PERINATAL HIV SCREENING: EFFORTS TO MONITOR TRENDS AND
TRANSMISSION[.]{dir="rtl"}

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**Michael Kogan:** []{dir="rtl"}Good afternoon. And welcome to today\'s
Dataspeak Internet audio conference. Perinatal HIV screening, efforts to
monitor trends and transmission. My name is Dr. Michael Kogan. And I'm
the director of the office of data and information management in the
maternal and child health bureau. The Dataspeak series is sponsored
through the office\'s MCH information resource center[.]{dir="rtl"}

[]{dir="rtl"}

Today we\'re pleased to present the second program in the 2004 Dataspeak
series. Our third program for 2004 will address integrated child health
information systems with a special focus on newborn screening. This
program is scheduled for tune 30th. A fourth program will be held in
September. Information on these programs will be shared as it comes
available and is also post on Dataspeak Web site. Our program today
focuses on efforts at the federal and state levels to promote HIV
screening for all pregnant women. Well hear about HIV prevention
initiative as well as state-level partnerships between title v maternal
and child health block programs and HIV aids offices to promote HIV
screening as a standard part of prenatal care[.]{dir="rtl"}

[]{dir="rtl"}

We\'re fortunate to have with us several teams of esteemed presenters
from the Centers for Disease Control and Prevention we\'ll be hearing
from Stephanie Sansom and Margaret Lampe who will provide an overview of
CDC\'s HIV prevention initiative and available surveillance data. We\'ll
then hear from officials from South Carolina and Utah regarding their
State\'s efforts. Our South Carolina presenters are Sara Balcerek, Lynda
Kettinger, and Sarah Cooper. And our presenters from Utah are Lois
Blobaum, Theresa Garrett and Nance Treater. Thanks to all of these
individuals for their contributions to today\'s important program. I\'d
also like to recognize the significant effort to plan this program
dedicated by a team of officials from CDC and the health resources and
services administration. Including Raul Romgarra, Jeff Bosshart,
Stephanie Sansom, Margaret Lampe, Jeff Koshle, Karen Hench, Jose Morales
and Julia Gauge[.]{dir="rtl"}

[]{dir="rtl"}

It\'s my pleasure to now introduce Beth Zimmerman, the coordinator of
Dataspeak and the moderator for today\'s program. Beth, I'll now turn
the floor over to you[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you, Dr. Kogan, and welcome to all
of our participants[.]{dir="rtl"}

[]{dir="rtl"}

We\'re delighted to have everyone with us. Before we begin our
presentations, I have just a few housekeeping items to take care of.
First for those of you who are logged into our Internet broadcast,
you\'ll be seeing an ongoing slide show throughout the next hour. At the
even of the program, you\'ll also see a short evaluation form appear on
your screen, and we\'d greatly appreciate you taking a moment to
respond[.]{dir="rtl"}

[]{dir="rtl"}

If you are on the phone and wish to see the slides as they\'re broadcast
over the Internet, go to www.you-niversity.com/w/Dataspeak and enter the
pin number 8285100. Although we don\'t anticipate you\'ll experience any
technical problems, I want to give you a few tips just in case they come
up if you\'re on the web, please call technical support at
1-877-867-7300 if you experience any technical problems. And that number
is located in the bottom left corner of the screen. If it appears that
the slides are not advancing, you may need to restart your browser and
log back in. If you experience any difficulty with the audio stream, you
may access the audio by phone by dialing 1-888-604-5272. And use the
password HIV screening. Please note that if you do change your audio
source, you need to close your browser, log back in, and select a new
audio source to ensure proper slide timing[.]{dir="rtl"}

[]{dir="rtl"}

There are a variety of resources on perinatal HIV screening that you can
find on the Dataspeak Web site including those that the presenters will
highlight in their presentations. And a link to this site is located in
the resource area in the lower left of the screen[.]{dir="rtl"}

[]{dir="rtl"}

After we hear the presentations, we\'ll have a question-and-answer
session. Those of you on the phone will have an opportunity to ask
questions through our operator who will come on at that time to provide
instructions as to how to do so. Questions can also be posted online at
any time during the program. If you\'re logged in through the Internet,
click the button that says \'in writing\' at the bottom of your screen
and just type your message and click send[.]{dir="rtl"}

[]{dir="rtl"}

It is my pleasure to introduce our first presenters, Drs. Stephanie
Sansom and Margaret Lampe from CDC\'s division of HIV/aids prevention.
Thank you both for being source[.]{dir="rtl"}

[]{dir="rtl"}

**Stephanie Sansom** []{dir="rtl"}Hello, thanks very much for the
introduction. I am Stephanie Sansom a health services researcher in the
epidemiology branch in the division of the HIV and aids prevention at
CDC. I\'m here with my colleague, Margaret Lampe, a health educator in
the same branch. Margaret and I both work on the prevention of perinatal
transmission in the United States. And we\'re very happy to have this
opportunity to participate on this Dataspeak. The title of our talk is
perinatal HIV screening, efforts to monitor trends and reduce
transmission. The objectives of our talk are to tell listeners about
CDC\'s advancing HIV prevention initiative, which was begun in April of
2003. We want to describe how the initiative relates to perinatal HIV
prevention and about specific efforts to eliminate perinatal HIV
transmission in the United States through teen, prenatal, HIV testing
and rapid testing among women who arrive at labor and delivery without a
documented prenatal test[.]{dir="rtl"}

[]{dir="rtl"}

I will deliver the first part of the talk through prenatal HIV testing.
And Margaret will talk to you about rapid testing at labor and
delivery[.]{dir="rtl"}

[]{dir="rtl"}

There are four components to CDC\'s advance initiative. One is to make
voluntary HIV testing a routine part of medical care in settings such as
emergency rooms. Two is to implement new models for diagnosing HIV
infections outside medical settings such as through outreach. Three is
to prevent new infections by working with persons diagnosed with HIV and
their partners. And four is to further decrease perinatal HIV
transmission[.]{dir="rtl"}

[]{dir="rtl"}

The perinatal components contain specific strategies such as to work
with partners to promote routine, voluntary prenatal testing use what we
call an opt-out approach. Two, to develop guidelines for using rapid
tests during labor and delivery or postpartum. Three, to provide
training and conducting prenatal HIV testing. And four, to monitor the
integration of routine prenatal testing in the medical practice. The
advancing HIV prevention initiatives perinatal strategies reflect the
thinking behind several years of U.S. Public Health Service
recommendations. In 1995, the U.S. Public Health Service recommended
that all pregnant women be counseled for HIV and encouraged to be
tested. In 2001, the Public Health Service strengthened the
recommendation what all pregnant women be tested as a routine part of
prenatal care and also recommended simplifying the pretest counseling
process whenever it was (inaudible) to testing and to allow for various
types of consent[.]{dir="rtl"}

[]{dir="rtl"}

There also was a recommendation for repeat screening in the third
trimester in communities of high prevalence of HIV among childbearing
women. In April of 2003, coinciding with the announcement of the
advancing HIV prevention initiative, CDC issued a Dear Colleague letter
to health care providers and national partners further strengthening
previous recommendations by saying that no child should be born in the
U.S. whose HIV status was unknown. And that this goal could be achieved
first by routine voluntary prenatal testing using the opt-out approach
where women are notified that HIV testing will be included in the
standard battery of prenatal tests and that it may be declined. And
second where women who arrive at labor and delivery without a documented
prenatal HIV test, the offer to rapid test, again, using an opt-out
approach[.]{dir="rtl"}

[]{dir="rtl"}

Also in 2003, CDC\'s Division of HIV and AIDS Prevention began asking
the grantees who receive prevention funds including all 50 States plus
U.S. territories to submit an annual assessment of prenatal HIV testing
rates. The effort to routinize HIV testing and streamline it through the
opt-out approach was due to the interventions that are available to
prevent perinatal transmission, to rates as low as 2% and under when
interventions are initiated early in pregnancy compared to about 25%
rates when no interventions are received[.]{dir="rtl"}

[]{dir="rtl"}

CDC estimates that perinatal HIV infections occur among 270 to 360
infants each year and 40% of their mothers do not know their HIV status
until delivery or later. Occasionally questions are raised about, you
know, why are we doing universal screening? It\'s not -- HIV is just not
that much of a problem to warrant universal screening of all pregnant
women. This slide -- borrowed from Vicky Peters at the New York City
Health Department -- show other screening tests recommended for
newborns, the difference here is for public health reasons, we prefer to
screen the mother. And the prevalence of these diseases in the
population, the data indicate that an infant\'s risk of being born to an
HIV-infected moral in the United States is 1 in 670. So this is really
quite high compared to other diseases for which we routinely
screen[.]{dir="rtl"}

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The data also show that the risk -- a child has a risk of infection in
the absence of preventive interventions as high as 1 in 200680. -- 1 in
2,680. Also follow publication of data indicating that documented
prenatal HIV testing rates remain low in the United States, despite
recommendations since 1995 for testing among all pregnant women. These
rates seem low particularly when compared with other recommended
prenatal screening tests[.]{dir="rtl"}

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These data from a paper published last October in obstetrics and
gynecology is based on 5,144 maternal chart abstractions in \'98 and
\'99 in eight States. You can see that the screening rates among
pregnant women for hepatitis B, syphilis and rubella are all above 95%
while HIV is 57.2%. Other published data suggests that women will accept
HIV testing when their provider recommends it. And prenatal care
providers may experience extensive pretest counseling requirements
(inaudible) HIV testing. We also see that prenatal HIV testing rates can
be substantially higher in areas where the opt-out approach is used. We
think that boosting prenatal HIV testing and generating better data on
current testing rates are linked endeavors[.]{dir="rtl"}

[]{dir="rtl"}

This year, CDC through its contractor research triangle institute and
with support from State health departments will conduct another
perinatal screening assessment through the review of maternal charts.
Among the goals of this chart assessment is to boost prenatal HIV
testing rates through data collection and feedback. It appears that
providing regular feedback to hospitals on their testing rates will in
itself improve those testing rates[.]{dir="rtl"}

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We also -- in a related goal, hope to monitor compliance with the U.S.
Public Health Service guidelines on perinatal HIV testing and to provide
technical assistance where these rates are sub-optimal. We want to
provide data to States with high prevalence of HIV among childbearing
women who are conducting programs to improve prenatal testing rates.
This data will be used to provide feedback data on the effects of their
programs[.]{dir="rtl"}

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And, three, we want to continue to assess the impact of State testing
policies on testing rates. During this assessment, we also hope to
improve collaborations between HIV and Maternal and Child Health in
order to improve the health of pregnant women and their infants.
Additional objectives of the project are to provide State or area-wide
estimates of perinatal screening rates, including HIV, to provide
hospital-specific estimates of screening rates, to provide health
departments and hospital estimates of other recommended perinatal
screening rates. And to provide a methodology that State and health and
local departments can use in their own jurisdictions[.]{dir="rtl"}

[]{dir="rtl"}

One task of the contractor is to develop a guide for implementing the
medical chart abstractions that health departments may use themselves. A
little bit about the methodology of the project. We\'ll be collecting
the data in eight States, Connecticut, Delaware, Florida, Georgia,
Illinois, South Carolina, Tennessee, and Washington, DC, during the
first year of the project. Data collection is expected to occur among
all delivery hospitals in Connecticut, Delaware, and Washington, DC, and
in selected areas of the other States. Within delivery hospitals, we\'ll
conduct a random sample of 100 to 200 births with about 1,000 to 2,000
charts sampled in each State. The sampling framework will be based on
State vital statistics data, which is one reason we\'re looking at 2,002
births. There often is a lag until the birth certificate data are
available[.]{dir="rtl"}

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State health departments will receive a statewide estimate of perinatal
screening rates along with hospital-specific testing rates. We hope to
be in the field very soon with this project, and we\'re excited about
the data it will provide and the potential impact on incorporating HIV
testing into a routine part of prenatal care[.]{dir="rtl"}

[]{dir="rtl"}

I would encourage you to please contact me if you have any questions or
comments. I\'m now going to shift our discussion to Margaret Lampe and
rapid HIV testing in labor and delivery, an important strategy among
women who are not tested during a prenatal visit or who do not receive
prenatal care[.]{dir="rtl"}

[]{dir="rtl"}

**Margaret Lampe** []{dir="rtl"}Thank you, Stephanie. As Stephanie
mentioned, maternal transmission rates are less than 2%. With achieving
these rates requires three fundamental issues, one early identification
of HIV infection that is testing before pregnancy or early in pregnancy.
A three-part anti-retroviral prophylatic regimen including AZT as well
as for women who are (inaudible) obstetric intervention such as an
elective cesarean section. (inaudible) for the woman. However, the next
best time for preventing mother to child transmission is early in
pregnancy[.]{dir="rtl"}

[]{dir="rtl"}

As Stephanie mentioned also, CDC estimates that approximately 280 to 370
perinatally HIV infected infants are born every year. And of those
infected infants, approximately 40% of them, their -- the mother\'s HIV
infection was unknown to their clinical provider prior to labor and
delivery. We also note that anti-retroviral therapy can reduce
transmission up to 50% even when begun before labor and delivery or
shortly after birth to the newborn. And when I say 50%, that means
reduction from around 25% to about 9% to 13% transmission rates. Good
rapid tests are now available in the U.S. and when I say good, I mean
that they have reasonable sensitivities and specificities so that there
are very few false-positive results and also, of course, few to zero
false negative results[.]{dir="rtl"}

[]{dir="rtl"}

Labor and delivery rapid testing has been demonstrated to be both
acceptable and feasible. However, there are, of course, some logistical
challenges as when implementing any new screening program or
intervention, particularly in a labor and delivery unit. And the
acceptability and feasibility has been demonstrated by a myriad of
studies and others[.]{dir="rtl"}

[]{dir="rtl"}

In 2002, the Office of Inspector General issued a report on a study that
they did called *Reducing Obstetrician Barriers to HIV Testing.* Within
this report, one of the many recommendations was that CDC should
facilitate the development and States' implementation of protocols for
HIV testing during labor and delivery in order to promote testing in a
setting as a standard of care. In response to the report, CDC convened a
diverse group of individuals with expertise in a variety of areas
pertinent to this topic. This working group represents academic
institutions and university hospitals, a peer advocacy and support
organization for women living with HIV, as well as an internationally
recognized HIV training organization. Each of the participants in the
working group brings unique expertise regarding HIV testing to the model
protocol[.]{dir="rtl"}

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The purpose of the model protocol is primarily to provide practical
guidance to hospitals as well as clinicians, laboratorians, hospital
administrators, public work -- as well as policymakers. And the primary
aim when we were writing the protocol was to provide a general structure
of a rapid HIV testing protocol that can be adapted locally at any
hospital. Just to give you some input as to what\'s in the contents of
some of the major sections planning and considerations when getting
started, some of the key areas, decisions to be made ahead of time are,
of course, choosing the type of test to run the actual test on the labor
and delivery unit[.]{dir="rtl"}

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We also get into some of the key elements of a local protocol such as
determining eligibility and we would define that as any woman who has
undocumented in her medical record a test result during pregnancy. Also
how to implement the opt-out approach during labor as well as some tips
on an opt-in approach for States that require that for HIV testing. We
get into providing results, both positive and negative, to women in
labor. We summarize the U.S. Public Health Service guidelines on
intrapartum clinical care as well as highlight the importance of
follow-up care for both the woman and the also describe some management
considerations when implementing a program such as this[.]{dir="rtl"}

[]{dir="rtl"}

As I mentioned, choosing the type of test is a critical decision to be
made before getting started. And currently, there are four rapid HIV
tests that are FDA-approved. Those include OraQuick, Reveal, Unigold,
SUDS, and I have on this table, the Single EIA. Elisa has typically been
the standard -- is the standard test used for HIV testing. I don\'t
include SUDS on this slide, as it\'s no longer being produced in the
U.S. this table is -- I put this table out to show you some of the
differences as far as positive predictive value using a single
screen[.]{dir="rtl"}

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This has been a primary concern among clinicians considering rapid
testing in labor and delivery. The concern being false-positive results.
You see with the OraQuick test, a prevalence of 0.1% which is somewhat
typical across the U.S. 50% of the positive results may be
false-positives. However, in higher prevalent settings such as a 1% or
higher, the predictive value is much better. We recommend, for any woman
with -- without documented tests that they still be offered a rapid
test, because we -- the benefits of anti-retroviral far outweigh the
risks of having a false-positive result[.]{dir="rtl"}

[]{dir="rtl"}

Just to reiterate the rationale for rapid testing in labor and delivery,
until all women access screening prenatally, the promise of the
(inaudible) 076, another clinical trials can\'t be realized in and that
is reducing rates down to 2% or less. Rapid testing in labor and
delivery provides this last opportunity to reduce the impact of these
missed prevention opportunities. So to reiterate, CDC\'s recommendation
is that hospitals should adopt a policy of routine rapid HIV testing,
using an opt-out approach for women who have undocumented HIV test
results when presenting to labor and delivery[.]{dir="rtl"}

[]{dir="rtl"}

To facilitate implementation, CDC is partnering with several national
partners, including the American College of Obstetricians and
Gynecologists, American Association of Maternal Child Health Programs,
Health Research and Education Trust, the -- an affiliate of the American
Hospital Association, as well as City Match. We are planning most
closely with (inaudible) center six or seven regional trainings
beginning this summer in \'04 and continuing through 2005[.]{dir="rtl"}

[]{dir="rtl"}

We are also developing training materials such as Web-based and CD
Web-based and CD-ROMs for those who can\'t attend our regional
trainings. We\'re working to provide technical assistance to our State
guarantees and we\'re also, as Stephanie mentioned, prenatal and labor
and delivery testing through the medical chart abstraction as well as a
hospital survey conducted by HRET[.]{dir="rtl"}

[]{dir="rtl"}

I wanted to describe some materials that are available not only for
rapid testing but for prenatal testing. We have worked with ACOG for
several years to develop a clinician folder, which includes important
patient brochures, information sheets, ACOG and AAP joint policy
statement. And also there is the (inaudible) clinician anti-retroviral
pocket guide, which is in a card that can sit in a clinician\'s pocket
-- the anti-retroviral prophylaxis guidelines[.]{dir="rtl"}

[]{dir="rtl"}

As I've mentioned we\'ve developed this model protocol, and the HIV/AIDS
News Center has a slide set that they discovered in conjunction with the
AIDS Education is Training Centers. It\'s a faculty trainer provides
that. And then, of course, the HIV/AIDS News Center has a training
curriculum for perinatal HIV transmission prevention. To access some of
these materials, you can go to our CDC Web site, which is listed here.
There\'s also for your information the U.S. Public Health Service
perinatal anti-retroviral prophylaxis guidelines, the AIDS Education and
Training Centers are -- has a very good Web page specific to perinatal.
The American College of Obstetricians and Gynecology, you can access
their materials from their Web site. And then the HIV/AIDS News Center
and others have posted many of their materials on the Women Children and
HIV Global Resources Web site, which is done with the University of
California in San Francisco[.]{dir="rtl"}

[]{dir="rtl"}

With that, I would like to turn it back over to our organizers and thank
you very much for inviting Dr. Sansom and my participation in this very
worthwhile and important topic. Thank you[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you very much to both of you for
your overview of CDC\'s perinatal HIV screening initiative. I\'d like to
note for our participants that the resources that Dr. Lampe mentioned at
end of her presentation are posted under the resources section on the
Dataspeak Web site[.]{dir="rtl"}

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> We have the opportunity to hear from two States with differing --
> about their experiences in trying to implement HIV screening for all
> pregnant women. In both of these States, partnerships between the
> States' MCH and AIDS programs has been critical to their efforts to
> women reach women and their providers. Had is the reason we have efrlg
> is people involved in making each of the State presentations today. So
> that we can hear from officials from both the MCH and AIDS program.
> Our first presentation will be from South Carolina Department of
> Health and Environmental Control. Representing the agency are Sara
> Balcerek, Sarah Cooper, and Lynda Kettinger. Thanks for all of you for
> being here. I\'ll now turn the floor over to you[.]{dir="rtl"}

[]{dir="rtl"}

**Sara Belsaric** []{dir="rtl"}Hello. My name is Sara Balcerek. I\'m the
Bureau Director for the Bureau of Maternal and Child Health at the South
Carolina Department of Health and Environmental Control. The other
presenters today are Lynda Kettinger, and she is in the Bureau of
Communicable Disease and is the Division Director for the STD and HIV.
And Sarah Cooper who is Division Director within MCH who\'s the Division
Director for Women and Children\'s services[.]{dir="rtl"}

[]{dir="rtl"}

> I want to explain before we move on a little bit about how South
> Carolina\'s organized in the health department that enable us to
> facilitate collaboration across the bureaus. We\'re a small State. We
> only have 46 counties, and they\'re organized into 12 health
> districts. Each health district provides services through the county
> health departments[.]{dir="rtl"}
>
> []{dir="rtl"}
>
> One of the things that\'s a little bit unique about South Carolina is
> that we are essentially organized health -- a centrally organized
> health department so all of the county services are accountable and
> report through the districts. The districts report to health services.
> That makes it much easier for us to implement consistent policies and
> to provide (inaudible) that is consistent across all of our county
> health departments. Here in central office, those are the bureaus that
> we\'re talking about today are located in the same building and under
> the same Deputy Commissioner and Assistant Deputy
> Commissioner[.]{dir="rtl"}
>
> []{dir="rtl"}
>
> We have a long history of working together on collaborations and
> integrated services. Sarah Cooper is going to explain a little bit
> about some of the history of those collaboratives and then Lynda
> Kettinger will give more detail about the specific initiative. I\'m
> going to turn this over now to Sarah Cooper[.]{dir="rtl"}

[]{dir="rtl"}

**Sarah Cooper** []{dir="rtl"}Hi. This is Sarah Cooper. And I just
wanted to reinforce what Sara said about the long history that we have
of developing partnerships and delivering services. The kinds of things
that we have done is assured prenatal screening for all prenatals who
come into our services. We have had, and you have the slide there, we
have co-funded an HIV social work consultant. We\'ve been awarded a RWJ
grant, Title IV project, and several other initiatives and have
developed mutually the prenatal screening recommendations[.]{dir="rtl"}

[]{dir="rtl"}

I think it\'s important to also say that one of our partnerships is that
we jointly participate in is both our Commissioner of Public Health. He
has an advisory committee for peds. trainings across -- pediatricians
across the State and obstetricians across the State. And both divisions,
STD/HIV and women and children service and the Bureau of Children and
Child Health participate in those meetings and then from then we can get
a lot of consensus about the decisions and the policies that we
develop[.]{dir="rtl"}

[]{dir="rtl"}

We have also many of our nurses in the clinics are cross-trained to
provide integrated preventive health services, which include services to
family planning recipients as well as those who might come in for
sexually transmitted disease services, such that we have a combined
clinical approach to support these partnerships that we have. With that,
I\'m going to turn this back over to Lynda Kettinger, who will go
through some of our data[.]{dir="rtl"}

[]{dir="rtl"}

**Lynda Kettinger** []{dir="rtl"}Hello. This is Lynda Kettinger, and I
will describe some examples of partnerships with MCH around HIV
perinatal prevention efforts. One area of collaboration has been efforts
to assess the level of HIV prenatal screening in South Carolina. And
we\'ve used a variety of provider and consumer surveys to assess
screening rates[.]{dir="rtl"}

[]{dir="rtl"}

Some examples of provider surveys were in 1997 we did a male survey of
whites and physicians and asked them how often do you or do you
routinely screen pregnant women for HIV. 97% had reported that they
routinely screened pregnant women in their practice. However -- pregnant
women in their practice. However 27% indicated they provided this
screening without patient consent. We also did a hospital survey in 2000
where we partnered with our MCH Regional Perinatal System staff who work
routinely with the hospital labor and delivery staff. And so they were
able to provide the survey to the staff, ask them or encourage them to
complete the survey, and were able to collect the surveys back and
provide them to us. And this worked really well[.]{dir="rtl"}

[]{dir="rtl"}

We had 94% of our hospitals respond with the survey. At that time, we
were asking the hospitals primarily -- did they have policies and
procedures in place to offer HIV screening during labor and delivery?
And about 54% did not provide rapid HIV screening at that
time[.]{dir="rtl"}

[]{dir="rtl"}

We also used the PRAMS survey, which is the pregnancy risk assessment
and monitoring surveillance survey, which is a survey of women
delivering live births in our State. And in year 2000 there was a
question added that stated, at any time during your most recent
pregnancy or delivery, did you have a blood test for HIV? And in South
Carolina, 81% indicated -- 81% of the women indicated that they did have
a blood test. About 18.7% said no. And of those women who said no, the
most common reason stated was -- was that they weren\'t offered the test
or they didn\'t think that they were at risk. If we look at the no
responses being 18% and compare it with the provider survey that we had
done earlier where 21% indicated that they screened women without
patient consent, we have reason to believe that more women may actually
have been screened but they just were not aware about it[.]{dir="rtl"}

[]{dir="rtl"}

Another area of collaboration has been in our efforts to educate and
reach prenatal providers to increase their awareness of HIV perinatal
transmission and to promote our recommended screening and treatment
recommendations. We have used a variety of mechanisms such as providing
updates to our Commissioner\'s OB Task Force made up of obstetricians in
the State. We have provided training to various prenatal and pediatric
providers around the public health recommendations for screening and
treatment. We have utilized a publication of our health department
called Epi Notes which is mailed to all primary care physicians,
laboratories, and it includes prenatal providers where we\'ve written
articles such as the results of our screening surveys that we did back
in 1997 and 2000[.]{dir="rtl"}

[]{dir="rtl"}

We have also recently developed some recommended prenatal screening for
HIV as well as other STDs and have published that on our Web site,
really at the recommendation of our OB Task Force who thought that it
would be very useful if we had the screening recommendations easily
available[.]{dir="rtl"}

[]{dir="rtl"}

So how well are we doing with our efforts in promoting screening and
reducing perinatal HIV transmission? Just to quickly show you some
examples of some slides that we have used when we have made our
presentations to providers, we have shown them slides that points out to
them how many women each year, how many HIV-infected women each year are
delivering babies. And in South Carolina, pretty much for the last ten
years, we\'ve had an average of 100 infants born annually exposed to
HIV. We have made progress in our screening rates[.]{dir="rtl"}

[]{dir="rtl"}

This slide shows you what our time of HIV diagnosis was in 1994 compared
to 2002. And this slide basically shows that women are being screened
earlier in the course of their pregnancy or even before pregnancy in
2002 as compared to ten years ago. We\'ve also made progress in the
proportion of HIV-infected women who have been prescribed AZT during
their pregnancy, during labor and delivery, and whose infants also
received AZT for the neonatal period. And we have at least 80% of
HIV-infected pregnant women who have received all three phases of this
treatment. And we -- and that has increased over time. And all of this
has resulted in our successful efforts like the country has seen in
dropping the number of perinatally acquired HIV from about 14 babies
born each year at 1994 down to 3 infants the last two years, which we
have data available for[.]{dir="rtl"}

[]{dir="rtl"}

We feel we have made significant progress, and we really attribute a lot
of this to our collaborative efforts with our MCH partners. We\'ll
continue to work with them around future efforts to assess screening
rates such as participation with CDC -- participation with CDC\'s
Medical Chart Review Project that is undergoing this year, and also as
we look to look at what we can do further to work with women who may not
be accessing prenatal care early, or who may need additional
interventions to help ensure that they maintain their prenatal care v
visits, their medical care and adhere to their treatment regimens. So
that\'s a brief summary of our partnership efforts. Thank
you[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you very much, to our South
Carolina team. Our next presentation is from Utah, which is represented
by three officials from the Utah department of health. Nan streeter,
Theresa Garrett and Lois Blobaum. They will talk about their experiences
about hi vismt testing of pregnant women. Thanks to all of you being
here. I will now turn the floor over to you[.]{dir="rtl"}

[]{dir="rtl"}

**Nan Streeter** []{dir="rtl"}Good afternoon. This is Nan Streeter,
Maternal and Child Health Bureau Director with the Utah Department Of
Health which is a State Title V agency that has partnered with the
Department as well as external partners to do some work on prevention of
perinatal HIV. The partnership actually started with participation in an
AMCHIP action learning lab on the prevention of perinatal HIV, which
involved external partners which you can see on this slide. I\'m going
to turn the time over to my colleagues Theresa Garrett who\'s with the
Bureau of Communicable Disease Control, and Lois Blobaum who is with the
Reproductive Health Program. And they will tell you little bit about the
efforts that they have been involved in. On this. Next
slide[.]{dir="rtl"}

[]{dir="rtl"}

**Theresa Garrett** []{dir="rtl"}Good afternoon. My name is Theresa
Garrett. And I direct the Bureau of Communicable Disease Control. Within
my Bureau, I have responsibility for all the Ryan White Title II
programs as well as HIV prevention and surveillance
activities[.]{dir="rtl"}

[]{dir="rtl"}

As part of the action learning lab, our first step was to look at the
data that we presently have within the health department. We looked in
three places. The first place we looked was the epidemiological data.
Approximately 15 women have delivered live infants during the last two
years. These women all have as a key risk factor injecting drug use
either with a personal history or having a partner who has been an
injecting drug user. Disproportionately Hispanic and African-American
women are affected by HIV infection in Utah across all risk
groups[.]{dir="rtl"}

We also did a match with the birth certificate data, and we didn\'t find
any additional cases there[.]{dir="rtl"}

[]{dir="rtl"}

Slide four. The second set of data that we examined was the Pregnancy
Risk Assessment Monitoring System or the PRAMS data. We have two key
questions that get asked each year in this process. The first question
addresses whether a health care provider talked with the woman about
getting HIV tested. And you can see the answer is -- about 27% recalled
that happened to them. And the second question is asking if the person
wanted to have an HIV test. And approximately 47% remember being asked
if they wanted to have an HIV test. Clearly, looking at this information
it\'s left a lot of gaps in knowledge and understanding of process for
us[.]{dir="rtl"}

[]{dir="rtl"}

Slide five. So our team set two goals to start with. The first was to
improve our data collection and analysis, particularly looking at HIV
prevalence among pregnant women and understanding more about counseling
and testing practices in offices and places where women receive prenatal
care. And the second goal was to really foster an integration of
universal counseling and testing in prenatal care
practices[.]{dir="rtl"}

[]{dir="rtl"}

Slide six. CDC guidelines focus on universal testing providing treatment
for HIV infection where appropriate for pregnant women, and encouraging
testing of women presenting in active labor into -- labor and delivery
units who have no HIV testing results documented in their medical
record. So in light of that[,]{dir="rtl"}

[]{dir="rtl"}

slide seven, please. We undertook a couple of different projects with
our team. I\'ll talk about the first one. With the assistance of our
partners in the department of obstetrics about gynecologist from the
you\'ve of -- University of Utah --Utah, hospitals in greater Salt Lake
area participated in this project[.]{dir="rtl"}

[]{dir="rtl"}

Slide eight. Three key questions were asked. The first was HIV screening
discussed during your prenatal care? And the second, as you can read.
And what was most intriguing to us about this information was the wide
variation ranging from 34% to 72%. The letters on this slide indicate
the hospitals. So hospital A was 34%. The women recalling this
information and hospital B was 72%. So there was a wide range. And this
also differed quite dramatically from what we saw in our PRAMS data.
I\'m going to turn the time over to my colleague, Lois Blobaum, who\'s
going to talk about the rest of the work that we\'ve been
doing[.]{dir="rtl"}

[]{dir="rtl"}

**Lois Blobaum** [ ]{dir="rtl"}Good afternoon. Could I have slide nine,
please[?]{dir="rtl"}

[]{dir="rtl"}

I\'m going to tell you a little bit about a project that the task force
took on to survey prenatal care providers throughout the State. The
purpose of the study was to understand providers\' practices regarding
universal HIV testing for pregnant women[.]{dir="rtl"}

[]{dir="rtl"}

Slide ten, please. Our data collection process entailed two mailings of
questionnaires to approximately 470 providers through a three-month
period in 2003. The providers that we included involved all the levels
of prenatal care providers in the State[.]{dir="rtl"}

[]{dir="rtl"}

Next slide, please. Our results were 59% response rate, as I mentioned
where after two mailings. And as you can see, I've given you a little
bit of information about their demographics as our prenatal care
providers in Utah[.]{dir="rtl"}

[]{dir="rtl"}

Next slide, please. The survey indicated that when asked how many
pregnant patients were offered HIV testing, 70% of the providers
reported offering it to all their pregnant patients. Slide 13, please.
We look at the percent of providers by provider type, and notice that
certified nurse-midwifes offered HIV screening at a higher rate than
medical doctors[.]{dir="rtl"}

[]{dir="rtl"}

Next slide, please. We also noted that female providers offered HIV
testing to all their pregnant patients at a higher rate than their male
counterparts[.]{dir="rtl"}

[]{dir="rtl"}

Next slide, please. We also asked the providers a little bit about their
informed consent process and found that 58% of providers reported that
all of their patients signed an informed consent for HIV
testing[.]{dir="rtl"}

[]{dir="rtl"}

Slide 16, please. We also noted information about pre- and post-test
counseling and found that over half reported that most to all of their
pregnant patients received pretest counseling while only 51% received
posttest counseling[.]{dir="rtl"}

[]{dir="rtl"}

Slide 17, please. We also surveyed the providers about their knowledge
of ACOG guidelines and found that very little difference existed in
counseling and testing rates among those providers who were aware of the
ACOG guidelines versus those providers who were not familiar with the
guidelines[.]{dir="rtl"}

[]{dir="rtl"}

Slide 18, please. These next two slides indicate that providers in Utah
have minimal experience managing HIV positive pregnant women due to our
extremely low prevalence. We found that half of the providers surveyed.
Next slide, please. Stated that their patients\' prenatal care would be
co-managed with another provider. And that provider would most probably
be an infectious disease specialist[.]{dir="rtl"}

[]{dir="rtl"}

Slide 20, please. 30% of the providers surveyed reported that they did
not provide HIV counseling to all of their patients. And among those
30%, the most common reason was the low perceived risk among the
population that they served. Again, as we discussed in the previous two
slides, this is a major barrier for universal prenatal testing in Utah,
lower prevalence indicates that provider don\'t feel like it\'s a risk
among their populations[.]{dir="rtl"}

[]{dir="rtl"}

Slide 21, please. One limitation of this study is the relatively low
response rate just by two mailings of the survey, 59% response rate. We
need to take into consideration may not be totally representative of our
prenatal care practices in Utah[.]{dir="rtl"}

[]{dir="rtl"}

Slide 22, please. So the recommendations that we derived from the
prenatal care provider survey mainly was the importance of emphasizing
to our providers that women will be missed if a risk-based approach is
used. We need to work to educate our providers about the opt-out
approach to prenatal care, the prenatal testing which we feel will
relieve one of the barriers. And also to continue to provide support to
help them offer HIV prevention education to women[.]{dir="rtl"}

[]{dir="rtl"}

Slide 23, please. Finally, the Task Force remains active, and I've
listed on this slide some of our plans for the future. You can also find
our current action plan on the Dataspeak Web site that you can feel free
to download. Thank you for your time and attention[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you to our team from Utah and to
all of our presenters. We now enter the question and answer part of our
program. And we have all our presenters standing by to respond to your
questions. I do realize we are running a bit behind schedule, but we do
have several questions that have come in from the audience already. So I
will go over a few minutes to give us a chance to address
them[.]{dir="rtl"}

[]{dir="rtl"}

As I mentioned at the beginning, we are able to take questions both
online and from our telephone participants. To post questions online,
click the button that says \'in writing\' at the bottom of your screen
under the heading \'communicate with lecturers\' and write your message
and click \'send.\' At this time I'd like to ask our operator to come on
the line and tell our participants how they can ask a
question[.]{dir="rtl"}

[]{dir="rtl"}

**Operator (Kevin)** []{dir="rtl"}Ladies and gentlemen, at this time, if
you have a question, you will be able to press the star key followed by
the one on your telephone. And please be aware that your questions will
be taken in the order they\'re received. If your question has already
been answered, you may remove yourself from the queue by pressing the
star key followed by two. Also if you are using a speaker phone, please
pick up your handset before pressing the button. Again, that\'s star one
to ask a question[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you, Kevin. Well, while folks on
our telephone are queuing for that, I\'m going to start with a question
from our Internet audience[.]{dir="rtl"}

[]{dir="rtl"}

Has to do with the topic of informed consent, which is obviously an
issue that was raised by the presentations we heard from South Carolina
and Utah. And the question, which I'd like to address to Stephanie
Sansom of CDC, is this, is there any evidence to suggest the possibility
that health care providers who operate in very busy prenatal care
practices may overlook the requirement to inform women of their opt-out
option? And how will providers be monitored to ensure that women\'s
rights are protected particularly for when they may have reduced
communication skills[?]{dir="rtl"}

[]{dir="rtl"}

**Stephanie Sansom** []{dir="rtl"}Thank you. That\'s a very good
question. As you know, CDC advocates -- or has recommended that this
opt-out approach include that at minimum, sufficient written information
be provided to women so that they can make an informed decision,
information about perinatal transmission and why testing is recommended
and of the interventions that are available to reduce transmission. I\'m
not currently aware of studies that are being done to monitor the
(inaudible) gap because this is all very new -- monitor the extent to
which women feel that they got enough information but I'm sure that they
will be conducted. I think it\'s a very good question[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you. Why don\'t I just open the
floor to members of our State presenters. Lynda Kettinger, would you
like that comment on that question? Okay. I\'m going to move on to the
next question. I\'m going to go back to our telephone audience. Kevin,
do we have anybody from our telephone audience who would like to ask a
question[?]{dir="rtl"}

[]{dir="rtl"}

**Operator (Kevin**) []{dir="rtl"}at this time, I show no
questions[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Okay. Thank you. Then I'm going to ask
another question from our Internet audience. And I'd like to address
this to South Carolina, Lynda, if you are there, and the question is,
did you work with your HRSA-funded AIDS Education And Training Center to
conduct the training to PRAMS[?]{dir="rtl"}

[]{dir="rtl"}

**Lynda Kettinger** []{dir="rtl"}Yes, we did. I\'m here. I\'m sorry. I
didn\'t get to respond earlier. But with respect to this question, we
actually provided a small amount of funding and contracted with our
South Carolina AIDS Training Network, which was part of the Southeast
Regional Training Network. And they were responsible for setting up
training and information dissemination activities to reach our perinatal
providers[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you what about Utah? Lois, would
you like to comment on that question? Is there work that you did with
aids education and training centers[?]{dir="rtl"}

[]{dir="rtl"}

**Lois Blobaum** []{dir="rtl"}actually, our AIDS Education And Training
Center Director, Michael Rigdon is a member of our task force. So
Michael has been involved from the beginning of our work with the action
learning lab process and continues to be involved[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you very. I have another question
I'd like to address to Margaret Lampe at CDC. And the question is, if we
are not one of the eight States that the CDC will abstract data from,
what specific strategies can State and local health departments
implement to promote rapid testing during labor and delivery and HIV
testing during prenatal intake[?]{dir="rtl"}

[]{dir="rtl"}

**Margaret Lampe** []{dir="rtl"}The question refers to two different
things. We -- Stephanie is actually leading a project to monitor testing
rates in eight States. And I work with our grantees and national
partners to promote rapid testing in labor and delivery settings. There
-- and so I guess the question then is how does one promote rapid HIV
screening in labor and delivery in their own jurisdiction? And we have
actual -- there is this model protocol available which clearly
articulates CDC\'s recommendation and has practical guidance on how to
implement rapid testing in labor and delivery. And that\'s available on
our Web site, and we also are having hard copies printed that can be
distributed. And if you would like a hardcopy of it, you could get that
through the national prevention information network, NPIN. Other ways
are how you typically promote behaviors of health care providers in a
variety -- in your setting through perhaps special marketing campaigns
or grand rounds training at your hospitals and so forth. I hope that
answers your question[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you very much, Margaret. Kevin, do
we have any questions from our telephone audience[?]{dir="rtl"}

[]{dir="rtl"}

**Operator (Kevin)** []{dir="rtl"}At this time, we still do not have any
questions[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Okay. Great. Then what I'd like to do is
just pose one final question to conclude our program, and I'd like both
of the States to comment on this, if they would, and we\'ll start with
Lois Blobaum in Utah. And that is, a question about collaboration
between your State\'s Title V MCH programs. We obviously selected Utah
and South Carolina because they do have this collaboration and it\'s
something we\'d like the other States to learn from. Utah, is there
anything that you can offer to States that might not have the same
history of collaboration between these programs to facilitate their
working around this issue[?]{dir="rtl"}

[]{dir="rtl"}

**Lois Blobaum** [ ]{dir="rtl"}Beth, I can honestly say that we had
collaborated minimally prior to the opportunity that AMCHIP and ACOG
offered us with the action learning lab process. But that was extremely
instrumental. It allowed us to carve out time and work together in a
facilitated environment. And since that experience, we continued to
collaborate. We share costs. We share staffing for all of our projects
and that process has been really helpful. So I would encourage States to
take advantage of that opportunity if it\'s going to arise
again[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}I believe as was mentioned earlier in
the program, there are going to be additional action learning labs
funded and there can be information obtained from that through the
association of maternal and child health programs. And a living to their
site is on our Dataspeak Web site. Lynda Kettinger from South Carolina,
would you like that comment on this question[?]{dir="rtl"}

[]{dir="rtl"}

**Lynda Kettinger** []{dir="rtl"}Sure. I think that one of -- I just
have to say that one of the reasons why I think we\'ve been able to form
such good collaboration here, it\'s something you can\'t replicate
easily in other places, is because a lot of us have been here for a long
time working together. So we have known each other in various roles at
various times, and we have just formed that knowledge and network that
was really useful as we started our perinatal HIV prevention
efforts[.]{dir="rtl"}

[]{dir="rtl"}

> But in addition to that, I think some things that help, money helps.
> In other words, when we, for example, were applying for the CDC
> perinatal prevention funding, CDC requested and I guess required that
> we have evidence of working with our MCH partners. So in our planning
> of what we were going to do with those funds, we included our MCH
> partners in the actual application process. In addition to that, as
> Sarah Cooper mentioned, we have a history of jointly funding staff,
> and I think when we jointly fund staff, it encourages and promotes
> communication around whatever it is that you\'re working
> toward[.]{dir="rtl"}
>
> []{dir="rtl"}
>
> And another example of jointly funding staff is we have a Ryan White
> Title IV project, and it\'s a statewide project until South Carolina,
> and we use a part of that funding to actually support a small
> percentage of local health department nursing staff that function as
> case managers. And lot of those staff are MCH staff. And so, again,
> their role is to help work with our pediatric HIV/AIDS providers in
> following up with babies born exposed to HIV, ensuring that they are
> linked to our Title IV system and to offer any assistance that those
> providers have in making sure that the mothers and babies are keeping
> their appointments, etc. So I guess -- I think those are the most
> important things that have facilitated collaboration for
> us[.]{dir="rtl"}
>
> []{dir="rtl"}
>
> One other thing is that we do have a plan in process in our health
> services area that is -- that promotes and e encourages joint
> participation across programs in planning our strategies. Of course,
> we\'ve integrated our planning efforts with MCH and HIV activities,
> and it\'s a very strongly promoted planning process and that also
> helps to facilitate collaboration[.]{dir="rtl"}

[]{dir="rtl"}

**Beth Zimmerman** []{dir="rtl"}Thank you very much. Definitely good
lessons are learned the importance of joint planning and going further
to fund joint activity and staff. That is all the time we have for
discussion today. This program will be archived on the Dataspeak Web
site in the next few weeks so that you can access it at your
convenience. Before you log out, we would greatly appreciate your taking
a moment to complete the feedback form that you will be seeing in a
moment on your screen. I\'d like to thank our presenters and all of you
in our audience for participating in today\'s program. And we hope that
you will join us again on June 30th for our program on integrated child
health information systems[.]{dir="rtl"}