<i>HUGHES ET AL. RESPOND</i>

Siemieniuk et al. reported their experience with routine opt-out HIV screening in Southern Alberta, Canada, and the limitations of this approach. While we believe that routine opt-out testing has been a critical factor in reducing mother to child transmission (MTCT) of HIV in our region, we acknowledge that this approach does not eliminate the risk. Over the past 5 years (2004 to 2008 inclusive), approximately 3.5% of women have opted out of HIV prenatal testing in Alberta. Opportunities to prevent MTCT may be missed in women who decline testing. In addition, women may not seek prenatal care, as was the case for the single infant who was perinatally infected with HIV in our study. Following the completion of our study in February 2006, we have had 2 additional cases of MTCT in Northern Alberta. In the first case, a woman originally from an HIV endemic country who had been living in Europe for several years arrived in Canada near the term of her pregnancy. She was assumed to have negative prenatal serology (records were in a foreign language) and was not tested by her obstetrician. She developed Pneumocystis jiroveci pneumonia 7 months postpartum and she and her infant proved to be HIV positive. In the second case, an Aboriginal woman with no other risk factors requested testing 6 weeks postpartum, as she suspected her partner had recently acquired HIV; both she and her infant were found to be HIV positive. An HIV test that had been performed during the second trimester of her pregnancy was negative. The cases presented by Siemieniuk et al., in addition to our own experience, confirm that further strategies to eliminate MTCT are needed. As recommended by the United States Centers for Disease Control and Prevention, strategies to further reduce the incidence of MTCT may include a second HIV test in the third trimester, either in all women or in identified high-risk groups. In addition, rapid HIV testing during labor is recommended for women with undocumented HIV status.1 The acceptability and feasibility of rapid HIV testing during labor has been demonstrated in a multicenter trial.2 We believe that approaches to eliminating MTCT should include development of more accessible, acceptable, and flexible antenatal services, including HIV testing for disadvantaged populations, to reduce the number of women not receiving prenatal care. In noncompliant pregnant women, minimizing the risk of MTCT will continue to require a flexible, multidisciplinary, and inevitably labor-intensive individualized response.

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