In July 2006, the American College of Obstetricians and Gynecologists (ACOG) updated their recommendations for preventing mother to child transmission of HIV: use an opt-out prenatal HIV testing approach where legally possible; repeat offer of HIV testing in the third trimester to women in areas with high HIV prevalence, women known to be at high risk for HIV infection, and women who declined testing earlier in pregnancy, as allowed by state laws and regulations; use conventional HIV testing for women who are candidates for third-trimester testing; use rapid HIV testing in labor for women with undocumented HIV status; and if a rapid HIV test result is positive, initiate antiretroviral prophylaxis (with consent) without waiting for the results of the confirmatory test. The most recent and most comprehensive recommendations for prevention of perinatal transmission of HIV infection were published in July 2006 by the Public Health Service Task Force. Despite availability of current data and recommendations from ACOG (2004) and the Public Health Service Task Force (2006), neither all women are tested for HIV during their pregnancy nor are all women who present in labor with undetermined HIV status offered rapid HIV testing.
Perinatal nurses are responsible for reviewing the prenatal history and laboratory data when women are admitted for labor. The admission assessment process provides an opportunity to identify women who have not been tested for HIV during pregnancy and those who could potentially benefit from repeat testing (history of sexually transmitted disease; illicit drug use or the exchange of sex for money or drugs; multiple sex partners during pregnancy or a sex partner known to be HIV positive or at high risk; and signs and symptoms suggestive of acute HIV infection at any time during pregnancy) (ACOG, 2004). A rapid HIV test can be offered on admission for these women. A negative rapid HIV test is definitive; however, a positive rapid HIV test must be confirmed with a Western blot or immunofluorescence assay. If the rapid HIV test is positive, the woman should be told that she may have HIV infection and her baby may be exposed (ACOG, 2004). She should be aware that the rapid test results are preliminary and false-positive results are possible. A confirmatory test should be done right away, however, in the interim, with the mother's consent, antiretroviral prophylaxis should be initiated without waiting for the results (ACOG, 2004). Breastfeeding should be postponed until the confirmatory test results are available (ACOG, 2004). The provider responsible for the baby should be informed of positive maternal test results (as allowed by federal and state privacy laws) so that they can begin neonatal prophylaxis after birth (ACOG, 2004). Consultation with a provider who is knowledgeable in HIV infection is recommended (ACOG, 2004).
Recommendations for antiviral medications for mothers and infants are available at http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf (Public Health Service Task Force, 2006). These recommendations are updated frequently.
Risk of perinatal transmission of HIV can be significantly decreased (from a 25% transmission rate to a 2% or less transmission rate) with antiretroviral prophylaxis during labor and the newborn period and by offering the appropriate type of birth (cesarean vs. vaginal) on the basis of the mother's viral load and labor status (ACOG, 2004). The perinatal nurse has an important role in promoting early identification and treatment of HIV-infected pregnant women and treatment of their babies in the first hours of life.
The Perinatal Nurses' Role in Preventing Perinatal Transmission of HIV Infection During Labor and Birth
* Work with members of the perinatal leadership team to make sure that the recommendations from ACOG (2004) and the Public Health Service Task Force (2005) are fully operational for pregnant women who present in labor.
* Carefully review prenatal laboratory data and maternal history on admission
* Identify women who are candidates for rapid HIV testing
* With the woman's consent, obtain an order from the primary care provider for rapid HIV testing
* Provide information about rapid HIV testing to the woman (and her support persons as appropriate, based on privacy laws and patient consent)
* If results are positive, insure that the primary care provider comes to the bedside to personally explain the implications to the woman and that antiretroviral prophylaxis for the mother and baby is initiated in a timely manner (with her consent).
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