ACOG Guidelines Recommend Repeat HIV Screening, Prophylaxis

Laurie Barclay, MD

April 24, 2014

Two committee opinions from the American College of Obstetricians and Gynecologists (ACOG) on HIV in women recommend lowering the age for screening and using preexposure prophylaxis (PrEP) in women at highest risk to prevent transmission.

The new guidelines were published in the May issue of Obstetrics & Gynecology, coinciding with the Centers for Disease Control and Prevention's Sexually Transmitted Disease Awareness Month.

"As physicians, our role does not end with HIV testing," Ruth Morgan Farrell, MD, a member of ACOG's Committee on Gynecologic Practice, said in an ACOG news release. "If a patient has a positive HIV test, the [obstetrician-gynecologist] should continue counseling the patient, referring her for appropriate clinical and supportive care."

There were approximately 10,000 women diagnosed with HIV in the United States in 2010 and 2011. Nearly 20% of persons infected with HIV are unaware of their condition, often resulting in treatment delays, increased risk for transmission, and other healthcare burdens. Committee Opinion 596 notes that obstetrician-gynecologists may play a crucial role in facilitating HIV screening and prevention, as they typically provide primary and preventive care. "Early diagnosis and treatment of HIV can improve survival and reduce morbidity," the opinion states.

Similar to the Centers for Disease Control and Prevention, ACOG now recommends that all females aged 13 to 64 years be tested for HIV at least once during their lifetime. In contrast, earlier guidelines recommended HIV screening beginning at age 19 years.

ACOG Committee Opinion 596 also now recommends retesting for HIV yearly or more often for women at high risk because of any of the following:

  • injection drug use or having sex with an injection drug user,

  • exchanging sex for money or drugs,

  • having sex since their most recent HIV test with men who have sex with men, or

  • having had sex since their most recent HIV test with more than 1 person.

Obstetrician-gynecologists should annually review patients' risk factors for HIV to evaluate the need for repeat testing. Even women without identified risk factors should be offered the opportunity for repeat testing.

"Women who are infected with HIV should receive or be referred for appropriate clinical and supportive care," the opinion states. "Obstetrician–gynecologists who use rapid tests must be prepared to provide counseling to women who receive positive test results the same day that the specimen is collected. Obstetrician–gynecologists should be aware of and comply with legal requirements regarding HIV testing in their jurisdictions and institutions."

PrEP May Be Useful for Highest-Risk HIV-Negative Women

When used with other methods to prevent transmission, PrEP with once-daily dosing of antiretroviral agents may be useful for HIV-negative women at highest risk for HIV infection, according to Committee Opinion 595. Although PrEP may have mild adverse effects, it has been shown to be effective in reducing transmission rates.

"Although PrEP may be an excellent option for women who are at the highest risk of acquiring HIV, as [obstetrician-gynecologists], we should continue to stress the importance of risk reduction, like safe-sex practices, especially consistent condom use," said Kevin A. Ault, MD, a member of the ACOG Committee on Gynecologic Practice, in the news release.

Potential candidates for PrEP include:

  • women who are HIV-negative who have a male sexual partner who is HIV-positive and

    • inconsistent or no condom use,

    • sexually transmitted disease diagnosis,

    • exchange of sex for money or other commodities,

    • use of intravenous drugs,

    • alcohol dependence, and/or

    • partners of unknown HIV status with any of the above risk factors.

Patient counseling and discussion to lower risk should address HIV education, testing, increased condom use, and other behavioral strategies, as well as emphasizing the need to adhere to the daily medication regimen.

Obstet Gynecol. 2014;123(5):1133-1136, 1137-1139. Opinion 595 full text, Opinion 596 full-text

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