Table 4. Reasons for testing (n = 272) * Good idea to have it as a routine test Concerned about my own health Concerned about risks to the baby Because it was offered Clinic staff thought it was a good idea *Study participants could choose multiple responses. doi:10.1371/journal.pone.0005166.t004 Abbreviated (n = 133) No. (%) 118 (89.4) 114 (86.4) 108 (81.8) 106 (80.3) 87 (65.9) Standard (n = 139) No. (%) 127 (91.4) 119 (85.6) 112 (80.6) 113 (81.3) 95 (68.3) p- value .58 .86 .79 .84 .67 While we attempted to minimize bias with the use of blinded study staff, standardized protocols and validated instruments, our study had limitations. As with most surveys assessing patient satisfaction and perceptions, participants may have been biased towards reporting positive attitudes towards testing and limited decisional conflict, despite reassurances about confidentiality of responses and the use of blinded study staff. The slight, though statistically insignificant, higher mean decisional conflict score seen among women in the abbreviated arm suggest that responses may indeed have been truthful. While we did not monitor in real time the nurses administering the standard and abbreviated counseling scripts, we utilized standardized protocols and scripts and trained the nurses during study implementation and conducted on-going education to the nurses about study protocols. Nonetheless, there may have been deviations from the assigned consenting script that went unnoticed. Moreover, efforts to optimize the uptake of prenatal HIV testing in this clinical setting were instituted prior to initiation of this study even with the use of more traditional standard pre-test counseling by nurses as we have reported elsewhere. [29] Given the very high acceptance of prenatal HIV testing under non-study conditions at our clinic, our results may not be generalizable to other clinical settings with lower baseline uptake of HIV testing. Similarly, our results may not be generalizable to areas with less developed HIV educational and public health campaigns as compared to San Francisco. Lastly, participants were, by definition, willing to give additional time and effort to participate in this research. As such, participants may have differed in significant and clinically relevant ways from non- participants. In particular, participants may have been more agreeable to health interventions as compared to non-participants and, thus, may have biased the data toward increased satisfaction and minimized the differences between the 2 arms of the study. This bias may also limit the generalizability of our results to References 1. US Department of Health and Human Services Office of the Inspector General (2002) Reducing Obstetrician Barriers to Offering HIV Testing. Washington, DC: US Department of Health and Human Services. 2. (2002) From the Centers for Disease Control and Prevention. Progress toward elimination of perinatal HIV infection–Michigan, 1993–2000. MMWR Morb Mortal Wkly Rep 51: 93–97. 3. (2002) HIV testing among pregnant women–United States and Canada, 1998– 2001. MMWR Morb Mortal Wkly Rep 51: 1013–1016. 4. Chou R, Smits AK, Huffman LH, Fu R, Korthuis PT (2005) Prenatal screening for HIV: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 143: 38–54. 5. Phillips KA, Morrison KR, Sonnad SS, Bleecker T (1997) HIV counseling and testing of pregnant women and women of childbearing age by primary care providers: self-reported beliefs and practices. J Acquir Immune Defic Syndr Hum Retrovirol 14: 174–178. Pretest HIV Counseling Trial populations of pregnant women who would not otherwise participate in research. While selection bias may limit the generalizability of our results, study participation was very high – only 14.5% of women approached for enrollment refused to participate. Despite these potential limitations, this study adds to the growing body of literature evaluating best practices in integrating routine HIV testing into medical settings. While there were no differences seen in testing uptake in our study, this streamlined approach to pretest consenting would likely facilitate the systematic implementation the CDC guidelines recommending universal HIV testing of pregnant women. As such, abbreviated HIV testing strategies may be associated with increased HIV testing uptake on a population level without jeopardizing patients’ decision-making process. There are numerous states in the U.S. that still require detailed pre-test counseling and consenting prior to prenatal HIV testing. [30] These data support the elimination of such requirements and should bolster legislative efforts to update HIV testing laws aimed at decreasing the burden on health-care providers and reducing overall barriers to HIV testing. Supporting Information Appendix S1 Found at: doi:10.1371/journal.pone.0005166.s001 (0.04 DOC) Appendix S2 Found at: doi:10.1371/journal.pone.0005166.s002 (0.04 DOC) Checklist S1 CONSORT Checklist Found at: doi:10.1371/journal.pone.0005166.s003 (0.07 DOC) Protocol S1 Trial Protocol Found at: doi:10.1371/journal.pone.0005166.s004 (0.05 DOC) MB MB MB MB Acknowledgments We would like to thank the women who participated in this study, the nurses at Women’s Health Center at San Francisco General Hospital, Teri Dowling, Julie French, Natalia Leva, Melisa Shah, Cynthia Feakins, Dr. Natali Aziz, Arlette Molina, Abby Sokoloff, Dr. Miriam Kuppermann and Dr. Rebecca Jackson. Author Contributions Conceived and designed the experiments: DC MG. Performed the experiments: DC EG. Analyzed the data: DC EG SW EDC. Contributed reagents/materials/analysis tools: DC MG SW EDC. Wrote the paper: DC EG MG SW EDC. 6. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, et al. (2006) Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 55: 1–17; quiz CE11-14. 7. Stringer EM, Stringer JS, Cliver SP, Goldenberg RL, Goepfert AR (2001) Evaluation of a new testing policy for human immunodeficiency virus to improve screening rates. Obstet Gynecol 98: 1104–1108. 8. O’Connor AM (1995) Validation of a decisional conflict scale. Med Decis Making 15: 25–30. 9. O’Connor AM, Stacey D, Rovner D, Holmes-Rovner M, Tetroe J, et al. (2001) Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. pp CD001431. 10. Simpson WM, Johnstone FD, Boyd FM, Goldberg DJ, Hart GJ, et al. (1999) A randomised controlled trial of different approaches to universal antenatal HIV testing: uptake and acceptability and Annex: Antenatal HIV testing - assessment of a routine voluntary approach. Health Technol Assess 3: 1–112. PLoS ONE | www.plosone.org 6 April 2009 | Volume 4 | Issue 4 | e5166