29 August 2021
WHO recommendation on human deficiency virus and syphilis testing in pregnancy
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.
First published: December 2016
Updated: No update planned
Assessed as up-to-date: December 2016
–– 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).
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
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.
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)?
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
The GDG did not identify any priority question related to this recommendation
WHO recommendations on antenatal care for a positive pregnancy experience
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.
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