Dr. Ronald Valdiserri
During this week’s observance of National Women’s Health Week, I want to highlight some important new guidelines for physicians and other healthcare providers that will help expand and improve HIV screening and prevention services for women in the United States.
ACOG’s HIV Expert Work Group Releases Committee Opinions on HIV in Women
Last month, the American College of Obstetricians and Gynecologists (ACOG) released two Committee Opinions on HIV in women: one lowering the recommended age for HIV screening, and one addressing prevention of HIV transmission through pre-exposure prophylaxis (PrEP). Representing the considered views of the sponsoring committee based on interpretation of published data in peer-reviewed journals, these two Committee Opinions were developed with the assistance of ACOG’s HIV Expert Work Group and reflect emerging clinical and scientific advances in HIV prevention for women.
Lowering the Recommended Age for HIV Screening
Previous ACOG guidelines recommended that HIV testing for women begin at age 19. The College’s updated Committee Opinion, “Routine Human Immunodeficiency Virus Screening,” now mirrors the Centers for Disease Control and Preventionâs (CDC) recommendation that all females ages 13 to 64 be tested for HIV at least once in their lifetime and annually thereafter based on factors related to risk. Additionally, new opinion recommends that ob-gyne doctors annually review their patients’ risk factors for HIV and assess their need for testing, and that women found to be HIV-positive receive or be referred for appropriate clinical and supportive care.
The updated Committee Opinion is an important step toward achieving the goals of the National HIV/AIDS Strategy, which calls upon us to identify everyone in the United States who is infected with HIV so that we can get them into care. In the United States, there are approximately 200,000 people who are living with HIV who haven’t been diagnosed and are thus unable to take advantage of life-extending HIV care. Obstetricians and gynecologists provide primary and preventive care to their patients, and are often the only healthcare professionals that women see regularly. Thus, they are ideally suited to play an important role in identifying women who are HIV positive and linking them into HIV care as soon as possible.
Addressing HIV Prevention through PrEP
ACOG’s second Committee Opinion, âPre-exposure Prophylaxis for the Prevention of Human Immunodeficiency Virus,â addresses the use of PrEP in combination with other proven HIV prevention methods as a useful HIV prevention strategy for women at the highest risk for becoming infected with HIV. PrEP, the once-daily dose of antiretroviral medications to HIV-negative individuals who are at very high risk of becoming infected, has been proven to be an effective biomedical intervention for reducing the risk of HIV acquisition among adult men and women at very high risk for HIV infection through sex or injecting drug use. The CDC has recommended PrEP for adults at high risk of HIV infection and for people who use injection drugs as part of a comprehensive HIV-prevention strategy.
ACOG’s new Committee Opinion states that potential candidates for PrEP are HIV-negative women who have a male sexual partner who is HIV positive and/or women who engage in sexual activity within a high HIV-prevalence area or social network, and who have one or more of the following risk factors:
- Inconsistent or no condom use;
- Diagnosis of sexually transmitted infections;
- Engagement in transactional sex (i.e, sex for money, drugs, or other forms of payment);
- Use of intravenous drugs or alcohol dependence or both; and/or
- Partners of unknown HIV status with any of the factors previously listed.
The Committee Opinion also recommends that ob-gyn doctors involved in the care of women using PrEP reinforce the importance of adhering to the daily anti-viral medication regimen and that physicians remain aware of new developments in this area as guidance for PrEP is likely to evolve in the coming years. Indeed, the U.S. Public Health Service guidelines on PrEP are expected to be released later this summer.
Quality Family Planning Services Recommended by CDC and HHS Office of Population Affairs
Also noteworthy, last month, CDC and the HHS Office of Population Affairs released updated, evidence-informed guidelines for the delivery of family planning services. The guidelines, Providing Quality Family Planning Services: Recommendations from the Centers for Disease Control and Prevention and the US Office of Population Affairs, were published as a CDC MMWR Recommendations and Reports . The primary audience for this report is all current or potential providers of family planning services, including those working in service sites that are dedicated to family planning service delivery, such as those funded by the Title X program, as well as private and public providers of more comprehensive primary care. The recommendations outline how to provide quality family planning services, which include contraceptive services, pregnancy testing and counseling, helping clients achieve pregnancy, basic infertility services, preconception health services, and sexually transmitted disease services.
The family planning guidelines integrate clinical recommendations from a number of federal sources and professional medical associations and include important HIV, STD (sexually transmitted diseases) and viral hepatitis recommendations. Specifically, the updated family planning guidelines recommend that providers conduct routine, opt-out HIV screening for both male and female clients, in accordance with CDC’s HIV testing guidelines. They also recommend that when counseling clients about contraceptive methods, providers should address the importance of consistent and correct condom use in providing protection from STDs, including HIV.
The guidelines also incorporate important viral hepatitis prevention and screening recommendations for providers. Vaccination for hepatitis B is included among the STD services and preconception care detailed in the new guidelines. CDC and OPA recommend that hepatitis B vaccination should be offered to all unvaccinated children and adolescents under 19 years old and all adults who are unvaccinated and do not have any documented history of hepatitis B infection. In addition, the new family planning recommendations incorporate the CDC and USPSTF recommendations for screening persons at high risk for infection for hepatitis C and one-time screening for HCV infection for persons in the 1945–1965 birth cohort.
These new guidelines, coupled with the Affordable Care Act’s expanded coverage for clinical preventive services – which includes coverage for HIV screening for sexually active women as well as hepatitis B screening for pregnant women at their first prenatal visit – will help realize the promise of the National HIV/AIDS Strategy for women in the United States.