**3.1. Early diagnosis**

biomedical interventions has been proven to be successful in the prevention of HIV transmis‐ sion from an infected pregnant woman to her child, decreasing risk levels to 2%, as observed

The attempt at improving epidemiological rates of HIV/AIDS through the prevention and treatment of the disease is one of the eight Millennium Development Goals proposed by the World Health Organization. Worldwide, the virtual eradication of mother-to-child transmis‐

The present guide will be developed based on the method proposed by Harbour et al., which in turn is based on the formulation of various questions that will be answered according to

Vertical transmission (VT) of HIV is defined as that occurring from mother to child during gestation, delivery, or breastfeeding. The VT rates range between 13% and 48%. [4-7]. Preven‐ tive strategies have been set out to lower VT rates to less than 2%. Pregnancy, delivery, and breastfeeding are the most susceptible periods for VT of HIV [8, 9]. Maternal viral load (VL) is the main independent risk factor for transmission. Certain sexually transmitted diseases (STD) also increase the risk of VT. Likewise, low maternal CD4 cell counts also constitute a

The prevalence of vertical transmission (VT) in the various regions of the world varies according to geographic site and specifically according to the contribution of economic resources invested by different countries worldwide in the various strategies for healthcare

In countries with low infection prevalence rates such as Chile, efforts have been targeted to the decrease of vertical transmission (VT), which is responsible for 99% of HIV infections

Mother-to-child transmission as route of exposure has decreased, from rates of approximately 30% in 1996, prior to the first VT prevention protocol (ACTG 076), to 0.7% for HIV and 0.6%

To optimize prevention of VT, the clinical approach to a seropositive pregnant woman must be based on a thorough assessment of her initial health status, with a full physical examination, focusing particularly on those signs that point toward an opportunistic infectious condition

The strategy for prevention of VT has been based on the continuous review of the pooled evidence and has followed the impact factor of such evidence to suggest valid recommen‐ dations from expert opinions. It is of key importance to further evaluate new behaviors tending to identify, among other aspects: the eventual induction of resistance and toxicity of antivirals both in the pregnant mother as well as in the newborn, and their potential

levels of evidence, grading of recommendation, and experts' opinions [3].

policies, aiming at the prevention and treatment of infected mothers [2].

in the United States.

**2. Developing the guide**

sion is one of the goals to be accomplished [1, 2].

52 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

risk factor for VT, which is independent from VL [10].

among children younger than 13 years old [5, 11].

for AIDS, during the 2006-2010 period [4, 12-14].

and evaluating her current immune status.

Most women discover their carrier status or disease during pregnancy or after delivery upon the detection of the infection in the newborn. With regard to the latter, and despite the fact that there is no consensus on the recommendation of universal screening to all women upon their pre- and/or postconception visit, the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists United kingdom recommend performing the test on a routine basis, a behavior commonly adopted in many countries worldwide [21, 22]. In fact, most of such countries have also integrated a mandatory pretest counseling, the need for an informed consent, and the willfulness of people upon deciding to undergo the testing. Thus, sample collection requires the participation of staff trained in "counseling". The latter has reinforced the decision of women to undergo the test and has resulted in a significant rise of adhesion to preventive behaviors and therapy (Uganda and Rwanda) [23, 29, 30].

The recommended test for screening is the fourth-generation ELISA. Such laboratory exami‐ nation enables the simultaneous detection of Ag p24 and its respective antibodies, and therefore the window period is reduced to approximately 30 days with a sensitivity of 99.9% and a specificity of 99.5%. Despite the latter, it is important to stress that the positive predictive value of such test during pregnancy is approximately 50%, as a result of being applied on a low prevalence population. Thus, a confirmation test is required, and therefore patients with positive ELISA test should undergo a confirmatory test with Western blot. The confirmatory Western blot technique is carried out with a nitrocellulose strip onto which HIV envelope proteins have been added. When patient serum is transferred to the strips, any antibody against the virus present in serum will bind to the respective specific antigen on the strip. Western blot results are interpreted by observing the colored bands that are identified according to their position and particular characteristics. When results are indeterminate, a new sample must be ordered after 3 months to reevaluate eventual positivity [2, 31, 32, 36].

Furthermore, for pregnant patients with unknown serological status that seek healthcare because of labor initiation or medical situations in which pregnancy interruption is imminent, health services should be equipped with rapid diagnostic techniques (visual or instrumental). Despite their nonoptimal specificity and sensitivity, in the event of being positive, such techniques would enable the recommendation of peripartum preventive measures, with prior provision of the informed consent by the patient. Such emergency evaluations may be performed even by individuals lacking a specific training when other human resources are unavailable [33-36].

#### **3.2. HIV detection test requisition among pregnant women: who is eligible?**

With regard to the indication of universal HIV testing for women at their preconception consultation and/or at the beginning of their antenatal follow-up visit, the American College of Obstetricians and Gynecologists recommends that it is carried out on a routine basis, as it is the common practice in many countries of the world. In fact, most women are aware of their carrier status during pregnancy or during the puerperium upon screening for neonatal infection. As for the latter, it has been demonstrated that ordering the test together with preand posttest counseling improves awareness on the disease, adherence to therapy, and development of behaviors in the carrier to prevent transmission to her individual environment [22-27]. With regard to pre- and postconception counseling, defined as a "confidential conversation between a patient and a counselor that aims at the acquisition by the former of skills to face the stress related to an eventual carrier status, at achieving HIV/AIDS-related decision making during pregnancy, and learning of strategies for the prevention of vertical transmission," it is advisable to address the following topics:


The trend worldwide regarding HIV test ordering has progressed toward mandatory pro‐ grams. These are more efficient and less harmful than those that are voluntary or the routine programs with implicit but revocable consent. International organizations (WHO/UNAIDS) recommend guidelines regarding avoidance of compulsoriness of HIV testing and prioritiza‐ tion of guidance, education, and advise for its performance [25, 27, 28]. The recommendations/ guidelines should be undertaken regardless of seropositivity prevalence in the population. Such management protocols would enable an adequate control of mother-to-child transmis‐ sion at the population health level, while protecting mother rights and preventing stigmati‐ zation and discrimination. To the WHO, national policies and practices regarding compulsoriness of HIV testing should be reviewed to eliminate any testing that is not volun‐ tary. Mandatory testing or testing under coercion on individuals belonging to vulnerable groups or groups with high risk of infection such as pregnant women should not be performed. Voluntary testing amplification and counseling must include a better protection of risk behavior and seropositivity related stigma and discrimination. Additionally, more support for bonding and connection to prevention, treatment, care, and support services should be provided. Despite the latter and the trends seen in both poor as well as in developed countries, there are some exceptions, such as several states at the United States of America and countries like Chile. In Chile, the HIV/AIDS law has been in force since 2005 but does not accept compulsoriness; however, the 2011 Decree of the Ministry of Health indicates that HIV testing is mandatory for pregnant women [23-27].

position and particular characteristics. When results are indeterminate, a new sample must be

Furthermore, for pregnant patients with unknown serological status that seek healthcare because of labor initiation or medical situations in which pregnancy interruption is imminent, health services should be equipped with rapid diagnostic techniques (visual or instrumental). Despite their nonoptimal specificity and sensitivity, in the event of being positive, such techniques would enable the recommendation of peripartum preventive measures, with prior provision of the informed consent by the patient. Such emergency evaluations may be performed even by individuals lacking a specific training when other human resources are

With regard to the indication of universal HIV testing for women at their preconception consultation and/or at the beginning of their antenatal follow-up visit, the American College of Obstetricians and Gynecologists recommends that it is carried out on a routine basis, as it is the common practice in many countries of the world. In fact, most women are aware of their carrier status during pregnancy or during the puerperium upon screening for neonatal infection. As for the latter, it has been demonstrated that ordering the test together with preand posttest counseling improves awareness on the disease, adherence to therapy, and development of behaviors in the carrier to prevent transmission to her individual environment [22-27]. With regard to pre- and postconception counseling, defined as a "confidential conversation between a patient and a counselor that aims at the acquisition by the former of skills to face the stress related to an eventual carrier status, at achieving HIV/AIDS-related decision making during pregnancy, and learning of strategies for the prevention of vertical

ordered after 3 months to reevaluate eventual positivity [2, 31, 32, 36].

54 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

**3.2. HIV detection test requisition among pregnant women: who is eligible?**

transmission," it is advisable to address the following topics:

**•** Record of the activity in the pertaining documents

**•** Information about basic aspects of HIV/AIDS transmission and prevention

**•** Signature of the informed consent or statement of declination of the test

**•** Evaluation of the HIV detection test final result, with posttest counseling

**•** Reinforcement of preventive strategies for HIV and other STD during pregnancy

ties level and consequent referral in cases with reactive or positive test results

**•** Support to therapy adherence, exams, and periodic follow-up if applicable

**•** Supply of emotional support in the case the result of one or both tests is reactive or positive

**•** Provision of information on pregnancy control and/or follow-up procedures at the special‐

The trend worldwide regarding HIV test ordering has progressed toward mandatory pro‐ grams. These are more efficient and less harmful than those that are voluntary or the routine programs with implicit but revocable consent. International organizations (WHO/UNAIDS) recommend guidelines regarding avoidance of compulsoriness of HIV testing and prioritiza‐

unavailable [33-36].

It is imperative, therefore, for women at the last trimester or those at due date with unknown serology for HIV antibodies to undergo an urgent HIV screening rapid test. Similarly, counseling must be offered in this case and the corresponding informed consent obtained [23-27]. Should such test be reactive, the vertical transmission prevention protocol should be applied immediately (Level 4 evidence) [19-21, 35, 36].

Based on experts' opinion, HIV testing should be offered to all pregnant women by their second control visit at the latest. Should the result of the test be negative, the latter should be repeated between 32 and 34 weeks of gestation in women under higher risk of acquiring HIV during the first trimester of pregnancy (pathological alcohol consumption, drug addiction, sex workers, multiple sexual partners, etc.), i.e., Grade D recommendation.
