# Presentation: 584503

## Prevention of Perinatal HIV TransmissioninUTAH-A Low Prevalence State 

- Lois D. Bloebaum B.S.N.
- Manager, Reproductive Health Program
- Utah Department of Health

## Utah Perinatal HIV Prevention Task Force

- Made possible by the Association of Maternal & Child Health Programs (AMCHP) and the American College of Obstetricians and Gynecologists (ACOG) Perinatal HIV Prevention Action Learning Lab (ALL)
- ALL designed to integrate work of health officials supported by Title V, Title II and Title X and ACOG around this important issue

## Utah Perinatal HIV Prevention “Travel” Team 

- Teresa Garrett, R.N., M.S., Director, Bureau of Communicable Disease Control, Utah Department of Health (Title II)
- Lois Bloebaum B.S.N., Manager Reproductive Health Program, Maternal & Child Health Bureau (Title V) Utah Department of Health
- Jennifer Trauscht-Van Horn M.D., Medical Director, Planned Parenthood Association of Utah (Title X)
- Michael Varner M.D. Professor, Maternal-Fetal Medicine University of Utah Department of Obstetrics and Gynecology (ACOG)
- Hilary Evans M.P.A., Director, Community Building Community, Midvale City
- Wanda Gutierrez, R.N. Bureau of Managed Care, Division of Healthcare Finance, Utah Department of Health

## Utah Perinatal HIV Prevention Task Force

- “Travel Team” of individuals convened in Washington D.C. July of 2002
- Provided two days for uninterrupted focus on issue, facilitated by insightful, thought-provoking leadership provided by AMCHP and ACOG representatives
- Developed ACTION PLAN

## Utah Perinatal HIV Prevention Task Force

- Convened both “travel” and “home” teams during 2002 and 2003 to follow up on action plan
- Travel team to Chicago July 2003 to report on progress and update action plan

## 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

## Pregnancy Risk Assessment Monitoring System Data (1999)

- 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%)

## 2002-2003 Goals  

- Improve data collection and analysis on:
- 	a. HIV counseling and testing practices
- 	b. HIV prevalence among pregnant women
- Foster integration of universal counseling and testing into prenatal care practices

## 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

## 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

## 
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%

**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%**

- Multi-hospital Quality Improvement Project (cont.)

## 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.

## Methods

- <date/time>

- 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).

## 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.

## 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”

## 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

## 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.

## 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.

## 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.

## 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.

## Prenatal Care Providers’ Experience with Diagnosing and Treating Pregnant Women with HIV

## 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.”

## 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%)

## 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

## 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 revised guidelines.
- Educate prenatal care providers about the “opt out” approach to prenatal testing.
- Offer HIV prevention education to pregnant women.

## 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

## Recent Taskforce Activities 

- Presentation to Medicaid contracted HMO’s QI, case management, and provider relations staff
- “Dear Colleague” CDC letter to prenatal care providers regarding  universal “opt-out” testing
- Presentation to the Rocky Mountain Public Health Consortium
- Postcard notifying prenatal care providers of CDC guidelines for rapid testing at L & D
- Presentation to University of Utah College of Nursing C.N.M. students
- Presentation to Utah Perinatal Association

## Evaluation 

- Phase V PRAMS (2004 data available ~ spring 2006)
- At any time during your most recent pregnancy or delivery, did you have a test for HIV (the virus that causes AIDS)?
- Were you offered an HIV test during your most recent pregnancy or delivery?
- Did you turn down the HIV test?
- Why did you turn down the HIV test?

## Slide 29