Recommendation

In high-prevalence settings, a provider-initiated testing and counselling (PITC) for HIV should be considered a routine component of the package of care for pregnancy women in all antenatal care settings. In low-prevalence settings, PITC can be considered for pregnant women in antenatal care settings as a key component of the effort to eliminate mother-to-child transmission of HIV, and to integrate HIV testing with syphilis, viral or other key tests, as relevant to the setting, and to strengthen the underlying maternal and child health systems.

(Recommended)

 

Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016

 

Remarks

• This recommendation has been integrated from the 2015 WHO Consolidated guidelines on HIV testing services (the strength of the recommendation and the quality of the evidence were not stated). (1)
• High-prevalence settings are defined in the 2015 WHO publication Consolidated guidelines on HIV testing services as settings with greater than 5% HIV prevalence in the population being tested. Low-prevalence settings are settings with less than 5% HIV prevalence in the population being tested.(1)
• A generalized HIV epidemic is when HIV is firmly established in the general population. Numerical proxy: HIV prevalence is consistently over 1% in pregnant women attending antenatal clinics (1).
• A concentrated HIV epidemic is when HIV has spread rapidly in a defined subpopulation (or key population, see next footnote) but is not well established in the general population (1).
• Key populations are defined in the 2015 WHO guidelines as the following groups: men who have sex with men, people in prison or other closed settings, people who inject drugs, sex workers and transgender people (1).
• PITC denotes an HIV testing service that is routinely offered in a health-care facility and includes providing pre-test information and obtaining consent, with the option for individuals to decline testing. PITC has proved highly acceptable and has increased the uptake of HIV testing in LMICs. (1)
• The availability of HIV testing at ANC services is responsible for the high level of knowledge of HIV status among women in many countries, which has allowed women and infants to benefit from ART.
• WHO recommends that ART should be initiated in all pregnant women diagnosed with HIV at any CD4 count and continued lifelong (2). This recommendation is based on evidence that shows that providing ART to all pregnant and breastfeeding women living with HIV improves individual health outcomes, prevents mother-to-child transmission of HIV, and prevents horizontal transmission of HIV from the mother to an uninfected sexual partner.
• Other recommendations relevant to ANC services from the Consolidated guidelines on HIV testing services include the following (1):

–– On disclosure: Initiatives should be put in place to enforce privacy protection and institute policy, laws and norms that prevent discrimination and promote tolerance and acceptance of people living with HIV. This can help create environments where disclosure of HIV status is easier (strong recommendation, low-quality evidence).

–– On retesting: In settings with a generalized HIV epidemic: Retest all HIV-negative pregnant women in the third trimester, during labour or postpartum because of the high risk of acquiring HIV infection during pregnancy (strength of recommendation and quality of evidence not stated).

–– On retesting: In settings with a concentrated HIV epidemic: Retest HIV-negative pregnant women who are in a serodiscordant couple or from a key population group (strength of recommendation and quality of evidence not stated).

–– On retesting before ART initiation: National programmes should retest all people newly and previously diagnosed with HIV before they enrol in care and initiate ART (strength of recommendation and quality of evidence not stated).

–– On testing strategies: In settings with greater than 5% HIV prevalence in the population being tested, a diagnosis of HIV-positive should be issued to people with two sequential reactive tests. In settings with less than 5% HIV prevalence in the population being tested, a diagnosis of HIV-positive should be issued to people with three sequential reactive tests (strength of recommendation and quality of evidence not stated).

–– On task shifting: Lay providers who are trained and supervised can independently conduct safe and effective HIV testing using rapid diagnostic tests (strong recommendation, moderate-quality evidence).

• Further guidance on HIV testing can be found in the 2015 WHO guidelines (1), available at: http://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/
• In addition, the 2015 Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (2) is available at: http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/ 
• To prevent mother-to-child transmission of syphilis, all pregnant women should be screened for syphilis at the first ANC visit in the first trimester and again in the third trimester of pregnancy.
• For further guidance on screening, please refer to the 2006 WHO publication Prevention of mother-to-child transmission of syphilis (3), available at:
• http://www.who.int/reproductivehealth/publications/maternal_perinatal_he...
• The latest (2016) WHO guidelines on the treatment of chlamydia, gonorrhoea and syphilis, and on the prevention of sexual transmission of Zika virus (4-7), are available at: http://www.who.int/reproductivehealth/publications/rtis/clinical/en/

 

Background

Sexually transmitted infections (STIs) are a major public health issue worldwide, affecting quality of life and causing serious morbidity and mortality. STIs have a direct impact on reproductive and child health through infertility, cancers and pregnancy.

There are approximately 36.7 million people living with HIV globally. 54% of adults and 43% of children living with HIV are currently receiving lifelong antiretroviral therapy (ART). The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called vertical or mother-to-child transmission (MTCT). In the absence of any interventions during these stages, rates of HIV transmission from mother-to-child can be between 15–=45%. MTCT can be nearly fully prevented if both the mother and the baby are provided with ARV drugs as early as possible in pregnancy and during the period of breastfeeding

Mother-to-child transmission may also occur if the expectant mother has syphilis. The burden of morbidity and mortality due to congenital syphilis is high with early fetal deaths/stillbirths, neonatal deaths, preterm/low-birth-weight babies and  infected infants. There is also an increase in mother-to-child transmission of HIV among pregnant women coinfected with syphilis and HIV. Untreated primary and secondary syphilis infections in pregnancy typically result in severely adverse pregnancy outcomes, including fetal deaths in a substantial proportion of cases. Latent syphilis infections in pregnancy result in serious adverse pregnancy outcomes in more than half of cases. Congenital syphilis is preventable, however, and elimination of mother-to-child transmission of syphilis can be achieved through implementation of effective early screening and treatment strategies for syphilis in pregnant women. The fetus can be easily cured with treatment, and the risk of adverse outcomes to the fetus is minimal if the mother receives adequate treatment during early pregnancy – ideally before the second trimester. There are indications that mother-to-child transmission of syphilis is beginning to decline globally due to increased efforts to screen and treat pregnant women for syphilis.

Chlamydial infection in pregnancy is associated with preterm birth and low birth weight. Infants of mothers with chlamydia can be infected at delivery, resulting in neonatal conjunctivitis and/or nasopharyngeal infection.

Infants of mothers with gonococcal infection can be infected at delivery, resulting in neonatal conjunctivitis manifesting as purulent ocular discharge and swollen eyelids. Untreated conjunctivitis may lead to scarring and blindness.

The primary transmission route of Zika virus is via the Aedes mosquito. However, mounting evidence has shown that sexual transmission of Zika virus is possible and more common than previously assumed. This is of concern due to an association between Zika virus infection and adverse pregnancy and fetal outcomes, including microcephaly, neurological complications and Guillain-Barré syndrome. The current evidence base on Zika virus remains limited

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (8). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (9) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)  (10) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (11) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does screening women for HIV infection in ANC settings (I) compared with not screening for HIV (C) improve health outcomes (O)?

 

Evidence summary

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at: http://apps.who.int/iris/bitstream/10665/179870/1/9789241508926_eng.pdf?ua=1&ua=1

http://apps.who.int/iris/bitstream/10665/186275/1/9789241509565_eng.pdf

http://apps.who.int/iris/bitstream/10665/249572/2/9789241549806-webannexD-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/10665/246114/5/9789241549691-annexD-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/10665/246165/5/9789241549714-webannexD-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/10665/204421/1/WHO_ZIKV_MOC_16.1_eng.pdf

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG did not identify any priority question related to this recommendation

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Sexually transmitted and reproductive tract infections

WHO Health Topics: HIV

Key considerations for differentiated antiretroviral therapy delivery for specific populations: children, adolescents, pregnant and breastfeeding women and key populations

 

 

References

1. Consolidated guidelines on HIV testing services 2015. Geneva: World Health Organization; 2015 (http://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/, accessed 29 September 2016).
2. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva: World Health Organization; 2015 (http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/, accessed 4 October 2016).
3. Prevention of mother-to-child transmission of syphilis: integrated management of pregnancy and childbirth (IMPAC). Standards for maternal and neonatal care 1.3. Geneva: Department of Making Pregnancy Safer, World Health Organization; 2006 (http://www.who.int/reproductivehealth/publications/rtis/syphilis-treatme..., accessed 14 September 2016)
4. WHO guidelines for the treatment of Chlamydia trachomatis. Geneva: World Health Organization; 2016 (http://www.who.int/reproductivehealth/publications/rtis/chlamydia-treatm..., accessed 27 October 2016)
5. WHO guidelines for the treatment of Neisseria gonorrhoeae. Geneva: World Health Organization; 2016 http://www.who.int/reproductivehealth/publications/rtis/gonorrhoea-treat..., accessed 27 October 2016)
6. WHO guidelines for the treatment of Treponema pallidum (syphilis). Geneva: World Health Organization; 2016 (http://www.who.int/ reproductivehealth/publications/rtis/syphilistreatment-guidelines/en/, accessed 27 October 2016).
7. Prevention of sexual transmission of Zika virus: interim guidance. Geneva: World Health Organization; 2016 (http://www.who.int/csr/resources/publications/zika/sexual-transmission-p..., accessed 27 October 2016)
8. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
9. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
10. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
11. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).

 

Citation: WHO Reproductive Health Library. WHO recommendation on sexually transmitted infections testing in pregnancy. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.