Since 1995 the Centers for Disease Control and Prevention (CDC) has recommended that all pregnant women be tested for HIV using the opt-out approach and if found to be infected, offered treatment for themselves and to prevent passing HIV to their infants. In October 1996, Florida responded to this recommendation by mandating (Florida Statute-s.384.31) that health care providers counsel and offer HIV testing to all pregnant women at the initial prenatal care visit and again at 28 to 32 weeks gestation (Florida Administrative Code-Ch.64-D3.019). The passage of this legislation did not include opt-out testing.

The counseling and consent process presented a barrier to testing leading to missed opportunities to prevent mother-to-infant infection. Florida law was reviewed and revised resulting in changes that have had a significant impact on how HIV and STD testing is conducted. Florida Administrative Code (F.A.C.) 64D.3.042 HIV/STD Testing Related to Pregnancy took effect on November 20, 2006. As a result of this legislation Florida moved from opt-in to opt-out HIV/STD testing in pregnancy.

The law requires that all healthcare providers attending pregnant women include HIV, Chlamydia, hepatitis B, gonorrhea and syphilis screening as a routine part of prenatal care. Women must be informed that these tests will be conducted and that they have the right to refuse any or all of them. Unlike the testing guidelines using the opt-in approach, pre-test counseling and a signed consent to test is not required. In both the in and out-patient setting, the standard consent to treat is considered consent to test. If a woman declines any or all of the tests, a signed statement of objection should be obtained. If she refuses or is unable to sign, the provider must document her refusal in the medical record.

Florida law also requires that hospitals and providers conduct routine HIV and STD testing of all women who appear at delivery or within 30 days postpartum without a record of testing after 27 weeks gestation. Coupled with the CDC’s long standing recommendation and the availability of multiple, low cost rapid tests that provide accurate and timely results, rapid testing in labor and delivery units will allow HIV positive women immediate access to treatment, further reducing the risk of transmission.

Women who are treated in the emergency department and are more than 12 weeks pregnant who have not been tested for HIV/STD must be referred in writing to a county health department for testing. The emergency department is required to send a copy of the referral to the health department. Health departments are required to have a policy in place to test and follow these referrals. If a woman does not follow-up, the opportunity to treat can be significantly delayed and the risk of transmission will increase. These missed opportunities highlight the importance of rapid testing in all labor and delivery units in Florida.

It is never too late to intervene and treat an HIV positive pregnant woman to prevent transmission. Based on the findings of several studies, including a large retrospective study of HIV exposed infants in the state of New York1, we know that even in cases where mothers are diagnosed just after delivery, immediate initiation of zidovudine to the infant in the first 24 hours of life can significantly decrease transmission rates.

This makes the data collected from the Mother Infant Rapid Intervention At Delivery (MIRIAD) study2 even more significant. The MIRIAD study determined the feasibility of testing women with an undocumented HIV status at delivery. The findings clearly indicate that testing in labor and delivery is not only possible, but can be successful in capturing positive women and preventing transmission.

Florida law is specific on HIV/STD Testing in Pregnancy making the goal of educating, identifying and treating all HIV positive women early in pregnancy attainable. With rapid testing, we have the knowledge and the tools to identify women with limited or no prenatal care before it is too late. Reducing mother-to-child transmission is one of the most significant HIV prevention success stories. In Florida, the first infected babies were born in 1978; by 1993, nearly 30% of the infants born to HIV-infected mothers were infected. Today, the transmission rate is less than 2%. Still, we continue to see new infant infections. This map clearly shows there is still work to be done.

1 Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus. N Engl J Med, 1998. 339(20):1409-14.

2 Bulterys M, Jamieson DJ, O’Sullivan MJ, et al. Rapid HIV-1 testing during labor: a multicenter study. JAMA, 2004. 292(2):219-23.