Roger Chou, MD; Ariel K. Smits, MD, MPH; Laurie Hoyt Huffman, MS; Rongwei Fu, PhD; P. Todd Korthuis, MD, MPH
Chou R, Smits AK, Huffman LH, Fu R, Korthuis PT. Prenatal Screening for HIV: A Review of the Evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:38-54. doi: 10.7326/0003-4819-143-1-200507050-00009
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Published: Ann Intern Med. 2005;143(1):38-54.
Each year in the United States, 6000 to 7000 women with HIV give birth. The management and outcomes of prenatal HIV infection have changed substantially since the U.S. Preventive Services Task Force issued recommendations in 1996.
To synthesize current evidence on risks and benefits of prenatal screening for HIV infection.
MEDLINE, the Cochrane Library, reference lists, and experts.
Studies of screening, risk factor assessment, accuracy of testing, follow-up testing, and efficacy of interventions.
Data on settings, patients, interventions, and outcomes were abstracted for included studies; quality was graded according to criteria developed by the Task Force.
No published studies directly link prenatal screening for HIV with clinical outcomes. In developed countries, the rate of mother-to-child transmission from untreated HIV-infected women is 14% to 25%. Targeted screening based on risk factors would miss a substantial proportion of infected women. â€œOpt-outâ€ testing policies appear to increase uptake rates. Standard HIV testing is highly (>99%) sensitive and specific, and initial studies of rapid HIV tests found that both types of testing had similar accuracy. Rapid testing can facilitate timely interventions in persons testing positive. Recommended interventions (combination antiretroviral regimens, elective cesarean section in selected patients, and avoidance of breastfeeding) are associated with transmission rates of 1% to 2% and appear acceptable to pregnant women.
Long-term safety data for antiretroviral agents are not yet available. Data are insufficient to accurately estimate the benefits of screening on long-term maternal disease progression or other clinical outcomes, such as horizontal transmission.
Identification and treatment of asymptomatic HIV infection in pregnant women can greatly decrease mother-to-child transmission rates.
Key question (KQ) 1: Does screening for HIV in pregnant women reduce mother-to-child transmission or premature death and disability? KQ 2: Can clinical or demographic characteristics (including specific settings) identify subgroups of asymptomatic pregnant women at increased risk for HIV infection compared to the general population of pregnant women? KQ 3: What are the test characteristics of HIV antibody (HIV ab) test strategies in pregnant women? KQ 4: What are the harms (including labeling and anxiety) associated with screening? Is screening acceptable to pregnant women? KQ 5: How many HIV-infected pregnant women who meet criteria for interventions receive them? KQ 6: What are the harms associated with the work-up for HIV infection in pregnant women? KQ 7: a) How effective are interventions (antiretroviral prophylaxis [to prevent mother-to-child transmission] or treatment [to improve maternal outcomes]; avoidance of breastfeeding, elective cesarean section [in selected patients], or other labor management practices; counseling on risky behaviors; immunizations; routine monitoring and follow-up; or prophylaxis against opportunistic infections) in reducing mother-to-child transmission rates or improving clinical outcomes (mortality, functional status, quality of life, symptoms, or opportunistic infections) in pregnant women with HIV infection? b) Does immediate antiretroviral treatment in HIV-infected pregnant women result in improvements in clinical outcomes compared to delayed treatment until the infected woman becomes symptomatic? c) How well do interventions reduce the rate of viremia, improve CD4 cell counts, or reduce risky behaviors? How does identification of HIV infection in pregnant women affect future reproductive choices? KQ 8: What are the harms (including adverse effects from in utero exposure) associated with antiretroviral drugs and elective cesarean section? KQ 9: Have improvements in intermediate outcomes (CD4 cell counts, viremia, or risky behaviors) in HIV-infected pregnant women been shown to improve clinical outcomes or reduce mother-to-child transmission? A separate report reviews KQs 6, 7b, 9, and parts of 7a (counseling, immunizations, labor management practices other than elective cesarean section, routine monitoring and follow-up, and prophylaxis against opportunistic infections); 7c (effects on viral loads, CD4 counts, and risky behaviors); and 9.
exp hiv infections/ or exp hiv/
exp Viral Hepatitis Vaccines/
exp Influenza Vaccine/
exp Bacterial Vaccines/
2 or 3 or 4
1 and 5
exp Immunization Programs/
7 or 8
10 or 11 or 12
1 and 9 and 13
6 or 14
exp Evaluation Studies/
exp Epidemiologic Studies/
16 or 17 or 18
15 and 19
limit 15 to (clinical trial or guideline or meta-analysis or multicenter study or practice guideline)
20 or 21
limit 22 to (human and english language)
from 23 keep 1-206
exp AIDS-Related Opportunistic Infections/pc [Prevention & Control]
exp HIV Infections/co [Complications]
exp AIDS-Related Opportunistic Infections/
2 and (3 or 4)
1 or 5
limit 6 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
from 7 keep 1-396
exp HIV Infections/ or exp HIV/
1 and 2
exp impulsive behavior/ or risk reduction behavior/ or risk-taking/
1 and 4
3 or 5
7 or 8 or 9
6 and 10
limit 6 to (clinical trial or guideline or meta-analysis or multicenter study or practice guideline)
11 or 12
limit 13 to (human and english language)
from 14 keep 1-1272
exp HIV Infections/mo, ep, eh, et, tm, pc [Mortality, Epidemiology, Ethnology, Etiology, Transmission, Prevention & Control]
limit 3 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
4 or 7
9 or 10 or 11
(3 or 6) and 12
from 8 keep 1-573
exp AIDS Serodiagnosis/
exp HIV SERONEGATIVITY/ or exp HIV ANTIGENS/ or exp HIV/ or exp HIV SEROPREVALENCE/ or exp HIV SEROPOSITIVITY/ or exp HIV ANTIBODIES/
exp Mass Screening/
2 and 3
1 or 4
exp “Sensitivity and Specificity”/
5 and 6
exp stress, psychological/
Life Change Events/
exp prejudice/ or prejudic$.mp.
8 or 9 or 10 or 11
5 and 12
exp diagnostic errors/
5 and 14
7 or 13 or 15
exp longitudinal studies/
17 or 18 or 19
16 and 20
limit 16 to (clinical trial or guideline or meta-analysis or multicenter study or practice guideline or review)
22 or 21
limit 23 to (human and english language)
limit 23 to (human and abstracts)
24 or 25
from 26 keep 1-247
exp HIV Infections/dt [Drug Therapy]
exp HIV/de [Drug Effects]
1 or 2
exp Reverse Transcriptase Inhibitors/ad, tu
exp HIV Protease Inhibitors/ad, tu
exp antihiv agents/ad, tu
4 or 5 or 6
3 and 7
limit 8 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
exp Reverse Transcriptase Inhibitors/ae, ct, to, po
exp HIV Protease Inhibitors/ae, ct, to, po
exp antihiv agents/ae, ct, to, to
3 and 13
limit 14 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
14 and exp epidemiologic studies/
14 and (exp evaluation studies/ or exp comparative study/)
16 or 17
limit 18 to (human and english language)
15 or 19
limit 9 to yr = 1998-2003
from 21 keep 1-1157
limit 20 to yr = 1998-2003
from 23 keep 1-732
from 24 keep 1-732
viral load.mp. or Viral Load/
exp HIV Infections/
2 or 3
(exp leukocyte count/ and cd4.mp.) or exp cd4 lymphocyte count/
exp “pathologic conditions, signs and symptoms”/ or disease progression/
7 and 8 and 9
exp “sensitivity and specificity”/
10 and 11
exp epidemiologic studies/
10 and 13
limit 10 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
limit 14 to (human and english language)
15 or 16
from 17 keep 1-232
exp HIV/ or exp HIV INFECTIONS/
exp Anti-HIV Agents/ad, ae, po, ct, tu, to [Administration & Dosage, Adverse Effects, Poisoning, Contraindications, Therapeutic Use, Toxicity]
exp Reverse Transcriptase Inhibitors/ad, ae, po, ct, tu, to [Administration & Dosage, Adverse Effects, Poisoning, Contraindications, Therapeutic Use, Toxicity]
exp HIV Protease Inhibitors/ad, ae, po, tu, ct, to [Administration & Dosage, Adverse Effects, Poisoning, Therapeutic Use, Contraindications, Toxicity]
1 and (2 or 3 or 4)
exp Disease Transmission, Vertical/
exp HIV Infections/tm
pregnancy complications/ or exp pregnancy complications, infectious/
6 or 7
8 or 9
limit 13 to (human and english language and (clinical trial or guideline or meta-analysis or multicenter study or practice guideline))
15 or 16 or 17
13 and 18
limit 19 to (human and english language)
14 or 20
from 21 keep 1-373
exp cesarean section/
1 and (2 or 3 or 4 or 5)
9 or 10
11 and 12
6 and 13
14 and 19
limit 20 to (human and english language)
15 or 21
exp “Costs and Cost Analysis”/
3 and 4
exp epidemiologic study characteristics/
5 and (6 or 7 or 8)
limit 9 to (human and english language)
9 and 11
5 and 11
3 and 15
16 and 11
limit 17 to (human and english language)
14 or 18
from 19 keep 1-179
hiv/de [mh] OR hiv infections/dt [mh]
anti hiv agents[pa] OR reverse transcriptase inhibitors[pa] OR hiv protease inhibitors [pa]
#1 OR #2
evaluation studies[mh] OR epidemiologic studies[mh] OR comparative study [mh]
#3 AND #4
tu[sh] OR ad[sh] OR ae[sh] OR to[sh] OR po[sh] OR ct[sh]
#5 AND #6
#7 AND systematic [sb]
#8 AND Limits: Publication Date from 1989 to 1997, English, Human
Screening test relevant, available for primary care, adequately described.
Credible reference standard, performed regardless of test results.
Reference standard interpreted independently of screening test.
Indeterminate results handled in a reasonable manner.
Spectrum of patients included in study.
Administration of reliable screening test.
Initial assembly of comparable groups: randomized, controlled trials—adequate randomization, including concealment and statement of whether potential confounders were distributed equally among groups; cohort studies—consideration of potential confounders with either restriction or measurement for adjustment in the analysis; consideration of inception cohorts.
Maintenance of comparable groups (includes attrition, crossovers, adherence, and contamination).
Important differential loss to follow-up or overall high loss to follow-up.
Measurements: equal, reliable, and valid (includes masking of outcome assessment).
Clear definition of interventions.
Important outcomes considered.
Analysis: adjustment for potential confounders for cohort studies, or intention-to-treat analysis for randomized, controlled trials.
Accurate ascertainment of cases.
Nonbiased selection of case-patients and controls, with exclusion criteria applied equally to both.
Diagnostic testing procedures applied equally to each group.
Measurement of exposure accurate and applied equally to each group.
Appropriate attention to potential confounding variable.
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