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ORIGINAL CONTRIBUTIONS

Received: August 28^th 2014

Accepted: December 19^th 2014

HIV screening through rapid testing to pregnant women in the Unidad de Medicina Familiar 171

Gustavo Figueroa-Hernández,^a Lizbeth Carlota Uriostegui-Espíritu,^a Edna Gabriela Delgado-Quiñones^a

^aUnidad de Medicina Familiar 171, Instituto Mexicano del Seguro Social, Zapopan Jalisco, México

Communication with: Lizbeth Carlota Uriostegui-Espíritu

Thelephone: (33) 36329608, extensión 31485

Email: lizzuriostegui@gmail.com

Background: Coverage for HIV in our country through the rapid test has increased, from 8.2 % in 2006 to 59.8 % in 2012; however, it is still insufficient. The objective is to determine the prevalence of HIV screening through rapid testing to pregnant women in the Unidad de Medicina Familiar (UMF) 171.

Methods: It was carried out a descriptive cross-sectional study with non-probability sampling that included pregnant women of any age who came to birth control in the UMF 171 of the Instituto Mexicano del Seguro Social. Review of medical records was applied as a tool to gather information on the rapid test. A sample of 85 patients was calculated and descriptive statistical analysis was performed.

Results: 85 patient records were reviewed in control pregnancy. Rapid testing for detection of antibodies to HIV was performed in 79 patients (93 %). In nine (10 %) of the patients who underwent the test, the result was not reported in their file. In six patients (7 %) of the total sample the rapid test was not requested or performed. The result of all rapid tests reported was HIV negative.

Conclusions: There is an increase in the coverage of rapid HIV testing in pregnant women; however, not reporting and not requesting the test are still common problems in the early detection of HIV infection in pregnant women.

Keywords: IDS serodiagnosis; HIV; Pregnancy

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The UNAIDS report for World AIDS Day 2012 reported that the global outlook of those infected with human immunodeficiency virus (HIV) was 34 million, approximately 50% of whom know their HIV status. In the same year, 2.5 million new HIV infections were detected, and the number of AIDS-related deaths that year was 1.7 million. There are 14,800,000 people worldwide eligible for antiretroviral treatment, of whom only eight million people are on treatment. Women infected with HIV globally now represent half of the population with the disease, i.e. approximately 20 million. Many of these infected women who become pregnant can transmit the virus to their children, either during pregnancy, at birth, or during breastfeeding. Currently, it is estimated that 2.3 million children under 15 worldwide are living with HIV, and more than 90% of them acquired the virus by vertical transmission.¹

In Mexico, the Summary of Epidemiological Surveillance of the National Registry of AIDS Cases 2013 (Resumen de Vigilancia Epidemiológica del Registro Nacional de Casos de SIDA 2013) mentions an estimated 170,000 people living with HIV in Mexico. With an estimated prevalence of 0.24% in the population 15 to 49 years of age, reported cases by sex from 1983 to 2013 correspond to 136,570 (82.1%) for males and 29,800 (17.9%) for females.²

In Mexico the cumulative cases of perinatal transmission from 1983 to 2013 were 2418, with a 0.7% transmission rate for 2013 compared with 3% in 2002. The state of Jalisco has a total of 1385 cases registered as HIV seropositive, which corresponds to 2.9% of total cases nationwide. Of these cases, 1038 correspond to males and 347 correspond to females.²

It is estimated that in this country 4.2 million pregnancies occur per year and 60% of these reach the end of gestation. Sentinel surveys in pregnant women from 12 states of the Mexican Republic made it possible to estimate a cumulative prevalence of 0.04% and in recent years 0.1%, which shows the possibility that 10 out of every 10,000 pregnant women with living children are infected with HIV. Considering the fertility rate in Mexico, it is estimated that there are between 1136 and 6531 pregnant women infected with HIV.³

The trend of the feminization of the AIDS epidemic has become evident worldwide. The growing presence of the epidemic in the female population is worrying due to the repercussions for the health of women and because most who acquire HIV are of childbearing age, have high chances of becoming pregnant, and if not detected and treated in a timely manner they present a high risk of transmitting the virus to their children. The main route of HIV transmission in the population under 18 years is perinatal, with seven out of 10 cases.⁴

There is an urgent need for rapid, sensitive, and specific procedures to carry out epidemiological surveys and accurate diagnoses without requiring the support of a specialized laboratory, and samples that do not require invasive procedures. The use of rapid tests (RT) in whole blood collected by fingerstick has shown comparable results in sensitivity (99%) and specificity (99%) to those obtained in serum samples, and they are as simple as the tests used to measure glucose levels.^3,5

In 2009 Mexico's public health sector proposed the goal for 2012 that 100% of pregnant women should take at least one HIV test during antenatal care. Petroleos Mexicanos (PEMEX) is the only institution that reports having given at least one HIV test to all pregnant women (100%) given prenatal care from 2006 to 2012. The Secretaría de Marina is the public health sector entity showing the most progress in increasing the HIV testing coverage in pregnant women, as its detections have increased up to 85.2%, followed by the Secretaría de Salud with 78.2% through 2012. The Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) has slightly increased the number of HIV testing in pregnant women, without it changing their coverage levels, which are less than 1%. For its part, the Secretaría de la Defensa Nacional increased coverage by almost 10 percentage points, reaching almost 40% in 2009; however, in 2012 it decreased to 27.2%. The Instituto Mexicano del Seguro Social (IMSS) has shown a significant increase, as in 2006 only 0.9% performed timely detection in their pregnant patients and in 2009 it managed to increase this to 9.6%; in 2012, the institute reported 39.1% timely detection in this group nationwide. HIV detection coverage in the country has increased, from 8.2% in 2006 to 59.8% in 2012. In 2006 approximately 150,000 HIV tests were performed in pregnant women in the public health sector; 949,625 were done in 2009. In 2012 1,815,383 pregnant women were treated in public institutions throughout the country, of which 1,085,861 received the rapid test for HIV screening, which is approximately 59.8%.⁶

Important data reported in the Bulletin No. 10 of the Grupo de Información Sectorial en VIH/SIDA in December 2012 updated in 2013 indicated that nationwide 531 HIV cases were detected in pregnant women in public institutions. In the IMSS bulletin 55 cases were detected only in 2012; in addition, the institute reported only four cases of AIDS from vertical transmission during the same year, compared to 20 cases in 2006 among their enrollees. IMSS has registered 48 pregnant patients on antiretroviral treatment nationwide, of which 62.5% had an undetectable viral load through 2012.⁶

In most cases, patients present with diagnosis and treatment to referral hospitals to receive prenatal care in the public sector; there is, however, an unprotected group: pregnant women who, lacking any apparent risk, do not get any screening tests, and to whom the private gynecologist does not suggest it, so they miss the opportunity for HIV detection.⁷

The application of the rapid test at the first level of care is important for all pregnant women, so the proper training of health professionals in the assessment and application of these tests is essential to ensure that these are accepted in 100% of pregnant women, as health care providers can speed up early HIV diagnosis and contribute to the improvement of individual and public health in Mexico.⁸

The possibility of a pregnant woman carrying HIV transmitting the virus to the child is between 25 and 45%. Since the results of the ACTG 076 protocol in 1994, which demonstrated that prophylaxis with Zidovudine (AZT) for pregnant women and women living with HIV reduced the likelihood of infecting the infant up to 67%, the use of preventive antiretroviral therapy has been widespread. The use of AZT and elective Caesarean section are independent but complementary factors for the decrease in perinatal HIV transmission. With both, the possibility of vertical transmission is decreased to 2%.⁹

There is a variety of rapid HIV detection tests in the world. In the United States there are currently four kits for rapid determination of HIV antibodies approved by the Food and Drug Administration (FDA). There are highly versatile rapid tests in our country, because they can be used interchangeably in whole blood samples, saliva, serum, or plasma with a sensitivity and specificity of 100%. In our environment rapid tests for detecting HIV-1 antibodies by fingerstick are used; their interpretation is visual and does not require special tools; they can even be used at the place of care with a sensitivity and specificity of 99%.¹⁰

With the variety of rapid tests, there are doubts about the sensitivity and specificity of them, so many studies have been conducted to assess their effectiveness, with varied results; however, most concluded that they are a reliable method.^9,11

A 2012 study sought to determine the presence of human immunodeficiency virus type 2 (HIV-2) in the Mexican population through rapid testing, and demonstrated that they are not a useful tool to determine the presence of HIV-2 antibodies in serum, as they have a low negative predictive value (51.7%). It concluded with unreliable results, as recommended by the "Guide to the implementation of the rapid test" from CENSIDA and NOM-003-SSA2-2012.¹²

A 2009 descriptive cross-sectional study conducted in Brazil found rapid HIV test coverage during pregnancy at 89.7, and related studies showed an estimated 63% and 78.3% national coverage, which concluded with 77% countrywide. These data show that Brazil has greater coverage in this area compared to Mexico, which has a national coverage of 59.8%.¹³

A 2009 clinical trial in South Africa mentioned that WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommend that rapid HIV tests should have a sensitivity of at least 99% and a specificity of 98%.¹⁴

All HIV detection regardless of the reagent type used must comply with the guidelines established in the Norma Oficial Mexicana NOM-010-SSA2-1993 for the Prevention and Control of Infection with Human Immunodeficiency Virus (HIV), which stipulates that the screening test should be governed by the principles of confidentiality and informed consent, and that the delivery of results "should be done individually by trained personnel".^15,16

Our health system uses the rapid fingerstick test, which has a sensitivity and specificity close to 100%, so we can continue using it to make early tests. However, there are failures in detecting recent infections, which can lead to bias in the incidence estimates in different populations.^17,18

As we know, the rapid HIV screening test for pregnant women is a fundamental tool in prenatal care because it helps us reduce the incidence of vertical transmission of this virus if caught early. The purpose of our study is to determine whether the rapid test for detecting antibodies to the human immunodeficiency virus is being performed in pregnant women in the first level of care, and to assess how we are taking preventive action in our environment, which is vitally important because the first contact with the pregnant woman is here.

Methods

A cross-sectional study was conducted with non-probability sampling that included pregnant women of any age who attended prenatal care in outpatient or with a maternal child nurse (MCN) in Unidad de Medicina Familiar 171 of IMSS. The sample size was calculated from the total population of pregnant patients in this unit. This population consisted of 1137 patients during 2013-2014. Epi Info statistical program, version 6 was used, and an average national rapid testing prevalence of 59.8% was used, with a 95% confidence level, so a total of 85 individuals were obtained.

After authorization by the local research committee, we proceeded to collect data from the paper and electronic medical records of pregnant women who attended prenatal care and who met the following inclusion criteria: female patients of any age determined to be pregnant, who came to the medical office or MCN at UMF 171 of the IMSS and were current enrollees in that unit, which is in Zapopan, Jalisco.

The necessary information was obtained, including age, marital status, occupation, education level, number of sexual partners, whether the patient had received a rapid test for the detection of HIV antibodies, in what trimester they had it, and what was the result. Once the information was collected, statistical analysis was done using SPSS, version 19. Frequencies and proportions were used for qualitative variables; mean, mode, and standard deviation for quantitative variables. 

Results

A cross-sectional study was made of records of pregnant patients attending prenatal care with their family doctor or the MCN service in the medical unit mentioned. The estimated sample consisted of 85 patients. There were no losses in the study. Sociodemographic characteristics identified were: age 17-44 years with average 26.98 and mode 23.00. The predominant marital status was married with 50%, followed by cohabiting with 20% (Table I). It was found that 60% were employed (Table II) with a high school education in 36.4% and secondary in 30.5% (Table III). Regarding the number of sexual partners, this was not specified in the clinical record in 100% of cases. The rapid test to detect HIV antibodies was made in 92.9% of pregnant women of this unit. The result of these tests was found positive in 0% and negative in 82.4%, because in 10.6% the test result was not specified in the clinical record (Table IV). This test was performed in the second trimester in 56.47% of cases, so early detection in the first trimester could only be made in 17.65% of cases (Figure 1).

Discussion

The growing presence of the epidemic in the female population is worrying due to repercussions for women’s health and because most of those who acquire HIV are of childbearing age with high chances of pregnancy. If not detected and treated early, they have a high risk of transmitting the virus to their children with a possibility of 25 to 45%.

The purpose of this study was to determine the prevalence of HIV detection by rapid testing for pregnant women in the unit mentioned. Since there is no statistical information for previous years of this or other family medicine units, comparison was made with national statistics, according to which there was a significant increase in this group of patients (92.9%) compared to the CONASIDA 2013 data, according to which in 2006 at the national level only in IMSS tests were given to 0.9%, in 2009 it increased to 9.6%, and 39.1% reported for 2012. In the same year in all public institutions in the country 59.8% of pregnant women received the rapid test for HIV detection. 

It is noteworthy that patients who did not receive the rapid test (7.1%) did not have the reason specified in their medical record. In such cases one imagines that the patient refused to receive this benefit for unknown reasons, or that there was a failure in the guidance and application of the test, because the rapid test should be offered to 100% of pregnant women.

The results obtained in our research surpass the data shown in the 2009 descriptive cross-sectional study by Espinosa et al. in Brazil, where the prevalence of rapid testing during pregnancy was 89.7% in that country.

According to the study by Vázquez in the Centro Médico Nacional Siglo XXI of the Instituto Mexicano del Seguro Social, in Mexico the age group with the highest rate of HIV infection is 15 to 44 years old; of these, 31.7% are between 20 and 29 years and it is this age group that gets the largest number of HIV tests. Coinciding with this author, we found that this age group is the one that gets the most timely detection in our unit, with an average of 26.9 years.

A cohort study conducted in 2008 by Covarrubias et al. states that illiterate mothers usually have physical, social, and access problems regarding health services, which result in an increased risk of sexually transmitted infections and reproductive risk. In comparison, our results demonstrate that high school education predominates with 36.5%, followed by secondary education with 30.6%, with no illiteracy found in our population, so the lack of rapid testing implementation in our group cannot be explained by this reason.

Among the results of this study we found that HIV testing is performed during the first trimester only in 17.6%, in the second trimester in 56.4%, and during the third trimester in 18.8%. These data are important because Vazquez et al. mention a low transmission rate (5%) during the second trimester of pregnancy, although transplacental transmission can occur early, since viruses have been detected in fetuses of 13-20 weeks. The IMSS Clinical Practice Guidelines on prevention, diagnosis, and treatment in the mother and child pair with HIV infection (246-12) mentions that the determination of antibodies against HIV through rapid testing should be part of prenatal care for all pregnant women, and it should be done as soon as possible during pregnancy, preferably during the first trimester; the guide also establishes that it should only be repeated in the third trimester when there are significant risk factors, some of which are omitted in the medical record in 100%, as shown by our study trying to identify the number of sexual partners in the group studied. In high-risk patients this test should be repeated preferably 12 weeks after a negative determination, and before 36 weeks of gestation.

The result is unspecified in 10.6% of rapid tests on pregnant women in the unit. In this sense it is very important to clarify that paragraph 6.6.2.1 of the amendment to the Norma Oficial Mexicana NOM 010-SSA2-1993 for the prevention and control of HIV infection states that all HIV or AIDS infection is subject to epidemiological surveillance and must be registered in all medical units of the public, social, and private sectors, through a clinical record, and must be notified immediately to the Secretaría de Salud. 

Conclusions

In Unidad de Medicina Familiar number 171 of IMSS, a significant increase in coverage of rapid HIV testing was found; however, non-reporting and non-application of the test remain common problems in the early detection of HIV infection in pregnant women.

These tests are most common during the second trimester of pregnancy, so steps must be taken to perform the rapid test from the first contact with the pregnant woman, preferably during the first trimester of pregnancy.

No positive results were identified in the sample group. The clinical record had no information on the number of sexual partners of the pregnant woman, a major risk factor that can affect testing intervals.

The proper training of health professionals in advising and implementing rapid tests is essential to gain its acceptance in 100% of pregnant women, as the primary care level should speed up the timely diagnosis of HIV and contribute to improving public health in Mexico.

Acknowledgments

This work was done thanks to support from staff of the various departments of Unidad de Medicina Familiar 171 IMSS, and the commitment and monitoring our thesis advisers and teachers.

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