Pai Nitika Pant, Barick Ritu, Tulsky Jacqueline P, Shivkumar Poonam V, Cohan Deborah, Kalantri Shriprakash, Pai Madhukar, Klein Marina B, Chhabra Shakuntala
Division of Infectious Diseases and Immunodeficiency Service, Montreal Chest Institute, McGill University Health Center, Montreal, Canada.
PLoS Med. 2008 May 6;5(5):e92. doi: 10.1371/journal.pmed.0050092.
Testing pregnant women for HIV at the time of labor and delivery is the last opportunity for prevention of mother-to-child HIV transmission (PMTCT) measures, particularly in settings where women do not receive adequate antenatal care. However, HIV testing and counseling of pregnant women in labor is a challenge, especially in resource-constrained settings. In India, many rural women present for delivery without any prior antenatal care. Those who do get antenatal care are not always tested for HIV, because of deficiencies in the provision of HIV testing and counseling services. In this context, we investigated the impact of introducing round-the-clock, rapid, point-of-care HIV testing and counseling in a busy labor ward at a tertiary care hospital in rural India.
After they provided written informed consent, women admitted to the labor ward of a rural teaching hospital in India were offered two rapid tests on oral fluid and finger-stick specimens (OraQuick Rapid HIV-1/HIV-2 tests, OraSure Technologies). Simultaneously, venous blood was drawn for conventional HIV ELISA testing. Western blot tests were performed for confirmatory testing if women were positive by both rapid tests and dual ELISA, or where test results were discordant. Round-the-clock (24 h, 7 d/wk) abbreviated prepartum and extended postpartum counseling sessions were offered as part of the testing strategy. HIV-positive women were administered PMTCT interventions. Of 1,252 eligible women (age range 18 y to 38 y) approached for consent over a 9 mo period in 2006, 1,222 (98%) accepted HIV testing in the labor ward. Of these, 1,003 (82%) women presented with either no reports or incomplete reports of prior HIV testing results at the time of admission to the labor ward. Of 1,222 women, 15 were diagnosed as HIV-positive (on the basis of two rapid tests, dual ELISA and Western blot), yielding a seroprevalence of 1.23% (95% confidence interval [CI] 0.61%-1.8%). Of the 15 HIV test-positive women, four (27%) had presented with reported HIV status, and 11 (73%) new cases of HIV infection were detected due to rapid testing in the labor room. Thus, 11 HIV-positive women received PMTCT interventions on account of round-the-clock rapid HIV testing and counseling in the labor room. While both OraQuick tests (oral and finger-stick) were 100% specific, one false-negative result was documented (with both oral fluid and finger-stick specimens). Of the 15 HIV-infected women who delivered, 13 infants were HIV seronegative at birth and at 1 and 4 mo after delivery; two HIV-positive infants died within a month of delivery.
In a busy rural labor ward setting in India, we demonstrated that it is feasible to introduce a program of round-the-clock rapid HIV testing, including prepartum and extended postpartum counseling sessions. Our data suggest that the availability of round-the-clock rapid HIV testing resulted in successful documentation of HIV serostatus in a large proportion (82%) of rural women who were unaware of their HIV status when admitted to the labor room. In addition, 11 (73%) of a total of 15 HIV-positive women received PMTCT interventions because of round-the-clock rapid testing in the labor ward. These findings are relevant for PMTCT programs in developing countries.
在分娩时对孕妇进行HIV检测是预防母婴传播（PMTCT）措施的最后机会，尤其是在妇女未接受充分产前护理的情况下。然而，对临产孕妇进行HIV检测和咨询是一项挑战，特别是在资源有限的环境中。在印度，许多农村妇女在没有任何产前护理的情况下前来分娩。那些接受产前护理的妇女也并非总是接受HIV检测，这是因为HIV检测和咨询服务存在缺陷。在此背景下，我们在印度农村一家三级护理医院繁忙的产房引入了全天候、快速、即时护理HIV检测和咨询，并调查了其影响。
在提供书面知情同意书后，入住印度一家农村教学医院产房的妇女接受了两次针对口腔液和指尖血标本的快速检测（奥然快速HIV-1/HIV-2检测，奥然科技公司）。同时，采集静脉血进行常规HIV ELISA检测。如果妇女通过两种快速检测和双重ELISA检测均呈阳性，或者检测结果不一致，则进行免疫印迹检测以进行确认性检测。作为检测策略的一部分，提供全天候（每周7天，每天24小时）的简短产前和延长产后咨询服务。对HIV阳性妇女实施PMTCT干预措施。在2006年9个月期间，有1252名符合条件的妇女（年龄范围18岁至38岁）被邀请签署同意书，其中1222名（98%）在产房接受了HIV检测。在这些妇女中，1003名（82%）在入住产房时没有既往HIV检测结果报告或报告不完整。在1222名妇女中，15名被诊断为HIV阳性（基于两种快速检测、双重ELISA和免疫印迹检测），血清阳性率为1.23%（95%置信区间[CI] 0.61%-1.8%）。在15名HIV检测呈阳性的妇女中，4名（27%）有报告的HIV感染状况，11名（73%）新的HIV感染病例是由于产房的快速检测而被发现。因此，11名HIV阳性妇女因产房的全天候快速HIV检测和咨询而接受了PMTCT干预措施。虽然两种奥然检测（口腔和指尖）的特异性均为100%，但记录到1例假阴性结果（口腔液和指尖血标本均为阴性）。在15名分娩的HIV感染妇女中，13名婴儿在出生时以及出生后1个月和4个月时HIV血清学检测呈阴性；2名HIV阳性婴儿在出生后1个月内死亡。
在印度农村繁忙的产房环境中，我们证明引入包括产前和延长产后咨询服务的全天候快速HIV检测项目是可行的。我们的数据表明，全天候快速HIV检测的可用性使得很大一部分（82%）入住产房时不知道自己HIV感染状况的农村妇女成功记录了HIV血清学状态。此外，在总共15名HIV阳性妇女中，11名（73%）因产房的全天候快速检测而接受了PMTCT干预措施。这些发现与发展中国家的PMTCT项目相关。
