Reducing HIV Transmission From Mother-to-Child: An Opt-Out Approach to HIV Screening 

The chance that HIV infection will be transmitted from an HIV-infected pregnant woman to her child can be reduced to 2% or less (fewer than 2 out of every 100). This is possible because better medicines are available to treat HIV. But first, the pregnant woman and her doctor must know if she is infected with HIV.
What do we know?

• Many women across the United States do not get tested for HIV during pregnancy.
• HIV-infected women who do not get tested often transmit HIV to their infants. 2005 CDC data show that among HIV-infected infants born in the 33 states which report HIV-exposed infants, 31% of the mothers of HIV-infected infants had not been tested for HIV until after delivery.
• Studies show that more women are tested when the HIV test is included in the standard group of tests that all pregnant women receive routinely, and when providers recommend HIV testing early in pregnancy to all their pregnant patients.
• Since 1995, CDC has recommended all pregnant women be tested for HIV and, if found to be infected, offered treatment for themselves to improve their health and to prevent passing the virus to their infant.

What Testing Approaches Are Available?
There are two different ways to approach pregnant women about HIV testing:

• Opt-in:
  • Pregnant women are given pre-HIV test counseling.
  • They must agree to receiving an HIV test, usually in writing.

• Opt-out:
  • Pregnant women are told that an HIV test will be included in the standard group of prenatal tests (that is to say, tests given to all pregnant women), and that they may decline the test.
  • Unless they decline, they will receive an HIV test.

Statistics published in the Nov.15, 2002, Morbidity Mortality Weekly Report (MMWR) showed that in eight states using the opt-in approach in 1998-1999, testing rates ranged from 25% to 69%. In Tennessee, which uses an opt-out approach, the testing rate was 85%. Other studies support this evidence that, of the voluntary approaches to prenatal HIV testing, more women are tested with the opt-out approach. An evaluation of opt-out testing in Birmingham, Ala. prenatal clinic showed that HIV testing increased from 75% to 88% after opt-out testing was implemented in August 1999. At the Denver Health Medical Center, 98.2% of women who delivered received HIV testing between 1998 and 2001, using opt-out testing.
For updated information about state laws in your area, please see the Compendium of State HIV Testing Laws.
Which Approach Does CDC Recommend?
In the 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Womenin Health-Care Settings, CDC recommended the opt-out approach to testing for all adult and adolescent patients in health-care settings, including pregnant women.
These recommendations emphasize:

• Universal “opt-out” HIV testing for all pregnant women early in every pregnancy;
• A second test in the third trimester in certain geographic areas or for women who are known to be at high risk of becoming infected (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy);
• Rapid HIV testing at labor and delivery for women without a prenatal test result; and
• Exploration of reasons that women decline testing.

Studies show that the opt-out approach can:

• Increase testing rates among pregnant women; thereby, increasing the number of pregnant women who know their HIV status;
• Increase the number of HIV-infected women who are offered treatment; and
• Reduce HIV transmission to their babies.

How is Opt-Out Implemented in the Health Care Setting?
Opt-out has three steps for health-care providers to follow to put this approach into practice (CDC recommends all three steps):

• Tell all pregnant women that an HIV test will be performed as part of the standard group of tests for pregnant women.
• Tell all pregnant women that they may decline this test.
• Give all pregnant women information about how to prevent HIV transmission during pregnancy and provide information about treatment for pregnant women who are HIV-positive.

Additional Information
For more detailed information on the Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings, please refer to the Morbidity and Mortality Weekly Report (MMWR) of September 22, 2006, or request a copy from the National Prevention Information Network at (800) 458-5231 or online