The necessary surveillance of screening of HIV infection in pregnant women: not a matter taken for granted

Background In developed countries the rate of vertical transmission of HIV has dramatically declined after the introduction of a combination of measures represented by antiretroviral treatment before and at delivery, elective caesarean section and elimination of breastfeeding. Such measures are strongly effective and COULD reduced vertical transmission in many cases close to 0%. However, they can only be applied if the woman with HIV infection is aware of being infected: although HIV testing is always recommended during pre-conception counselling, many pregnancies are not preceded by a counselling visit, and a substantial proportion of pregnancies are not planned at all; so it is not uncommon to have a first assessment for HIV and other infections once pregnancy is already established. National data about pregnancies of HIV-infected women reported rate of 26.6% pregnancies characterized by a previously undetected HIV infection. The objectives of the present study were to assess the rate of women arriving at the time of delivery with unknown HIV status and to register the timing of availability laboratory results of the screening, in order to detect the possibility of a dismissed diagnosis before delivery. Material and Methods Data were collected by informatics consultation of clinical documentation of pregnant women delivering at the S. Orsola Hospital, where more than 3000 deliveries take place every year. We evaluated deliveries occurred during 4 sample-monthes in the years 2008-2009. We registered the effective annotation in the patients charts of HIV testing occurred during pregnancy, determined by a review of prenatal care records, which women submit ad admission and we evaluated the timing of availability of laboratory results (enzyme immunoassay) versus timing of delivery, were testing was performed at admission in women with no documented HIV testing records. Results: HIV status was present in 1136 (99.5%) charts of 1142 women at delivery: in 1002 cases (87.7%) HIV testing was performed during pregnancy and it was absent in the remain 134 (11.7%) women, so laboratory analysis (EIA) was performed. Laboratory results were available prior to delivery in 74 cases (55.2% of women tested at admission), on useful time to carry out all known strategies to prevent vertical transmission of HIV infection. In 28 cases (20.8%) serological diagnosis was received after delivery, but on time for an eventually promptly starting of antiretroviral prophylaxis on the newborn. The receipt of test results after 12 hours from delivery occurred in 32 cases (23.9%) and they were very late to enactment the necessary prevention strategies. Conclusion We found an important percentage of pregnant women reach to delivery without a HIV screening performed during pregnancy. This underline the necessary close surveillance that nurses, midwives and obstetrician must keep and the importance of HIV testing suggestion during pregnancy in order to achieve a timely HIV assessment, performed in the early stages of pregnancy. The attention of maternity hospital personnel, registering prenatal records, show crucial importance for a complete preventive intervention against HIV transmission to the newborn. Our study emphasizes the importance of a promptly HIV testing results and suggest the possibility of presence of rapid testing in delivery rooms, in order to carry out the prevention strategies soon as possible during labour in positive cases. We want to underline the recent up-date of international guidelines, where HIV testing is simplified adopting an opt-out approach and the abolition of a specific written informed consent in order to permit a major efficiency of pre-natal care ad an better manage of high risk pregnancies.