Reducing the Odds Preventing Perinatal Transmission of HIV in the United States (1999) / Chapter Skim
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D Workshop II Summary
D Workshop II Summary
Pages 203-235
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Both are populationbased surveillance systems. Pediatric HIV surveillance includes information on perinatally exposed infants and monitors their subsequent HIV infection and 203
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HIV/AIDS Trends in Infants and Children Perinatal transmission accounts for virtually all new HIV infections in children. It is estimated that more than 15,000 HIV-infected children have been born to HIV-infected mothers in the United States.
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This indicates that the decline in pediatric AIDS cases is not being driven solely by changes in PCP, but rather appears to reflect declining perinatal transmission rates. In order to estimate the impact of the ACTG 076 results, Byers and colleagues (1998)
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Chain of Events for Prevention Success As a framework for understanding the impact of efforts to prevent perinatal HIV transmission, CDC representatives presented its data in terms of a chain of events or steps that must be taken to ensure prevention success. The chain is based on ensuring timely and complete implementation of the ACTG 076 regimen and includes the following steps: (1)
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Testing Offered Among childbearing women responding to the PRAMS survey in 1996, approximately 75% said their health care worker talked to them about HIV testing during pregnancy (based on the median for the 11 participating states)
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, more than 150 perinatal HIV infections were prevented in these eight states alone in 1995. Population-based pediatric HIV surveillance data from 29 reporting states for 1993 to 1996 shed further light on the extent to which ZDV is being accepted and received among mothers who were diagnosed as HIV-positive before giving birth.
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To achieve greater success in preventing perinatal HIV transmission, CDC presenters recommended that efforts be undertaken to (1) improve prenatal care access and utilization, especially for substance-using women; (2)
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Discussion focused next on the impact of state statutes on overall outcomes. Are laws that require prenatal counseling and offering of HIV testing rigorously enforced?
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with adequate counseling, women accept HIV testing, particularly during pregnancy; and (2) significant advances have been made by HRSA-supported programs in reducing perinatal HIV transmission through voluntary, non-regulated HIV counseling, testing, and perinatal ZDV prophylaxis.
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A small survey of obstetricians and gynecologists in New Orleans found that more than three-fourths of providers reported at least 90% acceptance of HIV testing. Of all women who received pre-test counseling through SPNS adolescent care projects, 91% accepted testing, and 94% of pregnant women accepted testing.
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Women's Initiative for HIV Care and Reduction of Perinatal Transmission HRSA's WIN, which includes ten sites across the country, was developed in FY 1995 in response to ACTG 076 findings. WIN goals include encouraging women to learn their HIV status as early as possible, linking women with a continuum of ongoing comprehensive care services, and facilitating strategies that reduce perinatal HIV transmission.
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the perceived barriers of providers and consumers need to be identified and addressed to further reduce perinatal HIV transmission. PROVIDER PRACTICES The provider panel included representatives from: the American Academy of Family Physicians (Marshall Kubota)
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Incorporation of Guidelines AAFP policies regarding HIV disease have closely followed those set forth by PHS. The academy recommends universal HIV counseling and voluntary testing for all pregnant women, and has adopted as policy the section "Guidelines for Counseling and Testing for HIV Antibody" from the CDC statement "Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS." In addition, the AAFP supports the enactment of state laws providing for (1)
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Ms. Shannon noted that the resource materials were of very high quality and recommended that they be evaluated for use in other states, as in the California Perinatal HIV Testing Project described below.
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mechanisms. Tracking HIV testing rates, however, is problematic because: some hospitals prohibit recording HIV testing in patient charts, some clients opt for anonymous testing, and targeting acceptable rates for HEDIS might lead to coercive testing.
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California Perinatal HIV Testing Project Mori Taheripour and Gail Kennedy provided a brief overview of the California Perinatal HIV Testing Project, funded by the California Department of Health, Office of AIDS, and the Health Care Financing Administration (HCFA) Medicaid Office in March 1997.
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Incorporation of PHS Guidelines The ACNM has incorporated PHS recommendations into its "ACNM Position on HIV/AIDS," which calls for universal counseling and offering of HIV testing, with informed consent. In addition, the statement specifically (1)
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Responsibilities are met through assessment, policy and program development, and assurance of care. Incorporation of PHS Guidelines AMCHP has incorporated PHS guidelines into its policy on HIV counseling and testing, which supports early and routine counseling to enable all pregnant women and others of reproductive age to understand the risk of HIV infection and the benefits of early testing, identification, and treatment.
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Massachusetts Title V Program Experience As in many states, the Massachusetts Title V program uses a range of approaches to address HIV/AIDS, including conducting a needs assessment to identify gaps in services, and developing and obtaining Ryan White Title IV funding for a regionalized care system. Under this system, pediatric HIV specialists provide care in community sites once a month in conjunction with local pediatric primary care providers.
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In general, NCQA evaluations show great variation across plans in the quality of clinical care. While there are HEDIS measures in place to reflect primary prevention of vaccine-preventable disease (immunization)
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Since this is not yet the case for populations other than pregnant women, it is unlikely that HIV testing in the general population would become a HEDIS measure. Rhode Island State Prison System Timothy Flanigan, an infectious disease specialist who directs an HIV clinical care practice at The Miriam Hospital in Providence, Rhode Island, and also directs HIV care for the Rhode Island State Prison System, spoke about the relationship of HIV to the correctional system.
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Flanigan recommended that: (1) HIV testing and diagnosis of incarcerated individuals always be linked to comprehensive HIV care during incarceration and community care after release; (2)
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. The Department of Public Health currently provides HIV counseling and testing to 20,000 to 25,000 pregnant women per year.
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Allen noted that having a case manager can influence women's acceptance of testing, particularly women who are not from the dominant culture. North Carolina Rachel Royce, an epidemiologist from the School of Public Health, University of North Carolina, presented an overview of efforts in her state to prevent perinatal HIV transmission through prenatal HIV counseling and testing.
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More specifically, while 93% of respondents said they support universal offering of testing, only 82% of practices had a policy of offering testing to all; 67% of providers reported that they offered testing to all women; and only 54% said they would recommend testing to women with no identifiable risk. The 1995 survey also indicated that providers' HIV testing recommendations and practices are influenced by practice setting and patient's insurance status.
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These discuss the benefits of ZDV in preventing perinatal HIV transmission. Trends/Findings Prevention of perinatal HIV transmission is a public health priority in New Jersey, since it is the state with the highest proportion of women among its cumulative AIDS case reports (27%)
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there has been a marked improvement in efforts to prevent perinatal HIV transmission in New Jersey; (2) physicians do offer counseling and testing; (3)
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The notice urged Medicaid agencies to work closely with Ryan White grantees to assure optimal counseling and testing. · In May 1996, HCFA conducted a survey of regional AIDS coordinators that looked at: state laws addressing HIV counseling and testing of pregnant women; access to HIV testing, counseling and treatment in the state; the nature of HIV provisions in Medicaid managed care contracts; and state Medicaid agency collaboration with other state agencies, providers, and consumers in implementing PHS guidelines.
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developments in new state legislative policy, regulation, and practice standards; (2) availability of trend/surveillance data on perinatal HIV transmission; (3)
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The state health department has been instructed to issue implementation guidance. One consequence of the legislative debate on this topic is a new awareness in Indiana that physicians are not providing HIV counseling to all pregnant women and are not offering tests.
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· Welfare reform and immigrants: With welfare reform, undocumented immigrants are cut off from publicly assisted prenatal care.
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· Funding: Finally, noting the importance of access to high quality, specialty care, Ms. Denison stressed the need for sustained and increased funding for comprehensive perinatal HIV/AIDS services such as those provided by BAPAC in San Francisco.
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APPENDIX D 1 :30-3:00 3:00-3:15 3:15-4:30 4:30-5:30 5:30 235 Lunch Provider practices American Academy of Family Practitioners, Marshall Kubota Association of Women's Health Obstetric, and Neonatal Nurses, Maureen Shannon American College of Nurse Midwives, Jan Kriebs Association of Maternal and Child Health Programs, Deborah Allen American Association of Health Plans, Johanna Daily National Committee for Quality Assurance, Joseph Thompson The Miriam Hospital [prison health) , Timothy Flanigan California, Mori Taheripour California, Gail Kennedy Break Impact of the PHS voluntary testing recommendations: Results from provider and patient surveys and state data systems Massachusetts, Deborah Allen North Carolina, Rachel Royce New Jersey, Sindy Paul Health Care Financing Administration, Theresa Rubin Patient perspectives: AIDS Policy Center for Children, Youth and Families focus groups APCCYF, Laquitta Bowers APCCYF, Kay Armstrong NASTAD, Joseph Kelly Respondent: WORLD, Rebecca Denison Adjourn
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