Perinatal HIV Testing in Utah

**\
**Lois Blobaum, BSN, Theresa Garrett, MSN

and Nan Streeter, RN, MS

Utah Department of Health

Slide Presentation

Slide #1:

Utah Perinatal HIV Prevention Task Force

Utah Department of Health's:

-   Bureau of Communicable Disease Control -- HIV Prevention Program

-   Bureau of Maternal & Child Health -- Reproductive Health Program

-   Division of Health Care Finance -- Bureau of Managed Health Care

Partners from:

-   Department of Obstetrics and Gynecology -- University of Utah

-   Planned Parenthood of Utah -- Utah's Title X Agency

-   Midvale Community Building Community Coalition

Slide #2:

HIV Epidemiology in Utah

-   Five pregnant HIV-positive women delivered a live-born infant during
    2002

-   Ten pregnant HIV-positive women delivered a live-born infant during
    2003

Risk Factors include:

-   Women who have a history of injecting drug use

-   Women who have sexual partners with a history of injecting drug use

-   Disproportionately affects Hispanic and African American women

Slide #3:

Pregnancy Risk Assessment Monitoring System Data

-   During any of your prenatal care visits, did a doctor, nurse, or
    other health care worker talk with you about getting your blood
    tested for HIV? (Yes-27%)

-   During any of your prenatal care visits did a doctor, nurse, or
    other health care worker ask if you wanted to be tested for HIV?
    (Yes-47%)

Slide #4:

2002-2003 Goals

-   Improve data collection and analysis on:

a\. HIV prevalence among pregnant women

b\. HIV counseling and testing practices

-   Foster integration of universal counseling and testing into prenatal
    care practices

Slide #5:

Revised 2001 Guidelines

-   Recommend HIV testing for all pregnant women

-   Permit flexibility in the consent process

-   Encourage health care providers to document consent or refusal and
    address reasons for refusal

-   Support HIV prevention and referral through education during
    prenatal care

-   Emphasize testing and treatment at labor and delivery for women who
    have not received testing

Slide #6:

Multi-hospital Quality Improvement Project

-   Four tertiary care hospitals in greater SL area

-   Research nurses conducted brief face-to-face interviews with women
    during the intrapartum or immediate postpartum period

Slide #7:

Multi-hospital Quality Improvement Project (cont.)

Was HIV Screening discussed with you during your prenatal care?

A- 34.7% B- 47.5% C-57.1% D-72%

Was an HIV test done during your prenatal care?

A- 22.3% B-49.2% C-33.5% D-65%

Do you know your HIV status?

A-43.2% B-36.4% C-36.4% D-57%

Slide #8:

Prenatal Care Provider Survey

-   To develop an action plan regarding perinatal HIV testing and
    collect baseline data.

-   The purpose of the study was to understand providers' perspectives
    and practices regarding universal HIV counseling and testing for
    pregnant women.

Slide #9:

Methods

-   Data collection process

-   Utah Department of Health sent questionnaires to all 461 prenatal
    care providers during January to March 2003.

-   Prenatal care providers included obstetricians, family practice
    physicians and certified nurse-midwives (CNM).

Slide #10:

Results

-   A total of 273 questionnaires were returned corresponding to a
    response rate of 59%.

-   Five percent of providers did not provide prenatal care and were
    excluded from the analysis.

-   Sample demographics:

-   More than half (52%) of the providers were
    obstetricians/gynecologists, 34% were family practice physicians,
    and the remaining 14% were CNM.

-   The majority (74%) of the providers were male.

-   In regard to location, 70% reported practicing in "urban" areas.

Slide #11:

HIV Testing Practice

-   When asked how many pregnant patients were offered HIV testing:

-   70% of providers reported offering it to "all"

-   16% of providers reported offering it to "most"

-   13% of providers reported offering it to "some" or "none"

Slide #12:

Percent of Providers Offering HIV Testing by Provider Type

Even though the majority (70%) of providers offer HIV testing to all
pregnant women, the proportion was higher among CNM (83%\*).

\*However, this difference was not statistically significant.

\~ Category "some" includes: none, some, half, and most

-   OBGYN: Offer Testing to \"All\": 68%. Offer Testing to \"Some\":
    32%.

-   Family Practitioners: Offer Testing to \"All\": 70%. Offer Testing
    to \"Some\": 30%.

-   CNM: Offer Testing to \"All\": 83%. Offer Testing to \"Some\": 17%.

Slide #13:

Percent of Providers Offering HIV Testing to All Pregnant Patients by
Provider Gender

The proportion of female providers offering HIV testing to all pregnant
patients was higher compared to male counterparts (76% vs 68%\*).

\* However, this difference was not statistically significant.

-   Male Providers: 68%

-   Female Providers: 76%

Slide #14:

Informed Consent Process

-   58% of the providers reported that "all" of their patients signed an
    informed consent.

-   However, 28% reported that "none" of their patients signed an
    informed consent.

-   The remaining respondents reported that "some" of their patients
    signed an informed consent.

Slide #15

Pre and Post-Test Counseling

-   Over half (62%) reported that "most" to "all" of their pregnant
    patients received pre-test counseling.

-   However, this percentage dropped to 51% for post-test counseling.

Slide #16

Familiarity with ACOG Recommendations on HIV Counseling and Testing

-   Results indicated, 74% of surveyed providers were familiar with ACOG
    recommendations and 26% were not.

-   Of those familiar with ACOG, 72% offered testing to all patients.

-   Of the 26% who were unfamiliar with ACOG, tests were offered to all
    patients 66% of the time.

-   According to the survey results, familiarity with ACOG
    recommendations had little impact on their respective testing
    practices.

-   Familiar with ACOG: Offer to \"All\": 72%. Offer to \"Some\": 28%.

-   Unfamiliar with ACOG: Offer to \"All\": 66%. Offer to \"Some\": 34%.

Slide #17

Prenatal Care Providers' Experience with Diagnosing and Treating
Pregnant Women with HIV

Identified/diagnosed pregnant women with HIV: Yes: 13%. No: 87%.

Prescribed antiretroviral therapy to pregnant women: Yes: 9%. No: 91%.

Delivered an infant whose mother was HIV infected: Yes: 16%. No: 84%.

Slide #18:

Prenatal Care Providers' Experience with Diagnosing and Treating
Pregnant Women with HIV(cont.)

-   Half of the providers (51%) surveyed stated that patient's prenatal
    care would be co-managed with another network provider if the woman
    was diagnosed with HIV infection.

-   When asked what type of provider would be involved in co-management,
    55% said they would work with an "infectious disease specialist."

Slide #19:

Reasons for Not Offering HIV Testing to All Pregnant Patients

-   30% of the surveyed providers reported they did not offer HIV
    testing to all patients.

-   The most common reasons for not providing HIV testing were:

-   Low perceived risk among population served (58%)

-   Limited time during prenatal visit (9%)

-   Concerned about offending patient (5%)

Slide #20:

Limitations

-   At the time of the survey the most recent PNC provider
    registry (461) was used to mail the surveys. However, this listing
    may exclude some newly practicing providers.

-   Interpretation of results need to take into account the response
    rate of 59%.\*

\*n=273

Slide #21:

Recommendations

-   Emphasize that women will be missed if only risk-based approach is
    used.

-   Encourage providers to implement policies and guidelines to
    facilitate universal HIV counseling and testing for pregnant women.

-   Ensure providers are aware of the revised guidelines.

-   Educate prenatal care providers about the "opt out" approach to
    prenatal testing.

-   Offer HIV prevention education to pregnant women.

Slide #22:

2004-2005 Perinatal HIV Taskforce Plan

-   Develop and maintain an active, engaged Perinatal HIV Prevention
    Workgroup

-   Integrate universal HIV testing, with notification and education,
    into prenatal care

-   Disseminate information regarding rapid testing to Labor and
    Delivery settings

-   Continue to monitor and evaluate HIV testing practices and HIV
    prevalence among pregnant women