test

Should pregnant women get a second HIV test ?

  • Yes

  • No

  • Only if women have high risk

Timing of a second prenatal hiv test

Timing of a Second Prenatal HIV Test

  • A second HIV test during the third trimester, <36 weeks is cost-effective even in areas of low prevalence and may be considered for all pregnant women

  • Women who are known to be at high risk (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy

  • Women who have symptoms consistent with acute HIV infection.

Addressing reasons for declining testing

Addressing Reasons for Declining Testing

  • Lack of perceived risk; fear of the disease; concerns: partner violence or potential stigma or discrimination

  • Women with previous - test should be informed of the importance of retesting during each pregnancy

  • Logistical reasons for not testing should be resolved

  • Some who initially decline accept later date, if their concerns are discussed

  • Other women will continue to decline testing, their decisions should be respected and documented in the medical record

Hiv testing reproductive health

Rapid Testing in Labor

Reactive Control




Read results in 20-40 minutes

Who are the pregnant women who will need rapid hiv testing on l d

Who are the pregnant women who will need rapid HIV testing on L&D?

  • Women with no or limited prenatal care

  • Women who were not offered testing

  • Women whose results are unavailable

  • Women who declined testing previously

  • Women who report new risk behavior, partner

  • All of the above

Rapid testing during labor

Rapid Testing During Labor

  • Any woman with undocumented HIV status at the time of labor should be screened with a rapid HIV test unless she declines (opt-out screening)

  • Reasons for declining a rapid test should be explored

  • Immediate initiation of appropriate antiretroviral prophylaxis should be recommended to women on the basis of a reactive rapid test result without waiting for the result of a confirmatory test

Timing of perinatal hiv transmission non breastfeeding women

Timing of Perinatal HIV Transmission: Non-Breastfeeding Women

  • Intrauterine (before 36 weeks) ~20% of cases

    • Virologic detection of HIV in newborn at 1–2 days of life

  • Peripartum ~80% of cases

    • Onset of placental separation

    • Mother-to-fetus microtransfusions

    • Labor and rupture of membranes

  • Most transmission occurs close to or during labor and delivery (L&D)

Postpartum testing

Postpartum Testing

  • If a woman's HIV status is unknown at the time of delivery, she should be screened immediately postpartum with a rapid HIV test unless she declines

  • When the mother's status is unknown postpartum, rapid testing of the newborn as soon as possible after birth is recommended so antiretroviral prophylaxis can be offered to HIV-exposed infants. Women should be informed that identifying HIV antibodies in the newborn indicates that the mother is infected.

Newborn testing treatment

Newborn testing / treatment

  • For infants whose HIV exposure status is unknown and who are in foster care, the person legally authorized to provide consent should be informed that rapid testing is recommended for infants whose biologic mothers have not been tested

  • The benefits of antiretroviral prophylaxis are best realized when it is initiated <12 hours after birth

Is perinatal hiv eliminated in your community

Is Perinatal HIV Eliminated in your Community?

  • Yes

  • No

  • Not sure

Why are some women not tested

Why are some women not tested?



Language barriers

Late entry or no prenatal care

Patient perceived as not at risk

Provider does not strongly recommend testing to all women

  • Women’s reasons for not being tested

    • Do not think they are at risk

    • Have been tested “recently”

    • Test not offered or recommended

  • Negative consequences of testing rarely mentioned

Hiv testing reproductive health

Experts Agree on Routine Testing for Women:

The CDC and the ACOG recommend that females aged 13–64 years be tested at least once in their lifetime and annually thereafter based on factors related to risk

Ob–gynsshould 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 are sex partners of injection-drug users exchange sex for money or drugs are sex partners of HIV-infected persons have had sex with men who have sex with men since the most recent HIV test have had more than one sex partner since their most recent HIV test

The opportunity for repeat testing should be made available to all women even in the absence of identified risk factors

ACOG Number 596, May 2014

Script for providers

Script for Providers

“I test all my patients who are between 19 and 64 years old for HIV as a routine part of their care

More than one million people in the U.S. have HIV and about one in five of these people don’t know it

Because they don’t know, they can’t get medicine that may help them live longer”

Script continued

Script Continued

“This brochure (HIV and Women) tells you about HIV and why you should be tested. When you have finished reading this information, I would be glad to answer any questions that you have. You will be tested for HIV today unless you tell me not to”

Advances in hiv testing

Advances in HIV Testing

Is there anything new in hiv testing going on in your community

Is there anything new in HIV testing going on in your community?

Will acute hiv infection be picked up on the home hiv test kit

Will acute HIV infection be picked up on the home HIV test kit?

  • Yes

  • No

  • Not Sure

Hiv testing reproductive health

Old & New Tests

in New Combinations

With More on the Way

Hiv testing reproductive health

Recommended Testing Algorithm

DRAFT Recommendations: Diagnostic Laboratory Testing for HIV Infection in the United States 2012,

Hiv testing reproductive health

How do these tests differ from

earlier HIV tests?

Hiv testing reproductive health

How do these differ from earlier tests?

Tests for both virologic (p24 antigen) and serologic (antibody) markers of HIV infection

Incorporates NAT to resolve discordant results, reduce indeterminate test results, and identify acute HIV infection

All antibody-positive specimens tested for HIV-2; previously, only those with negative or indeterminate HIV-1 Western blot received specific HIV-2 testing

Emphasizes sensitivity during initial testing. Rare false-positive antibody test results might occur; will be resolved during subsequent laboratory testing recommended as part of initial clinical evaluation

Hiv testing reproductive health

  • Testing’s Role in Preventing HIV Infection

Nearly 1.2 million people in the United States are HIV-positive.

One in five of those don’t know they’re infected, a major contributing factor to the 50,000 new HIV infections each year

Testing is the first step to engaging HIV-positive patients in care, stopping individual disease progression, and stemming the spread of HIV

Providers should test all patients between 13 and 64 years old, regardless of risk profile, at least once in their lifetime, and preferably on an annual basis as part of routine health screening

Hiv testing reproductive health

There is an urgent need to increase the proportion of persons who are aware of their HIV-infection status

Expanded, routine, voluntary, opt-out screening in reproductive health care settings is needed

Such screening is cost-effective and feasible

Hiv testing reproductive health

Getting the Word Out

Pasa la voz spread the word using women s social networks for hiv education and testing

Pasa la Voz (Spread the Word): Using Women's Social Networks for HIV Education and Testing

Rebeca L. Ramos MA, MPH, et. alPublic Health Rep. 2010 Jul-Aug; 125(4): 528–533

Hiv testing reproductive health

Test Everyday!

Hiv testing reproductive health

Perinatal HIV/AIDS

Rapid perinatal HIV consultation from practicing providers

HIV testing in pregnancy

Treating HIV-infected pregnant women

Preventing transmission during labor and delivery and the post-partum period

HIV-exposed infant care

Call for a Phone Consultation

(888) 448-876524 hours, Seven days a week

Hiv testing reproductive health

Call for a Phone Consultation

(888) 448-876524 hours, Seven days a week

Advice from national experts in perinatal HIV care

rovideconsultation on all levels of perinatal HIV management, including on complex and unique treatment dilemmas, to provide you the best possible information on up-to-date, high-quality care

Consultation on complex perinatal HIV treatment issues

Addressing adherence issues

Managing HIV-positive pregnancies with late presentation to care

Safer conception options for HIV-affected couples

Referral to perinatal providers and reproductive health services

Connecting HIV-infected women and exposed infants to HIV-experienced clinicians

Connecting HIV-affected couples considering conception with supportive providers

Resources for clinicians

Resources for Clinicians

  • Offering information on AIDS treatment, prevention, and research

  • Clinical guidelines for ARV treatment

    • Perinatal/Mother-to-Child Transmission

    • Pediatrics

    • Adults and Adolescents




A Guide to the Clinical Care of Women with HIV, 2013 Edited by Jean R Anderson, M.D.

Distributed by HRSA, available online at

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, MMWR September 22, 2006 / 55(RR14); 1-17.

Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1-Transmission in the United States, 2014. Updated yearly.

Rapid Human Immunodeficiency Virus Testing on Labor and Delivery

Lisa Rahangdale, MD, MPH, and Deborah Cohan, MD, MPH

OBSTETRICS & GYNECOLOGY VOL. 112, NO. 1, JULY 2008, 159-163

Women’s Opinions about Routine HIV Testing During Pregnancy:

Implications for the Opt-Out Approach Linda S. Podhurst, Ph.D.,

Deborah S. Storm, Ph.D., and Sarah Dolgonos, M.P.H.

AIDS PATIENT CARE and STDs Volume 23, Number 5, 2009



  • American College of Obstetricians and Gynecologists.(ACOG) Committee Opinions

  • A comprehensive, Internet-based library of materials on mother and child HIV infection



  • Pacific AIDS Education Center: Resources & References for HIV Rapid Testing in Labor & Delivery TLD/RTLDManual/index.htm

  • Treatment Guidelines:

  • CDC Perinatal HIV:

  • Perinatal Hotline Service 888-448-8765

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