# Presentation: 484141

## Reducing Obstetrician Barriers to Offering HIV Testing

- Ann Maxwell
- Project Leader
- Office of Inspector General
- Office of Evaluation and Inspections

**Notes:**
GOOD MORNING

I am here to provide you with a sneak peak at an IG report that is just about to go final. 

I guess this would qualify as our pre-release promotional campaign to drum up interest in our products.  Coming soon to a theater near you.....

Like any good promotional campaign, I can only offer a teaser.  I cannot provider our actual findings or recommendations.  I have to leave it as a cliff-hanger to entice you to read the report...  

However, I can offer you a look at the data we collected and what says about obstetrician barriers to HIV testing.

First, a little background about the report, so you have a sense of the context, scope and methodology of the findings I will present

## PURPOSE

- Examine obstetrician barriers to offering HIV
- testing to pregnant women and newborns
- in order to reduce the incidence of perinatally
- transmitted HIV

**Notes:**
Modeled very closely on the Congressional mandate

## FINDINGS

- .	Prenatal setting
- . 	Labor & delivery setting

**Notes:**
Our findings can be grouped into 3 categories.

## Prenatal Care Setting: Testing Practices

- To how many of your patients do you offer HIV testing?

**Notes:**
1) Obstetricians in both high and low prevalence counties showed similar standard practices of offering testing.  

2) However, obstetricians in high prevalence counties differ from those in low prevalence counties in other respects regarding their test offering practices.
high prevalence counties

2. More likely to:
    --  “recommend” testing to pregnant women at low risk for HIV rather than 	just “offer” testing. 
    -- document a woman’s refusal of testing and re-offering testing at a 		subsequent prenatal appointment. 
    --- recall receiving educational materials or training from CDC and from 	their State or local health departments significantly more often. 
    ---- know their State laws on HIV testing of pregnant women.

51% - Advise her that I will perform the test and that she has the right to refuse
49% - Offer to perform an HIV test but indicate that it is her choice

## Prenatal Care Setting: Barriers

- 32% of all OBs indicated ever facing a 		barrier that prevented them from 			offering an HIV test to a prenatal patient

-   66 % of OBs reported both routinely   	  	testing and having never encountered a 	barrier

**Notes:**
A.   Barriers less likely to obstruct obstetricians:
1.  Who practice in high prevalence counties
2.  Whose workplaces had written policies on HIV testing of pregnant women.  
3.  who report receiving educational materials or training on 		perinatal HIV from CDC
4.  who knew their State’s laws regarding HIV testing

B.    However, some of the same obstetricians who reported routinely offering testing also acknowledged specific barriers that have prevented that practice on at least one occasion. 

## Prenatal Care Setting: Barriers

- Barriers are less likely to obstruct OBs:
-  	Who practice in high prevalence counties
-  	Whose work places have written policy on HIV 		testing of pregnant women
-  	Who report receiving educational materials or 		training on perinatal HIV from CDC
-  	Who knew their State’s laws regarding HIV 			testing

## Prenatal Care Setting: Barriers

**Barriers That Have Ever Been a Reason for **
**Not Offering an HIV Test to a Prenatal Patient**

**Notes:**
1) Table ranking ob barriers by the number of obs that face them
2) Top three barriers - affected the greatest number of obstetricians
3) Consent and counseling
4) LANGUAGE & LATE ENTRY
+  however, finding language or late entry to be a barrier did not seem to dictate obstetricians' routine testing practice.  
+ Among obstetricans facing any barriers, those obstetricians who routinely offer HIV testing to all pregnant patients were more likely to report a language barrier and late entry barrier than those who only offer testing to some patients.  
+ Thus, it appears that a language and late entry barrier represents an exception to their routine practice.  For these obstetricians, these barriers constitute a practical but formidable problem that arises occasionally.  
+ In qualitative interviews, some obstetricians and other health professionals have noted that a lack of multilingual patient education materials and consent forms and shortages of bilingual staff have exacerbated this barrier.
. 
5) RISK ASSESSMENT 
+ An important difference emerged between the barrier of using risk assessments and the other top barriers.  
+ Although language and late entry barriers seem to operate as exceptions to the physician’s routine practice, an obstetrician’s risk assessments seem to partly determine routine testing practices.  
+ Unlike language and late entry barriers, there is demonstrated a negative relationship between risk assessment barriers and routine test offering practices.  
+ Considering obstetricians who reported any barriers, those who routinely offer HIV testing to all prenatal patients were less likely to identify the risk perception barriers than those who offer testing only to some prenatal patients. 

## Labor & Delivery: Testing Practices

- Do you offer HIV testing to women in labor with unknown HIV status?

**Notes:**
1)  Compare / contrast to prenatal numbers

2) BARRIERS
       A) All Obs -  44% reported at least one barrier during L&D
       B) Predictors
          ---- high prevalence counties less likely to face barriers
          ----- Educational information from the hospital also decreased Obs 		reporting barriers. 

3)  41 percent of obstetricians reported both routinely offering HIV testing during labor and having never been prevented from that practice by any barriers. 

Were some predictors of testing patterns and facing barriers
        A) TESTING PATTERNS
            ---  Obstetricians practicing in a high prevalence county were more likely to routinely offer testing during delivery.  
            ---- educational information or training on perinatal HIV from one’s hospital or from an educational course predicted that an obstetrician routinely offered testing during labor

## Labor & Delivery: Barriers

- 44% of OBs reported at least one barrier
- OBs are less likely to face barriers if:
-  	 practice in high prevalence county
-  	 received educational materials from the 		 hospital

## Labor & Delivery: Barriers

- Barriers That Have Ever Been a Reason for Not Offering an
- HIV Test  to a Patient during Labor and Delivery

**Notes:**
1) Top 4 barriers can be broken into two categories.  Process barriers and technology barriers

2) Process barriers:  60%  
       A) COUNSELING
	---- Obstetricians whose work places had developed a written policy regarding HIV testing of pregnant women were less likely to report insufficient time to counsel

3) Technology barriers: 37%
     --- Conjecture as to why technology barriers not higher.

     --- State HIV/AIDS directors and ACOG representatives identified the unavailability of rapid or expedited tests more frequently than any other barrier during labor and delivery.  

## Obstetrician Solutions

- To What Extent would each of the following help you to
- routinely offer HIV testing to all of your pregnant patients?

**Notes:**
1) The three solutions that obstetricians indicated would be most helpful are:    
     a) including testing in the standard battery of prenatal tests, 	
     b) making voluntary testing of all pregnant women the standard of care in their 	hospital/clinic 
     c) receiving patient education materials.

2) OBs do not seem to favor additional educational or training efforts as the most helpful solutions to promote their routine offering of testing.          
        A)  On this list of 10 possible solutions, obstetricians ranked continuing education courses on perinatal HIV as the 8th  and training on HIV counseling as the 10th  most helpful to them.  
        B)  Furthermore, it appears that most obstetricians pay more attention to educational 	efforts by professional organizations and CDC than by the public health 	department.  
          -----   When asked about the educational materials on perinatal HIV that they received
	-- 94 percent of all OB remember receiving ACOG  materials  
	-- 71 percent remember receiving materials from CDC
	--- only 53 percent remember receiving materials from State/ local health 		departments.  
        ---  This is despite the fact that 90 percent of these obstetricians practice in States where the State health department indicated that they sent materials.  

## Contact Information

- Ann Maxwell
- 312-353-1012
- amaxwell@os.dhhs.gov

**Notes:**
1)  THANK YOU for your time.

2)  I hope that this presentation as well as our report will provide you with useful information as you move ahead with your efforts to maximally reduce perinatal transmission

3) If you have any questions or would like to discuss the issue further, I have put my contact information up.

4)  Thank you.  Are there any questions that you would like to address right now?