Reducing the Odds Preventing Perinatal Transmission of HIV in the United States (1999) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-14
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A reduction of this magnitude in only a few years certainly represents great progress, yet it is far less than the ACTG 076 findings can offer. Two years after the publication of the ACTG 076 findings, Congress addressed perinatal transmission issues in the Ryan White Comprehensive AIDS Resources Emergency (CARE)
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to "conduct an evaluation of the extent to which State efforts have been effective in reducing the perinatal transmission of the human immunodeficiency virus, and an analysis of the existing barriers to the further reduction in such transmission." In its analysis, the committee has found it helpful to consider a chain of factors affecting perinatal transmission, as illustrated in Figure 1. PUBLIC HEALTH SCREENING PROGRAMS Disease screening is one of the most basic tools of modern public health and preventive medicine.
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Such data on perinatal AIDS cases reflect the number of children born with HIV infection in previous years, and more recent data are not available because of reporting delays. Changes in the number of perinatal AIDS cases, therefore, are not direct estimates of the impact of prevention activities on perinatal transmission of HIV.
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In terms of preventing perinatal transmission, newborn HIV testing has fewer benefits than maternal testing. When maternal serostatus is unknown, however, newborn HIV testing permits early identification and evaluation of exposed infants, allows for initiation of Pneumocystis carinii pneumonia (PCP)
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The complex patterns of medical care, financing mechanisms, program authority, and organizations that influence care make it difficult to institute uniform policies for reducing perinatal HIV transmission. In addition, the multiple lines of funding responsibility and accountability have made it extremely difficult to educate providers and convince them of the necessity of testing all pregnant women, as called for in the PHS counseling and testing guidelines (CDC, 1995b)
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RECOMMENDATIONS Universal HIV Testing, with Patient Notification, as a Routine Component of Prenatal Care To meet the goal that all pregnant women be tested for HIV as early in pregnancy as possible, and those who are positive remain in care so that they can receive optimal treatment for themselves and their children, the committee's central recommendation is for the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care. There are two key elements to the committee's recommendation.
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The committee believes it is also important that these approaches be evaluated carefully, and that successful models be disseminated widely in the professional community. Education of Prenatal Care Providers One way to achieve the goal of universal HIV testing in prenatal care is for federal, state, and local health agencies, professional organizations, regional perinatal HIV research and treatment centers, AIDS Health Education Centers, and health plans to increase efforts to educate prenatal care providers about the value of testing in pregnancy.
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Performance Measures and Contract Language Health care plans and providers increasingly are being held accountable for the services they provide through performance indicators in such areas as cost, quality of care, and patient satisfaction. In order to take advantage of this approach, The committee recommends that health care plans and providers adopt performance measures for a policy of universal HIV testing, with patient notification, as a routine component of prenatal care.
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Thus, The committee recommends efforts to improve coordination of care and access to high-quality HIV interventions and treatment for HIVpositive pregnant women. Without linkage to specialty care for HIV-positive women, the committee's recommended policy of universal HIV testing, with patient notification, as a routine component of prenatal care would violate one of the fundamental criteria for public health screening programs, that is, there should be adequate facilities for diagnosis and resources for treatment for all who are found to have the condition, as well as agreement as to who will treat them.
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Doing so now would go a long way toward building the infrastructure needed to lower perinatal transmission rates. As discussed in Chapter 1, The Ryan White CARE Act Amendments of 1996 set up a decision-making process that could result in states losing significant amounts of AIDS funding unless they demonstrate substantial increases in prenatal HIV testing or a substantial decrease in HIV transmission rates, or institute mandatory newborn testing.
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Thus, in order to support the previous recommendation about performance measures, and to generally guide prevention efforts, The committee recommends that federal, state, and local public health agencies maintain appropriate surveillance data on HIV-infected women and children as an essential component of national efforts to prevent perinatal transmission of HIV. The universal testing approach that the committee recommends, as well as the call for health plan performance measures, should facilitate the development of appropriate public health surveillance systems.
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Increasing Utilization of Prenatal Care Roughly 15% of HIV-infected pregnant women, many of whom are drug users, receive no prenatal care. Efforts to increase the proportion of women, especially drug users, who receive prenatal care should therefore be a high prior
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Many interventions could be introduced in correctional settings either for primary prevention of HIV transmission or, particularly, for prevention of perinatal transmission among HIV-infected pregnant women. Interventions should focus on HIV testing and treatment, drug testing and treatment, prenatal care, and efforts to ensure continuity of care for HIV-positive patients who leave the correctional setting.
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interventions to overcome pregnant women's concerns about HIV testing and treatment; (6) and efforts to increase utilization of prenatal care, as described above.
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