# Presentation: 689215

## Barriers and Strategies for Universal Offering and Accepting of Perinatal HIV Counseling and Testing in Los Angeles County: Pregnant Women’s and Providers’ Perspective 

- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Infection Reporting (PHIR) Project
- Pediatric Spectrum of HIV Disease

**Barriers and Strategies for Universal Offering and Accepting of Perinatal HIV Counseling and Testing in Los Angeles County: Pregnant Women’s and Providers’ Perspective **

- Getahun Aynalem, Toni Frederick, Pamela Mendoza
- Laurene Mascola,
- Los Angeles County (LAC) Department of Health Services

## Introduction (I)

_**January 1, 1995**_: LAC mandated all county clinics and hospitals offer universal voluntary HIV counseling and testing to all pregnant women
_**January 1, 1996 (Senate Bill (SB) 189**_: State of California mandated all prenatal care providers offer HIV information, counseling and testing (either directly or through referral) to all prenatal patients and documents that HIV information and counseling has been offered

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Infection Reporting (PHIR) Project
- Pediatric Spectrum of HIV Disease

## Introduction (II) 

- Women with prenatal care in Los Angeles County:
- Not offered testing 		5% - 15%
- Not accepting testing 		8% - 50%
- Are not re-tested later in pregnancy
- HIV infected women with no prenatal care 	7 % - 20%
- Despite declining rates of maternal-infant  HIV transmission, some HIV-infected women are still not identified prenatally

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Infection Reporting (PHIR) Project
- Pediatric Spectrum of HIV Disease

## Objectives

- To identify barriers and strategies of universal offering and accepting of perinatal HIV counseling and testing in Los Angles County (LAC), we:
- Interviewed pregnant women after a prenatal visit and asked about HIV testing and counseling
- Surveyed private OB/GYN practices in LAC using the ACOG directory and hospital lists of on-staff
- Evaluated the availability of HIV educational materials specific to pregnant women at prenatal clinics

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Methods

- Between July 2000 and August 2001, 826 pregnant women were interviewed after a prenatal visit at 33 public and private clinics in LAC.
- Interviews were conducted both in English and Spanish
- Most interviews were performed after their first prenatal visit, random interviews were performed post-partum. .
- Variable collected .....

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Demographic Characteristics of Women Interviewed  (n=826)

- 					_**N**_		_**(%)**_
**Race/Ethnicity:**
- 	White				85		(10.3)
- 	African-American		118		(14.3)
-      	Hispanic			596		(72.2)
- 	Asian/Pacific Islander		19		(2.3)
- 	Other 			8		(1.0)
**Country of birth:**
- 	US				330		(40)
- 	Non-US			496		(60)
**Year Immigrated to US:**
- 	Before 1990			326		(66.7)
- 	1990 - 1996			90		(18.1)
- 	1997 - 2001			80		(16.1)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Demographic Characteristics of Women Interviewed  (n=826)

- 					_**N**_		_**(%)**_
**Age:**
- 	13 - 19			109		(13)
- 	20 - 24			229		(28)
-       25 - 29			229		(28)
- 	30+				255		(31)
- 	Mean 			26
**Insurance:**
- 	MediCal			660		(80)
- 	Pending MediCal		127		(15)
- 	Private/self			15		(2)
- 	None				14		(2)
- 	Other				10		(1)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## HIV Testing & Counseling, LAC, 02/02(n=826)

***DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## HIV Test Acceptance LAC, 02/02(n=826)

***DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## HIV Test Acceptance LAC, 02/02(n=826)

***DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## HIV Test Refusal, LAC 02/02(n=286)

- * p-value < 0.05

***DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## HIV Test Refusal, LAC 02/02(n=826)

- * p-value < 0.01

***DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Reasons for Not Accepting HIV Test(n=65)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Conclusions

- Only half (50%) of women reported receiving information about HIV treatment and pregnancy
- Almost all (99%) women reported that an HIV test was offered prenatally and _eight percent (8%)_ did not accept the HIV test.
-  Women not receiving information about HIV and pregnancy are twice more likely to refuse test than those who did receive information (OR=2.03)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Diseases

## Conclusions

- In logistic regression analyses, non-US born were almost 3 times more likely not to accept HIV testing compared to US born and this relationship remained after controlling for other potential confounders. (age,stay in US, facility type, insurance etc.)
- The most common reasons for not accepting the test were:
- Monogamous relationship for foreign born women (41%)
- Being already tested for US born women (65%)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## OB/GYN Providers Surveys, PSD 2000(n=203)

- A telephone questionnaire was administered to a randomly selected ob/gyn provider in charge of prenatal care
- Prenatal HIV screening practice:
- Provide HIV testing 		201		99%
- Provided counseling		178		89%
- Document	 		187		92%

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## OB/GYN Survey, Perinatal HIV Infection Screening Practice, PSD (n=203)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## OB/GYN Survey, Testing Characteristics if Respondent had Received HIV Training (n=203)

- P<0.05

- P<0.05

- P<0.05

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## OB/GYN Survey, Testing Characteristics if Respondent had Identified an HIV+ Woman

- P<0.05

- P<0.05

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## OB/GYN Survey, Reasons for Test Refusal, PSD (n=203)

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Summary Findings,  OB/GYN Survey, PSD (n=203)

- Fifty seven percent (57%) of providers reported 95-100% acceptance rate, 20% reported 75-94% acceptance rate 10% reported 45-74% acceptance and 11% reported less than 45% acceptance rate.
- Receiving HIV training was associated with more than 75% acceptance rates, documentation in the chart and offering prenatal counseling (p<0.01).
- Test acceptance was associated with the practice being in a high seroprevalence area and previously identifying an HIV + woman (p<0.01).

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project(PHIR)
- Pediatric Spectrum of HIV Diseases

## Availability of Educational Materials Specific to Pregnant women (n=33 clinics)

- 					_**N**_		_**(%)**_
**Brochures:**
- 	Language
- 		English			29		(88)
- 		Spanish			29		(88)
- 	Contents:
- 		HIV test			33		(100)
- 		HIV Risk			31		(94)
- 		HIV treatment		15		(46)
- 		HIV & pregnancy		8		(24)
**Videos:**
- 	English & Spanish		27		(82)
- 	English only			2		(6)
- 	None				2		(6)
**VCR****	****	****	****	****30****	****	****(91)**

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease

## Recommendations

- To increase perinatal test acceptance rate:
- increase the provision of counseling and testing
- increase the training of providers
- address ways to educate women who refuse testing because they are monogamous or afraid to know their status
- Special attention for perinatal HIV screening is needed for pregnant women:
- with no prenatal care, incarcerated/jailed, substance abusers, undocumented, non-English speaking, uninsured, homeless, and teens

***LAC - DHS***
- Acute Communicable Disease Control Unit
- Pediatric HIV/AIDS Reporting Project
- Pediatric Spectrum of HIV Disease