Health Alert: Steps to Further Reduce Mother-To-Child HIV Transmission in New York State
New York State providers have successfully reduced the statewide mother-to-child HIV transmission (MTCT) rate. In 1997, the statewide rate of MTCT was 10.9% with 97 infants infected; in 2004, the rate was 2.8% with 16 infants infected. The purpose of this Alert is to highlight important strategies to continue reducing MTCT with the goal of eliminating perinatal HIV transmission.
- Identifying Acute HIV Infection During Pregnancy
- HIV Testing in the Third Trimester
- Point-of-Care Rapid HIV Testing in Delivery Settings
- Assuring access to Care and Supportive Services
1. Identifying Acute HIV Infection (AHI) During Pregnancy
Between 2002 and 2004, 31 cases of AHI during pregnancy were identified in NYS, resulting in 12 cases of MTCT. AHI during pregnancy results in MTCT because the HIV infection often goes undetected and untreated. Also, maternal HIV viral load (VL) can be very high during and following AHI, which may increase the risk of MTCT.
Immediate testing is recommended for any pregnant woman who presents with a clinical syndrome compatible with AHI without a known cause, even if she tested HIV-negative earlier in pregnancy. Guidelines for the medical management of pregnant women with AHI and their exposed newborns are being developed. General information on AHI may be found on the Clinical Guidelines & Quality of Care website.
| Signs and Symptoms of AHI: | Laboratory Test Results in AHI: |
|---|---|
| Fever, pharyngitis, fatigue, myalgia, arthralgia, rash, nausea, vomiting, diarrhea, headache, night sweats, lymphadenopathy, hepatosplenomegaly. | HIV antibody test - May be negative or indeterminate in AHI. HIV RNA test - Will be positive earlier than antibody testing; may be high. |
In suspected cases of AHI during pregnancy, the Department recommends:
- Immediate testing using an HIV antibody test and an HIV RNA test. If either is positive or there is strong clinical suspicion:
- Immediate consultation with an HIV specialist regarding diagnosis and treatment,
- Confirmatory antibody testing 3-6 weeks later if the HIV RNA test is positive and the initial antibody test is negative or indeterminate.
Testing for AHI in pregnancy may be accessed by contacting:
- In New York City: New York City Department of Health & Mental Hygiene, HIV Surveillance and Epidemiology Program, Provider Line (212) 442-3388
- Outside New York City: New York State Department of Health, Wadsworth Center, Diagnostic HIV Laboratory (518) 474-2163
Recognize AHI and diagnose using an HIV RNA test in addition to an HIV antibody test.
2. HIV Testing in the Third Trimester
In concert with the Centers for Disease Control and Prevention (CDC), the Department recommends that prenatal providers routinely recommend repeat HIV testing, preferably at 34-36 weeks, for all women who test negative early in prenatal care (See MMWR 2006; 55[RR-14]: 1-17.) The second test ideally should be at least three months after the initial test. Repeat testing will identify women who become infected with HIV during pregnancy, a group which accounts for an increasing proportion of MTCT. The Informed Consent to Perform HIV Testing form allows pregnant women to have repeat HIV testing during pregnancy without signing another consent form. (Consent Forms DOH-2556 and 2556i)
Routinely recommend a second HIV antibody test in the 3rd trimester.
3. Point-of-Care Rapid HIV Testing in Delivery Settings
Some cases of MTCT occurred in association with delays in expedited HIV testing at delivery of women without prior HIV testing or with suspicion of recent HIV infection. Implementing point-of-care (rapid) testing facilitates timely administration of prophylaxis to HIV-positive women and their exposed newborns. For women diagnosed with HIV during labor, HIV antiretroviral (ARV) regimens to prevent MTCT are most effective if initiated during labor or, if intrapartum ARV is not possible, to the newborn within 12 hours of birth.
The Department of Health recommends:
- All birth facilities adopt point-of-care rapid HIV testing in labor and delivery settings.
- Expedited HIV test results should be available within an hour to facilitate effective administration of ARV prophylaxis.
- Delivery units should achieve a one-hour turnaround time for reporting expedited HIV test results.
- More information on Rapid Testing is available at the New York State Department of Health website.
4. Assuring Access to Care and Supportive Services
Limited or no prenatal care is an important contributor to residual MTCT in New York. Other associated factors include substance use, sexually transmitted infection(s) during pregnancy and poor adherence to HIV antiretroviral (ARV) medications.
HIV Case Management is a Standard of Care:
To facilitate linkages to care and to provide the support many women need, the Department of Health considers it a standard of care to link HIV-positive pregnant and postpartum women, including those who deliver without prenatal care, to HIV-specific case management and supportive services. Resources are available at:
- Women on Medicaid have access to COBRA (intensive community-based case management); see COBRA Community Follow-Up Program for resources in your area.
- Contact the AIDS Institute, Women's Services Section at (212) 417-4699 for additional resources in New York City.
Education and Technical Assistance Resources
Consultation and technical assistance for prenatal care providers and hospital obstetrical departments are available through:
- HIV Clinical Education Initiative (CEI). The CEI is a statewide network providing technical assistance and education. To contact the HIV CEI program nearest you, call (518) 473-8815 or go to the Clinical Guidelines & Quality of Care website.
- HIV/AIDS Regional Training Centers. These centers offer training on reducing MTCT and expedited and rapid testing in obstetrical settings. For information see the Statewide HIV/AIDS Training Calendar website.
HIV-positive pregnant and postpartum women should be actively linked to case management and supportive services.
