Challenges preventing HIV, viral hepatitis, and syphilis during pregnancy

HIV challenges

Maternal diagnosis very late in pregnancy is the main challenge. Other challenges among pregnant women and mothers include poor retention in HIV care postpartum, unaddressed mental health and substance abuse problems, lack of family planning and preconception care services, and racial/ethnic disparities.

Screening

Women entering prenatal care late or who do not receive prenatal care are less likely to be screened. Providers who test on the basis of perceived risk, and who do not provide repeat HIV testing in elevated HIV incidence areas are less likely to diagnose infection early in pregnancy.

Access to and availability of treatment

Mental health and substance abuse problems, no or late HIV testing during pregnancy, and poor retention in HIV care postpartum affect access to and success of HIV care and treatment.

Knowledge

Providers or patients who are unaware of the patient’s HIV status, lack knowledge of the HIV status of partners of pregnant women, and have challenges with reporting and interpreting HIV test results can delay early diagnosis and access to treatment.

HBV infection challenges

Approximately half of the expected births to hepatitis B surface antigen (HBsAg)-positive women are identified, indicating not all HBsAg-positive pregnant women are identified and subsequently reported to perinatal hepatitis B coordinators at health departments. An important reason for under-identification of HBsAg-positive pregnant people is that test results may not include information identifying the person with an HBsAg-positive test as pregnant.

Screening

Providers or patients might believe women known to be chronically infected with HBV do not need to be tested during pregnancy. In addition, women with Medicaid and those residing in the northeastern United States have lower screening rates. However, testing during every pregnancy helps to ensure infants are identified for postexposure management. HBsAg-positive pregnant women should receive HBV DNA testing at 26-28 weeks if not on treatment.

Knowledge

Antiviral therapy during pregnancy for HBsAg-positive women is recommended by the American Association for the Study of Liver Diseases. This recommendation was based on published evidence revealing that maternal antiviral therapy during pregnancy further reduces perinatal HBV transmission.

HCV infection challenges

Increasing reported incidence of acute and chronic HCV infection among persons aged 20-39 years over the past decade affects the number of pregnant women with HCV infection and infants who are exposed to HCV at birth.1 CDC's recommendations to screen pregnant women for HCV infection during each pregnancy may aid practitioners in identifying HCV-infected mothers, which can lead to treatment for the mother during the postpartum period and identify infants who should receive testing at a pediatric visit. The risk of an HCV-infected mother transmitting infection to their infant is approximately 6% per pregnancy, but the risk is higher if the mother has a high viral load or is coinfected with HIV.2 There are currently no treatments approved for use in pregnancy to prevent transmission of HCV infection to infants.

Screening and perinatal testing

CDC recommends screening pregnant women during each pregnancy, and testing 1) all perinatally exposed infants ages 2–6 months for hepatitis C virus (HCV) with a nucleic acid test (NAT) for detection of ribonucleic acid (RNA); 2) all perinatally exposed infants and children aged 7–17 months who have not previously been tested should receive NAT RNA; and 3) all perinatally exposed children 18 months and older who have not previously been tested should receive an HCV antibody test with reflex to NAT for HCV RNA when antibody is reactive. Additionally, new parents and/or clinicians should consult a health care provider with expertise in pediatric hepatitis C management whenever an infant or child has detectable HCV RNA.

Access to and availability of treatment

No recommended curative treatments are FDA approved for pregnant women or young children (aged <3 years), but curative treatment is approved for older children (aged ≥3 years) and women who are not pregnant (which can be given before or after pregnancy).

Knowledge

More studies are needed on the safety and efficacy of curative HCV treatments for pregnant women and young children.

Syphilis challenges

Lack of prenatal care and gaps in testing and treatment among those who do receive prenatal care are significant challenges for preventing congenital syphilis.

Screening

Even among those receiving some prenatal care, the detection and treatment of maternal syphilis often occurs too late in pregnancy to prevent congenital syphilis. Health departments, in partnership with prenatal care providers and other local organizations, should work together to address barriers to obtaining early and adequate prenatal care for the most vulnerable pregnant women in their communities.

Access to and availability of treatment

Women who are uninsured or underinsured and women with substance use problems are likely to be at increased risk for receiving inadequate or no prenatal care, increasing the unborn babies’ risk for congenital syphilis.