Missed Opportunities for HIV Prevention in Perinatal Care Settings in the United States

Abstract

Universal opt-out HIV screening in pregnancy is an essential intervention toward eliminating perinatal HIV transmission in the US. However, it fails to identify pregnant people who are HIV negative at the time of testing but are at ongoing risk for HIV acquisition. Those of us involved in caring for women living with HIV are acutely aware of the many diagnoses of HIV that might have been prevented if only a partner had been tested for HIV or preexposure prophylaxis (PrEP) had been offered to a patient. This perspective article will review current recommendations and evidence-based interventions to evaluate missed opportunities for HIV prevention in US perinatal care settings. We identified three barriers to implementation of HIV prevention strategies during pregnancy and breastfeeding: (1) HIV risk for women is underestimated and poorly defined in clinical practice; (2) Partner testing is challenging and implementation studies in the US are lacking; and (3) PrEP remains underutilized. In March 2020, the National Perinatal HIV Hotline convened a group of clinicians and researchers specializing in perinatal HIV care to a case-based discussion of missed opportunities in perinatal HIV prevention. From our review of the literature via PubMed search as well as expert opinions gathered in this discussion, we make recommendations for addressing these barriers.

Progress in Eliminating Perinatal HIV Transmission in the Metropolitan DC Area Between 2018-2022

“…21 To achieve national PMTCT and EHE goals, providers need to actively engage women of reproductive age in sexual health discussions and education during all patient encounters, offer partner HIV testing and pre-exposure prophylaxis. 22,23 Despite high rates of maternal viral suppression (78.1%) in our cohort, there were 54 mothers who had an HIV RNA .1000 copies/mL and 9 mothers with unknown HIV RNA near delivery who represent a population for enhanced PMTCT interventions. Many of these women were newly diagnosed with HIV during pregnancy, which is known to be associated with a lower likelihood of initiating ART and thus achieving viral suppression compared with those diagnosed before pregnancy.…”

‘Ending the HIV epidemic’: where are African American women in the plan?

“…However, among the rapidly growing population of older adults aged 50 years and higher, HIV associated non-AIDS comorbidities have a greater impact on antiretroviral therapy (ART) adherence, HIV care engagement, function, and quality of life than HIV coinfections. Although individuals with HIV are living full lives, they do so with much higher rates of mental illness, pain conditions, obesity, cognitive impairments, and social isolation than individuals without HIV [19,20]. Among older adults living with HIV, African American women have the highest rates of these comorbid conditions, and HIV complications including faster progression to AIDS [17].…”

“…We must also remember that older adults ages 50 years and higher are a large proportion of the United States population and are the real face of the HIV epidemic [17,18]. For older adults of color, HIV continues to decimate their communities as many treatment and prevention benefits have excluded them [19][20][21][22][23][24][25][26][27][28][29]. We must take a holistic look at the picture by addressing the structural, systemic, interpersonal and individual.…”

“…Due to intersectional stigma, and institutional racism, African American women are often living with comorbid depression and other behavioral health issues, which go underdiagnosed and undertreated [18]. Historically, African American women living with HIV also have benefitted less from reproductive health promotion interventions and sexually transmitted infection prevention, resulting in higher rates of both perinatal HIV transmission and sexually transmitted infections compared with other races [19]. In particular, women living in the rural communities of the Deep South face these health challenges in a desert of both emotional and instrumental support services.…”