Effect of CDC 2006 Revised HIV Testing Recommendations for Adults, Adolescents, Pregnant Women, and Newborns on State Laws, 2018

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.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV’s vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

HIV testing during pregnancy among women with a recent live birth-Seven US States, 2016-2019

BACKGROUND

Although the United States has made progress in reducing the transmission of HIV from mother-to-child, it has not yet met the goal of reducing such transmissions to 70%. Self-reported HIV testing varied by state of residence. Approximately, two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

OBJECTIVES

The aim of this study was (1) to examine the prevalence of receipt of an HIV test during pregnancy and (2) to examine differences in HIV testing during pregnancy by race/ethnicity, state of residence, and other sociodemographic characteristics.

DESIGN

Population-based surveillance of women with a recent live birth from seven US states. Individuals were sampled from birth certificate records 2-6 months postpartum and surveyed about their behaviors and experiences before, during, and shortly after pregnancy.

METHODS

Data from the Pregnancy Risk Assessment Monitoring System, a large, population-based survey, were used to estimate the prevalence of HIV testing during pregnancy during 2016-2019. Weighted prevalence estimates and 95% confidence intervals were calculated overall and by demographic and other selected characteristics.

RESULTS

Approximately two-thirds of women (66.1%) self-reported having a test for HIV during pregnancy. Prevalence varied by maternal characteristics and was highest among women who were non-Hispanic Black (80.7%) and among women who were aged ⩽ 24 years, had a high school education or less, were unmarried, or had Medicaid or no insurance for prenatal care (each > 70%). Self-reported HIV testing varied by state of residence. Approximately two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

CONCLUSION

About one in three Pregnancy Risk Assessment Monitoring System respondents did not report an HIV test during pregnancy. Health care providers can help educate pregnant patients about the importance of HIV testing and ensure universal testing to help identify individuals needing treatment and reduce the rates of mother-to-child HIV transmission.

Latent infection screening and prevalence in cancer patients born outside of Australia: a universal versus risk-based approach?

PURPOSE

Contention surrounds how best to screen patients for latent and undiagnosed infection prior to cancer treatment. Early treatment and prophylaxis against reactivation may improve infection-associated morbidity. This study sought to examine rates of screening and prevalence of latent infection in overseas-born patients receiving cancer therapies.

METHODS

A single-centre retrospective audit of 952 overseas-born patients receiving chemotherapy, targeted agents and immunotherapy between January 1 and December 31 2019 was undertaken at Peter MacCallum Cancer Centre. Pre-treatment screening for hepatitis B (HBV), hepatitis C (HCV), human immunodeficiency virus (HIV), latent tuberculosis (LTBI), toxoplasmosis and strongyloidiasis was audited.

RESULTS

Approximately half of our overseas-born patients were screened for HBV (58.9%) and HCV (50.7%). Fewer patients were screened for HIV (30.5%), LTBI (18.3%), strongyloidiasis (8.6%) or toxoplasmosis (8.1%). Although 59.7% of our patients were born in countries with high epidemiological risk for latent infection, according to World Health Organization data, 35% were not screened for any infection prior to commencement of therapy.

CONCLUSION

The prevalence of latent infections amongst overseas-born patients with cancer, and complexities associated with risk-based screening, likely supports universal latent infection screening amongst this higher-risk cohort.

Routine Opt-Out Screening is Key to Understanding and Identifying HIV/HCV Incidence

In 2006, the Centers for Disease Control (CDC) recommended routine HIV screening for all patients aged 13-64 years old who access healthcare for services. To date, 40% of people in the United States have never had an HIV test, and less than 30 % of people in the United States most at risk for acquiring HIV were tested in the past year. Description of Services: Baptist Hospital of Southeast Texas (BHSET) through support from Texas Department of State Health Services (TXDSHS) implemented Routine HIV screening in their ED in October 2011, and with additional support from Gilead Sciences, Inc. FOCUS program in 2016. Patients18 and older, are tested for HIV/HCV and linked to medical care within BHSET, and external community partners. Opt-out routine screening tests those who may not perceive themselves to be at risk and identifies those previously diagnosed for re-engagement in care. CDC reported 15% of those who do not know their status account for 38% of new transmissions, and 23% of those who knew their status, but were not engaged in care accounted for 43% of new transmissions.

Results

BHSET performed 160,000 tests, identified (0.3 % seropositivity) (0.1%) of new diagnosis (.05%) of acute cases, and (95%) linked to care. October 2016 HCV testing has performed 52% testing on patients outside the birth cohort, with a positivity rate of tested 43%.During COVID-19, HIV tests numbered 11,960 (0.1% seropositivity) with (.02%) new diagnosis, (98%) linked to care. HCV tests 9, 487, identified (6% HCV Ab seropositivity), (38% RNA positivity) linked (40%) to care.

Conclusion

BHSET has utilized its policy-driven opt-out HIV routine screening practices, protocols, and processes to improve Jefferson County's HIV prevalence from being ranked 4th in the state with cases of people who are living in 2010 to 14th in 2018.