Evidence-based guidelines for universal counselling and offering of HIV testing in pregnancy in Canada.

OBJECTIVE: To provide Canadian health care workers with evidence-based guidelines for universal counselling about HIV testing and the offering of such testing to all pregnant women. OPTIONS: Universal counselling and offering of HIV testing to all pregnant women versus targeted testing of only pregnant women at high risk for HIV infection. Antiretroviral treatment protocols for HIV-positive mothers and their infants are discussed as the intervention to reduce mother-to-child transmission rates. OUTCOMES: Main outcomes are mother-to-child HIV transmission rates and consequences of HIV testing on the mother and infant. EVIDENCE: Articles published from January 1985 to March 1997 identified through a MEDLINE search; articles published in pertinent medical journals in 1996 and 1997 identified through a manual search; and abstracts presented at international HIV/AIDS conferences. BENEFITS, HARMS AND COSTS: Early diagnosis of HIV infection in a pregnant woman optimizes her medical and psychosocial care, decreases the incidence of mother-to-child transmission and decreases the risk of horizontal transmission to sexual partners. New, third-generation HIV tests have reduced false-positive rates and thus diminished the harm of screening. RECOMMENDATIONS: A screening strategy consisting of universal counselling and offering of HIV testing is recommended for all pregnant women in Canada (grade B recommendation). Targeted testing of only pregnant women at high risk for HIV infection fails to identify a substantial proportion of HIV-positive pregnant women and is therefore not recommended (grade D recommendation). Women who identify themselves as being at high risk and whose initial HIV test result is negative should be counselled about the reduction of high-risk behaviours and retested in 6 months (grade B recommendation). Treatment of seropositive women and infants with zidovudine to prevent mother-to-child transmission is recommended (grade A or B recommendation depending on gestational age and CD4 count). VALIDATION: These guidelines are endorsed by the Canadian Pediatric AIDS Research Group and are in agreement with the recommendations of the Canadian Paediatric Society and the US Public Health Service Task Force.