The national Perinatal HIV Hotline has fielded hundreds of calls for advice over the past 2 years. Its directors anticipate getting much busier as more labor and delivery services begin offering rapid HIV testing.
There's no nationwide mandate for universal prenatal HIV testing, but it's very strongly recommended by the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Institutes of Medicine.
“The burden is on the provider to offer it. I can tell you that there are plenty of providers who still do not offer routine HIV testing, even though it's been found to be cost effective,” said Dr. Deborah Cohan, an obstetrician at San Francisco General Hospital and codirector of the hotline. “We know that only offering HIV testing to so-called high-risk patients misses a lot of HIV-infected women.”
In 2000, more than a third of HIV-positive neonates in the United States were born to women who did not know their HIV status until after delivery. “That's totally unacceptable,” she said.
Ideally, every pregnant woman would get prenatal care including HIV testing. At her institution, though, 12% of women in labor have had no prenatal care, making rapid HIV testing the last resort for HIV management before delivery. Dr. Cohan looks forward to more clinicians offering rapid HIV testing and calling the Perinatal HIV Hotline for help in interpreting the result or making management decisions.
Officially called the National Perinatal HIV Consultation and Referral Service, the hotline started taking calls on Labor Day of 2004. Staffers provide free advice and assistance to clinicians every day of the year and around the clock, because labor can happen at any hour.
The requests for help come from a variety of specialties, including the following:
▸ A family physician facing her first HIV-positive pregnant patient needed assurance about her treatment plan.
▸ An urban obstetrician sought help in finding the best program to care for a monolingual Spanish-speaking patient who was pregnant and HIV positive.
▸ A rural midwife and the obstetrician with whom she practices hoped to comanage an HIV-positive pregnant patient with an HIV specialist but didn't know where to find a specialist in their area.
▸ A nurse wanted help in planning a training session for rural pediatricians on the care of newborns exposed to HIV.
The hotline handles around 30 calls per month but is capable of handling four or five times as many, said Dr. Jessica Fogler, a family physician at San Francisco General Hospital and codirector of the hotline.
“I think our numbers will pick up when rapid testing becomes more available,” she added. “A lot of people who are inexperienced are going to be sitting there with a positive test on their hands.”
The U.S. Health Resources and Services Administration's National HIV/AIDS Clinicians' Consultation Center at the hospital runs the Perinatal HIV Hotline and two other telephone help lines for clinicians managing nonpregnant patients with HIV or health care workers who are exposed to HIV or hepatitis B or C.
More than half of calls to the Perinatal HIV Hotline relate to prepartum pregnant women and are fairly evenly divided among the trimesters, records from a 15-month period suggest. Around 5% of calls involve women in labor. Advice includes counseling on HIV treatment of the neonate and postpartum maternal HIV treatment. The hotline also offers advice related to contraception or preconception counseling for HIV-positive women or for HIV-negative women whose sexual partners have HIV.
More than half of callers have MD or DO degrees and are almost evenly represented by obstetricians, family physicians, and infectious disease specialists. Internists, pediatricians, and nurses each make up about 8%–13% of callers.
The hotline's referral service, run by social worker Shannon Weber, maintains a list of clinicians in every state with experience managing HIV who are willing to accept or to comanage infected pregnant patients.
One patient, for example, had started antiretroviral therapy in her third trimester and developed an abacavir hypersensitivity reaction, prompting her health care provider to call for advice. Hotline staffers recommended stopping the medication.
The patient decided at week 34 of pregnancy to move from California to Atlanta. The hotline's referral service helped find her a new doctor there and facilitated communications before the woman got on the bus to move. “She's getting good care,” Ms. Weber said.
More and more calls to the hotline concern women who have been heavily pretreated with antiretroviral medications and now have multidrug-resistant HIV. These patients are “quite complex to manage in pregnancy,” Dr. Cohan said.