Third-trimester repeat HIV testing: it is time we make it universal

Progress in Eliminating Perinatal HIV Transmission in the Metropolitan DC Area Between 2018-2022

BACKGROUND

The number of perinatal HIV cases have continued to decline since the United States achieved the goal of perinatal HIV elimination in 2019. We aimed to evaluate dynamics in perinatal HIV transmission in the metropolitan District of Columbia (DC) area during 2018-2022.

SETTING

Children's National Hospital's (CNH) is a major referral site for the metropolitan DC area, including suburban Maryland and Virginia, and evaluates >95% of HIV-exposed infants (HEI) in the region.

METHODS

A retrospective cohort study of mother-infant pairs with perinatal HIV exposure seen at CNH during 2018-2022. We describe the demographics, intrapartum/postpartum management, and outcomes among mothers and HEI.

RESULTS

We analyzed 503 HEI; most (78.9%) were at low risk for perinatal HIV. Most mothers were African or African American (87.1%) and had HIV RNA <50 copies/mL around delivery (78.1%). The proportion of HEI at high risk for perinatal HIV decreased from 28.2% to 15.5% in 2018 and 2020, respectively, but increased to 24.8% in 2022. Most HEI received postnatal antiretroviral drugs for at least 4 weeks (95.3%). Seventy-nine infants (15.7%) were born to mothers diagnosed with HIV during pregnancy. Two infants (0.4%) were diagnosed with perinatally acquired HIV.

CONCLUSIONS

We report high rates of antiretroviral drugs use among mother-infant pairs and a low rate of perinatal HIV transmission in metropolitan DC. Despite a 1.8-fold decrease in the number of high-risk perinatal HIV exposures since 2018, this rate rebounded in 2022. There remain opportunities to optimize maternal care and reduce the number of high-risk HEI.

Advances in HIV Management During Pregnancy and Infant Feeding

Recent advances in human immunodeficiency virus (HIV) management during pregnancy and infant feeding encompass several key elements: expanded HIV testing guidance; growing evidence of safety, efficacy, and pharmacokinetic data favoring the use of preferred antiretroviral therapy (ART) during pregnancy and breastfeeding; increasing advocacy for the inclusion of pregnant individuals with HIV in clinical trials to expedite access to new ART; and updated guidelines supporting shared decision-making for choice of infant feeding methods in people with HIV.

Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV

Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.

Statewide Implementation of Universal Third-Trimester Repeat HIV Testing in Illinois

OBJECTIVE

This article aims to assess statewide uptake of HIV repeat testing in the first 2 years after the implementation of an amendment to the Illinois Perinatal HIV Prevention Act (IPHPA) mandating universal repeat HIV testing in the third trimester.

STUDY DESIGN

This is a retrospective, population-based study of all birthing individuals in Illinois (2018-2019). Data were collected using the state-mandated closed system of perinatal HIV test reporting. We evaluated the incidence of mother-infant pairs with negative early tests and repeat third-trimester tests (RTTTs) performed in adherence with the law, as well as the timing of the performance of the RTTTs (outpatient vs. inpatient). Chi-square tests of trend by quarter were performed to ascertain sustainability.

RESULTS

Of 138,805 individuals delivered in 2018, 80.6% presented with early test and RTTTs. In 2018, outpatient RTTTs improved from 71.8% (quarter 1) to 85.1% (quarter 4; p < 0.001). In 2018, the proportion of mother-infant dyads who received testing that was adherent to the IPHPA Amendment was 92.1, 95.5, 96.7, and 96.4% in quarters 1 through 4, respectively (p < 0.001). In 2019, outpatient RTTTs performance remained high (87.4%) and stable (p = 0.06). In 2019, 99.9% of mother-infant dyads had testing adherent to the mandate in quarters 1 through 4 (p = 0.39). Of individuals who presented without RTTTs, 93.5% (2018) and 98.8% (2019) underwent inpatient testing before delivery.

CONCLUSION

Implementation of RTTTs in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing RTTT programs.

KEY POINTS

· In 2018, Illinois enacted statewide RTTT for HIV among all parturients.. · In 2019, over 99% of mother-infant dyads had documentation of both early and repeat HIV testing before hospital discharge.. · Implementation of repeat third-trimester HIV testing in Illinois was rapid, successful, and sustained in its first 2 years.. · Public health methodologies from Illinois may benefit other states implementing similar programs..

Evaluation of State-Mandated Third Trimester Repeat HIV Testing in a Large Tertiary Care Center

OBJECTIVE

The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center.

STUDY DESIGN

This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks' gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing.

RESULTS

Of 12,053 people eligible for inclusion, 3.4% (n = 414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80 to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing.

CONCLUSION

Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance which reinforces the goal of a universal screen to test all people equitably and effectively without bias.

KEY POINTS

· Little is known about adherence to repeat third trimester HIV testing in pregnancy.. · Universal third trimester HIV screening was implemented with high uptake and without disparity.. · Protocolization of repeat HIV testing in pregnancy may reduce bias compared to risk based-screening..

Adherence to Sexually Transmitted Infection Screening in Pregnancy

Objective: Professional guidelines and state law require screening for sexually transmitted infections (STI) during pregnancy. Our objective was to evaluate adherence to these recommendations. Methods: This is a retrospective cohort study of patients initiating prenatal care before 20 weeks' gestation. Demographic characteristics and STI screening were abstracted from prenatal records. Tests of interest included initial syphilis, human immunodeficiency virus (HIV), hepatitis B, chlamydia, and gonorrhea tests, as well as repeat (third trimester) syphilis and HIV tests. All patients were eligible for initial screening. Patients were eligible for analysis of whether they received adherent repeat third trimester screening for syphilis (mandated by state law) and HIV (institutional protocol) if they delivered at or after 32 weeks' gestation. Adherent screening was defined as performance of all recommended screening. Results: Of 2370 patients, 1816 (76.6%) received adherent initial STI screening and 181 (7.8% of 2308 patients who delivered at or after 32 weeks' gestation) received adherent repeat third trimester STI screening. After adjusting for covariates, private insurance (adjusted odds ratio [aOR] 1.45, confidence interval [95% CI] 1.12-1.95) was associated with adherent initial screening, whereas being non-Hispanic Black or Hispanic were associated with lower odds of adherent initial screening. Factors associated with adherent repeat third trimester STI screening were younger age (aOR 0.93, 95% CI 0.90-0.97) and non-Hispanic Black race (aOR 3.24, 95% CI 1.94-5.42). Those with private insurance (aOR 0.10, 95% CI 0.06-0.15) were less likely to receive adherent repeat third trimester screening. Conclusion: STI screening rates remain suboptimal. Multiple disparities exist in performance both of initial and repeat third trimester screening.

Human Immunodeficiency Virus in Pregnancy

Approximately 5000 people living with human immunodeficiency virus (HIV) give birth each year. Perinatal transmission of HIV will occur in about 15% to 45% of pregnancies without treatment. With appropriate antiretroviral therapy for pregnant people as well as appropriate intrapartum and postpartum interventions, the rate of perinatal transmission can be reduced to less than 1%. Antiretroviral therapy will also reduce health risks for pregnant patients living with HIV. All pregnant people should be offered the opportunity to learn their HIV status and access treatment as needed.

Testing for HIV Increases the Odds of Correct Fetal Ultrasound Result

Introduction: Infectious diseases during pregnancy may pose a threat to both mother and the developing fetus. It also creates an opportunity to screen for diseases being widely underdiagnosed among women in Poland, such as human immunodeficiency virus (HIV) or sexually transmitted infections (STI). Therefore, we aimed to assess the number of pregnant women that had not been tested for HIV despite the recommendations. In addition, a comparison of clinical evaluation between HIV-tested and non-tested pregnant women was also performed. Material and methods: Medical records of all consecutive pregnant women, referred to our Infectious Diseases Hospital between September 2019 and March 2020 were retrospectively analyzed. Implementation of recommended screening testing towards infectious diseases during pregnancy including human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV), syphilis, and rubella, were also analyzed. Results: Medical records of 273 women were included in the analysis. The median age was 32 years (interquartile range: 26−33 years). In total 243/273 (89.0%) had been tested for HIV as recommended, and the remaining 30/273 (11.0%) had not been tested. HIV infection was not confirmed in any of the participants. Only one woman within the HIV non-tested group had been correctly tested towards other infections during her pregnancy. The recommended full testing was more likely to be correctly implemented in women who had also been tested for HIV (171/243, 70.4% vs. 1/30, 3.3%, OR 68.9; 95% CI 9.2−515.3, p < 0.00001). Moreover, the correct fetal ultrasound result was more likely to be obtained in women who had been tested for HIV as recommended (234/243, 96.3% vs. 11/30, 36.7%, OR 44.9; 95% CI 16.6−121.8, p < 0.00001). Conclusions: Despite the law regulations, 11% of pregnant women referred to consultations to the infectious diseases center had not been tested for HIV. At the same time, correct fetal ultrasound results are more likely to occur in women tested for HIV according to recommendations. This suggests that a holistic approach to screening, both for communicable and non-communicable diseases, among pregnant women may translate to better pregnancy outcomes.

Disparities in state-mandated third-trimester testing for syphilis

BACKGROUND

Since 1999, Illinois has had a legal statute mandating both first-visit and third-trimester syphilis testing in all pregnancies. However, the incidence of syphilis infection is increasing at the national and state level, including among individuals of reproductive age, conferring risk of congenital syphilis. Although state-mandated infectious disease screening is purported to be a strategy to improve equity and quality of care, adherence to such mandates and disparities in adherence are unknown.

OBJECTIVE

We sought to evaluate compliance with state-mandated third-trimester syphilis testing at a single tertiary hospital in Illinois and to identify disparities in testing.

STUDY DESIGN

This is a retrospective cohort study of all pregnant individuals who delivered between January 1, 2015 and February 28, 2018 at a large-volume academic center. Patients who delivered after 28 weeks of gestation were included. Frequency of state-mandated first-visit (<28 weeks) and third-trimester (≥28 weeks) syphilis screening was evaluated over the study period. The primary outcome was completion of any third-trimester screening (ie, performed as an initial or repeat test in the third trimester) in accordance with state law. Demographic and clinical factors associated with the primary outcome and with completion of both first-visit and third-trimester screening were evaluated with multivariable logistic regression.

RESULTS

Of the 9048 eligible deliveries, 96.9% (N=8766) of patients had first-visit syphilis screening, whereas only 27.3% (N=2469) had third-trimester screening. Performance of third-trimester syphilis testing increased over time from an average of 5.8% of deliveries during the first 6 months of the study period to 59.8% over the last 6 months of the study period. Non-Hispanic Black or Hispanic race or ethnicity, non-English primary language, public insurance, age <25, multiparity, and greater body mass index were independently associated with increased odds of third-trimester screening.

CONCLUSION

Despite a decades-old state mandate for third-trimester syphilis screening in this high-prevalence region, third-trimester screening performance was suboptimal. Several demographic characteristics were associated with adherence to screening, suggesting inequity and bias exist in testing practices. It is important to acknowledge that legal statutes do not fully eliminate bias and health disparities.

HIV knowledge and attitudes among minority pregnant patients and their non-pregnant partners in an urban hospital clinic

OBJECTIVE

HIV seroconversion during pregnancy disproportionately affects urban, minority pregnant individuals. In order to prevent perinatal HIV transmission, it is essential that individuals are aware of HIV risk factors and effective transmission prevention strategies are employed. Thus, we aimed to examine knowledge about HIV transmission and attitudes about HIV among low-income, minority pregnant individuals and their partners living in a high HIV prevalence area.

METHODS

In this qualitative study, pregnant participants were HIV-seronegative individuals receiving publicly-funded prenatal care in an urban academic center in the United States. Pregnant individuals and their partners were recruited to participate in a quality improvement program offering HIV testing to partners of pregnant people. Semi-structured guides were used to conduct individual interviews about participant sources of information about HIV, knowledge about transmission, and attitudes regarding those living with HIV. Transcripts were analyzed using the constant comparative method to determine themes and subthemes.

RESULTS

Of 51 participants, 29 were pregnant individuals and 22 were non-pregnant partners. We found that inaccurate knowledge about perinatal HIV transmission was prevalent. Sources of information about HIV included reputable literary information or educational experiences, broadcast media, and word-of-mouth sources. Participants held dichotomous perceptions of people living with HIV.

CONCLUSIONS

Among low-income, minority pregnant people and their partners in a high HIV prevalence area, inaccuracies and lack of knowledge about HIV transmission were common. Efforts to educate pregnant individuals and their partners about HIV and perinatal HIV transmission should address common misconceptions and use popular sources of information.