Reducing the Odds Preventing Perinatal Transmission of HIV in the United States (1999) / Chapter Skim
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7 Recommendations
7 Recommendations
Pages 109-133
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From page 109... ...
The number of children born with HIV infection, however, continues to be far above what is potentially achievable, and the medical care that some HIV-infected women receive is, regrettably, substandard. To improve this situation, the committee recommends a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care, as detailed below.
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From page 110... ...
Under the proposed policy, women found to be HIV-positive would receive extensive counseling and be referred for treatment for themselves and to prevent perinatal transmission. For the small proportion of women who test positive, PHS counseling and testing guidelines suggest that post-test counseling include information about the clinical implications of a positive test result; the benefit of, and ways to obtain, HIV-related medical interventions and treatment; the interaction between pregnancy and HIV infection; the risk for perinatal HIV transmission and ways to reduce this risk; transmission to partners; and the prognosis for infants who become infected (CDC, 1995b)
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From page 111... ...
Rather, providers should not allow the requirements for pre-test HIV counseling to become a barrier to testing itself. Clinical policies to implement universal HIV testing, with patient notification, as a routine component of prenatal care, will have to be developed, as discussed below.
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From page 112... ...
Taken in the context of the cost of caring for an HIV-infected child,2 even though not all women found to be HIV-positive will benefit, these figures indicate the clear benefits of routine prenatal HIV testing. Second, universal screening is the only way to deal with possible geographic shifts in the epidemiology of perinatal transmission.
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From page 113... ...
As noted in Chapter 2 for screening programs in general, and in Chapter 6 for prenatal HIV testing, there is no evidence that making a program "mandatory," in and of itself, leads to more testing. Routine testing with patient notification thus is likely to be at least as or more effective in meeting public health goals, and less onerous.
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From page 114... ...
In particular, The committee recommends that health departments, professional organizations, medical specialty boards, regional perinatal HIV centers, and health plans increase their emphasis on education of prenatal care providers about the value of universal HIV testing and about avenues of referral for patients who test positive. Through its workshops and site visits, the committee found many examples of existing provider education programs initiated by state and local health departments and professional organizations.
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From page 115... ...
There is also a variety of specific clinical policies that facilitate HIV testing, such as inclusion of HIV tests in the standard prenatal test panel and no longer requiring counseling as a prerequisite for HIV testing. Clinical practice guidelines offer a means to facilitate HIV testing in the prenatal setting.
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From page 116... ...
In Southern California, prenatal HIV testing among pregnant Kaiser members rose from 55% to 85% between 1994 and 1997 (Pettiti, 1998~. A provider survey conducted in Massachusetts found the adoption of an HIV clinical practice policy to be the single most important predictor of the occurrence of HIV prenatal testing (Allen et al., unpublished)
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From page 117... ...
Another way to integrate public health goals and clinical practice is to develop contract language for managed care plans, especially those serving Medicaid populations. 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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From page 118... ...
In particular, The committee recommends that health care purchasers adopt con tract language supporting a policy of universal HIV testing, with patient notification, as a routine component of prenatal care. If universal HIV testing with patient notification is to become a routine component of prenatal care, contracts should not allow health insurers to deny benefits under "pre-existing conditions" or similar clauses based on the client's HIV status.
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From page 119... ...
First, HIV testing in pregnancy should be seamlessly linked to specialty care for HIV-infected women identified in the prenatal setting. Without linkage, 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, that is, there should be adequate facilities for diagnosis and resources for treat
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From page 120... ...
Some women reject HIV testing out of misplaced fears that a positive result is a "death sentence." These women would be more inclined to accept testing with the knowledge that perinatal transmission often can be prevented and that HIV infection no longer signals an imminent death. Immediate linkage to care is also important for patients who are in a state of fear, shock, depression, or denial after the diagnosis.
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From page 121... ...
Addressing Concerns about HIV Testing and Treatment While lack of prenatal care and not being offered a test are the primary reasons why women are not being tested for HIV, some proportion of women refuse testing when offered. To enhance acceptance of routine HIV prenatal testing, therefore, providers should understand the constellation of reasons why some pregnant women refuse HIV testing.
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From page 122... ...
Indeed, analyses have shown that prenatal HIV testing and subsequent treatment of infected women and infants can be very cost-effective (Ecker, 1996; Gorsky et al., 1996; Mauskopf et al., 1996; Myers et al., 1998; see also Appendix K)
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From page 123... ...
Appropriating these funds now would go a long way towards 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 process that could result in states' losing substantial 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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From page 124... ...
To effectively identify HIV-infected women and prevent transmission, moreover, this infrastructure must include the education of prenatal care providers; the development and implementation of practice guidelines; the implementation of clinical policies, the development and adoption of performance measures and Medicaid managed care contract language for prenatal HIV testing; interventions to overcome pregnant women' s concerns about HIV testing and treatment; interactions with HIV prevention programs and drug treatment programs; and efforts to increase utilization of prenatal care, as discussed in this chapter. A Ryan White-funded program in Tampa, Florida, for example, provides nurse case managers for all pregnant women who are HIV-positive, whether they are being cared for by public or private providers.
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From page 125... ...
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-in fected 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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From page 126... ...
OTHER APPROACHES TO PREVENTING PERINATAL HIV TRANSMISSION Although the committee's charge was focused on prenatal HIV testing and appropriate care, other ways to prevent perinatal transmission of HIV should be also considered. A detailed discussion of these interventions would be beyond the scope of this report, yet the committee believes that the following areas offer possibilities for preventing HIV infection in children, and should be included in a prevention package.
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From page 127... ...
Insofar as women and their partners avail themselves of this opportunity, preconception visits provide an early opportunity to obtain HIV testing for the woman and her partner. For those found to be HIV-positive, it provides a chance to consider avoiding pregnancy, and/or to be counseled about antiretroviral therapy during pregnancy.
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From page 128... ...
Since the publication of the ACTG 076 results, the prenatal setting offers the additional opportunity for combating perinatal HIV transmission by HIV testing and by initiating effective treatment for women who test positive. Yet roughly 15% of HIV-infected pregnant women, many of whom are drug users, receive no prenatal care (Chapter 61.
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From page 129... ...
Many interventions could be introduced in correctional settings either for general primary prevention of HIV transmission or for prevention of perinatal transmission among HIV-infected pregnant women in particular. Interventions could 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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From page 130... ...
. The CDC is currently developing guidelines on the implementation and quality assurance of rapid HIV testing.
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From page 131... ...
. Sexually transmitted disease clinics and drug abuse treatment programs are among the sites that should introduce an accurate rapid testing program for the purpose of primary HIV prevention (CDC, 1998g)
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From page 132... ...
, a substantial fraction of low-income women and children will remain uninsured and HIV-infected children will be born ineligible for Medicaid. Continued support for public health clinics and neighborhood health centers and innovative insurance programs can help to provide prenatal and HIV testing care for these populations.
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From page 133... ...
Adopting this policy will require the establishment of, and resources for, a comprehensive infrastructure that includes education of prenatal care providers; the development and implementation of practice guidelines; the implementation of clinical policies, the development and adoption of performance measures and Medicaid managed care contract language for prenatal HIV testing; efforts to improve coordination of care and access to high-quality HIV treatment; interventions to overcome pregnant women's concerns about HIV testing and treatment; and efforts to increase utilization of prenatal care, as described above.
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