Reducing the Odds Preventing Perinatal Transmission of HIV in the United States (1999) / Chapter Skim
Currently Skimming:
6 Implementation and Impact of the Public Health Service Counseling and Testing Guidelines
6 Implementation and Impact of the Public Health Service Counseling and Testing Guidelines
Pages 68-108
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 68... ...
in 1994, there has been a concerted national effort to bring the benefits of HIV testing and appropriate treatment to as many women and children as possible. Federal and state public health agencies, as well as many professional organizations, have issued a series of guidelines, recommendations, and policies about HIV counseling and testing in prenatal care, and some states have passed laws regarding pro- and postnatal HIV testing.
|
From page 69... ...
. The adoption of voluntary, as opposed to mandatory, testing was recommended for a number of reasons: widespread support for the policy, particularly from patients for whom adherence to a demanding drug regimen is essential for prevention of transmission; a concern that mandatory testing might have served as a potential deterrent to prenatal care; the risks of testing positive (e.g., discrimination and domestic violence)
|
From page 70... ...
Tb~cc stoics Wanda, Nc~ Jcrsoy, abode Island) bloc routine "opted" procc~rcs, ~bicb require prcn~1 chic providers to oar the tosL TcsOng is volume with in~cd consent in the ~cm~ning 47 Sacs.
|
From page 71... ...
Eighteen states have reviewed their contracts with managed care organizations regarding HIV issues, and nine states report having required changes in the covered programs to implement the PHS guidelines. Although the issue has not been carefully studied, the committee has identified no evidence that the existence of state laws or policies mandating HIV testing for either pregnant women or newborns has had any effect on offering or accepting tests, or on avoidance of prenatal or other health care.
|
From page 72... ...
zation that supports mandatory HIV testing of all pregnant women and newborns, but this policy is not without controversy. In June 1995, the AMA Council on Scientific Affairs reviewed the available scientific data available and recommended that the AMA adopt a policy encouraging physicians to give a high priority to educating all women about HIV infection, and calling for prenatal HIV testing to be voluntary and its acceptance the responsibility of the woman (AMA, 1995~.
|
From page 73... ...
The American College of Nurse Midwives (ACNM) policy is that all women should be counseled on HIV risk behaviors and risk reduction strategies, and following counseling, all women should be offered HIV testing with informed consent.
|
From page 74... ...
These studies would suggest that roughly 15% of HIV-infected women receive no prenatal care. Counseling and Offering HIV Testing PHS guidelines recommend that all pregnant women in the United States be offered and encouraged to accept voluntary HIV antibody testing early in pregnancy (CDC, 1995b)
|
From page 75... ...
It is difficult to draw a national picture from the results of these selected states, but there does appear to be significant variation across geographic areas and significant gaps between provider awareness and application of recommended practices. Awareness of CDC's guidelines, state HIV testing laws, and the ACTG 076 results appears to vary among prenatal care providers: · In 1997, 60% of prenatal care providers in Oregon were familiar with CDC' s recommendations regarding perinatal HIV transmission (Rosenberg et al., undated abstract)
|
From page 76... ...
. Analysis limited to 159 prenatal care providers Mail survey of 326 OB/ GYN and family practice physicians statewide.
|
From page 77... ...
15% report that 10% or fewer patients accept the test. Physicians report that the most common reason women decline testing is that they think that they are not at risk or they have already been tested New Jersey requires providers to provide HIV counseling, discussion of HIV test benefits, and a voluntary HIV test offer Responding providers attend approximately 40% of Oregon births As of July 1995, providers are required by law to counsel women seeking prenatal care about HIV and to offer voluntary testing Continued
|
From page 78... ...
prenatal providers) , and 400 nurse practitioners providing prenatal care, nurse midwives, and physician assistants specializing in family practice and OB/ GYN.
|
From page 79... ...
Percentage of women tested varied from 0 to 100%, with a median value of 60% 75% stated familiarity with findings of ACTG 076. 90% screen pregnant women for HIV infection, 50% always test for HIV, 75% strongly agree/agree that "all pregnant women should be tested for HIV regardless of stated risk behaviors" According to a 1993 survey, only 39% of prenatal care providers reported that they offered HIV testing to all of their pregnant patients Barriers to counseling mentioned were lack of support staff and lack of time 92% of providers are aware of Michigan's HIV laws, Michigan law requires all 94% of midwives and 82% of OBs said that they were pregnant women be counseled compliant all the time with the counseling aspects of the about, and tested for HIV.
|
From page 80... ...
RR 74% M.D.s, 82% CNMs. 430 provided prenatal care
|
From page 81... ...
, California providers are required by law to offer all pregnant women voluntary HIV testing and document this in the medical record Continued
|
From page 82... ...
RR 99% Statewide mail survey of prenatal care providers (OB/GYN, FPs, nurse ., . mauves, nurse practitioners)
|
From page 83... ...
10% to 20% do not provide any level of HIV counseling or testing, 45% expressed competence and "comfort" to care for HIV+ patients 70% of OBs and 57% of FPs aware of 1994 PHS guidelines on use of ZDV; 90% or more of providers reported that all pregnant women should be offered HIV testing by their prenatal care provider. 68% of OB/ GYNs, 55% of GP/FPs, and 69% of advanced practice nurses offer HIV testing to all pregnant women who are present for care 89% of physicians agreed with a recommendation for universal HIV counseling and voluntary screening of pregnant women.
|
From page 84... ...
· In 1996 to 1997,86% of Hawaii obstetric providers offered HIV counseling and testing to 76% to 100% of their pregnant patients (Partika and Johnson, 1997~. · In 1996, 55% of Michigan obstetricians said they complied with the laws in terms of routinely incorporating HIV testing in the care of pregnant patients (Michigan Department of Community Health, 1997~.
|
From page 85... ...
. On average, OB/GYNs reported pre-test counseling for 62% of patients and post-test counseling for 45% 90% of prenatal care providers agree that all pregnant women should be assessed for their risk of HIV infection, and 89% agree that HIV testing should be offered to all pregnant women in their community.
|
From page 86... ...
John A Burns School of Medicine, University of Hawaii Personal communication May 1998 Mitchell B 1998 Personal communication April 1998 New York Department of Health, MaternalPerinatal HIV Prevention and Care Program April 1997 to Hawai March 1998 January to June Texas 1997 February to New York October 1997 Analysis of HIV testing data from Hawaii laboratories Analysis of birth certificate reports of HIV testing (prenatal and at delivery) Analysis of administrative data from the New York State program Pettiti DB, Southern 1994-1997 Southern Analysis of health plan California Kaiser California, HIV testing data.
|
From page 87... ...
In 1997, there were an estimated 32,000 women who had a prenatal care screening panel In 11 states, the proportion of women reporting that a provider talked to them about getting an HIV test ranged from 60% to 84% (median 75%)
|
From page 88... ...
Brooklyn, involved in-person New York; interviews with women in Connecticut prenatal care regarding HIV-related communications with provider, content of HIV counseling, and factors related to acceptance of HIV test. Postpartum survey conducted in four sites Simonds RJ, Rogers M IOM workshop presentation, April 1, 1998; CDC, 1998f Alderton D, CDC, HIV/ AIDS Surveillance Branch Personal communication April 8, 1998 1993-1996 New Jersey, South Carolina, Louisiana, Michigan 1993-1996 United States State Enhanced Pediatric HIV Surveillance Program (STEP)
|
From page 89... ...
Major reasons women said they were not tested included "no perceived need," "previously tested," and "did not want to know" Barrier to testing and treatment among HIV+ women is that 14% receive no prenatal care and 23% start prenatal care in third trimester. Among those with a history of drug use, about 35% had no prenatal care.
|
From page 90... ...
Ongoing study Central North Prospective cohort study of IOM workshop Carolina 7,000 pregnant women presentation, April 1, attending public prenatal 1998 care clinics Carusi D, Learman LA, 1996 San Francisco Survey of a convenience Posner SF sample of 247 antenatal 1998 patients at San Francisco Published report General Hospital (English and Spanish speakers) regarding HIV testing policy (routine vs.
|
From page 91... ...
69% said prenatal HIV testing should be routine and 27% said that it should be done only after specific written consent. Nearly twice as many women experiencing a recent pregnancy as non-pregnant women reported HIV testing (60% vs.
|
From page 92... ...
, telephone and in-person interviews with 98 HIV counselors, and inperson interviews with 354 women Descriptive study of HIV education and counseling program within a hospital prenatal care program Prospective cohort study of HIV test use among 23,432 pregnant women registered for care at Grady Memorial Hospital
|
From page 93... ...
Women with a drug risk were more than nine times as likely as others to have delivered without receiving any prenatal care 61% offered newborn testing accepted. In multivariate analyses, acceptance was higher among African Americans 95% of women provided HIV counseling and follow-up services according to a protocol involving a multidisciplinary team accept HIV testing Slightly fewer than 60% of women agreed to be counseled, and of those, less than half consented to an HIV test at the counseling site.
|
From page 94... ...
These estimates refer to "ever" having been tested for HIV, but most testing occurred within a year of the currently reported pregnancy. When offered an HIV testing on a voluntary basis, most pregnant women accept.
|
From page 95... ...
counseled regarding HIV consented to testing Study hospital provides care for a predominantly AfricanAmerican inner-city population Study hospital provides care for a predominantly AfricanAmerican inner-city population University obstetric unit serves inner-city, poor, predominantly African-American and Hispanic women 75% to 86% of pregnant women accepted HIV testing when it was offered (HIV testing rates ranged from 59% to 77%~. Test acceptance was higher when providers strongly recommended testing, and among women seen in public settings, those with Medicaid coverage, African Americans, and those with low educational attainment (Appendix D)
|
From page 96... ...
Since 1995, Texas has required all prenatal care providers to test every pregnant woman for HIV, unless the woman refuses. Other states that are monitoring perinatal HIV test use have relatively low prenatal testing rates.
|
From page 97... ...
Some have suggested that intensive nurse case management increases adherence to the ACTG 076 regimen and reduces perinatal transmission (Havens et al., 1997~. Barriers to use of ZDV among HIV-infected pregnant women include not having information about maternal HIV status, late onset of prenatal care, insufficient time to administer ZDV (e.g., short labor)
|
From page 98... ...
of Health, 1998 Newborn HIV testing program data from February 1 to October 31, 1997 1992-1997 Michigan HIV/AIDS surveillance data reported through October 1, 1997 Lindegren ML 1995-1996 New Jersey STEP project IOM workshop South presentation, April 1, Carolina 1998 Louisiana Michigan Lindegren ML 1993-1996 29 HIV- Surveillance data IOM workshop reporting presentation, April 1, states 1998 Lindegren ML 1994-1995 Florida, ZDV assays of HIV+ SCBW IOM workshop Louisiana, samples from eight states. presentation, April 1, Michigan, Positive assay indicates 1998 Minnesota, administration of ZDV New Jersey, intrapartum or to newborn to Nevada prevent perinatal transmission.
|
From page 99... ...
of women who completed their pregnancy took ZDV prenatally, intrapartum, and administered ZDV to their infants Compliance might be improved by using outreach workers, integrating prenatal care with drug treatment programs, or expanding women's support structures Continued
|
From page 100... ...
With prenatal and intrapartum ZDV therapy, the rate of perinatal HIV transmission has been dramatically reduced and new, more complex therapies promise even greater reductions in mother-to-child transmission. High-risk HIV care centers specializing in maternity and postpartum services for HIV-infected women and their babies have been developed in high-incidence areas of the country.
|
From page 101... ...
Getting Timely, Accurate, and Confidential Test Results The committee repeatedly heard reports about the emotional difficulty of receiving positive HIV test results, even under ideal circumstances. For some women, however, the shock is intensified by the circumstances under which they are informed of their status.
|
From page 102... ...
Women seeking specialty care must travel an hour across the bay to San Francisco. For women living in low-incidence and/or rural areas, the difficulty in reaching specialty care is even more pronounced.
|
From page 103... ...
. Standards of Care Even when women receive care from specialty clinics, they and their providers are often faced with difficult decisions about care options.
|
From page 104... ...
Denison, however, reports that WIC programs, which promote breast-feeding as the best alternative for infant nutrition, in some instances are not sufficiently sensitive to the needs of HIV-infected mothers.3 STRATEGIES TO REDUCE PERINATAL HIV TRANSMISSION Inadequate prenatal care among women at high risk for HIV, health care providers' lack of adherence to PHS guidelines, and women's rejection of HIV testing and ZDV use all limit the ability to further reduce perinatal HIV transmission. This section of the report provides estimates of each potential barrier to HIV transmission reduction, and presents a simple model for assessing the implications of different intervention strategies.
|
From page 105... ...
Alternatively, if the current environment remained the same, but all HIV-infected women accepted HIV testing when offered, and accepted and complied with ZDV treatment, there would be a 19% reduction in the number of HIV-infected babies (i.e., from 1,172 to 947~. If both providers and HIVinfected women had optimal rates (i.e., if all but prenatal care is set to 100%)
|
From page 106... ...
, there would only be a 29% decline in the number of HIV-infected babies (i.e., from 1,172 to 830~. Here it is assumed that 92.5% of HIV-infected pregnant women obtain early prenatal care, 87.5% of women are offered HIV testing, 90% of women accept testing, 95% of HIV-infected women are offered ZDV, and 95% of women accept and comply with ZDV therapy.
|
From page 107... ...
prenatal care providers are more likely now than in the past to counsel their patients about HIV and the benefits of ZDV and to offer and recommend HIV tests; 3. women are more likely to accept HIV testing and ZDV if indicated; and 4.
|
From page 108... ...
Increasing the rate at which providers offer HIV tests from 75% to 100%, and increasing the proportion of women who accept it from 80% to 100%, for instance, would reduce the number of HIV-infected babies by 33% about 386 children per year. To reduce perinatally acquired HIV even further, efforts are needed to increase the availability and utilization of prenatal care, especially in women who use drugs; to improve the coordination and quality of health care for HIV-infected women; and to prevent HIV infection in women initially.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.