Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
LESLIE E. LISCOMB: Thank you, Margaret. Good morning. I’ll be presenting data on the prenatal care discussion of HIV testing among women having a live birth in 17 states, and I’m using 1996 to 1999 data. I’d like to acknowledge my coauthor, Dr. Amy Lansky. I’d also like to acknowledge the assistance of *Raquel *Richards, *Brian *Morrow, and the PRAMS working group, which consists of a representative from each of the PRAM states. Just to give some background, HIV, the virus that causes AIDS, can be transmitted from the mother to the infant during pregnancy, during delivery, and through breastfeeding. For several reasons, it is important that health care providers discuss HIV with their pregnant patients and counsel them about getting tested for the disease. More than 80 percent of pediatric HIV infections and almost all of pediatric AIDS cases are linked to maternal transmission. Some recent research shows that two-thirds of maternal to infant transmission of HIV can be prevented with antiretroviral medication during pregnancy.
In 1995, because of the proven success of antiretroviral medication in preventing maternal to infant transmission, the U.S. Public Health Service recommended that pregnant women be offered counseling and voluntary HIV testing. Our objective is to assess the implementation of the 1995 U.S. Public Health Service recommendation, and we’re doing this by examining trends and the prevalence of self-reported receipt of HIV counseling during prenatal care. And we’re using the PRAMS data from 1996 to 1999. PRAMS is a state-specific, population-based surveillance system. It started in 1987 and has been ongoing ever since. States collect data using a standardized protocol. PRAMS collects information on maternal attitudes, behaviors, and experiences around the time of pregnancy. Women having a recent live birth are sampled from the birth certificate files, and they receive a mailed questionnaire at two to six months postpartum, and there’s telephone follow-up for non-responders. In 1996, questions about the overall content of prenatal care during pregnancy were incorporated into the PRAM survey.
Women were asked whether during any prenatal care visits, a doctor, nurse, or other health care worker had discussed their getting tested for HIV. This question has been on the PRAM survey since 1996. *Studan software was used to analyze weighted PRAMS data for states in which response rates were 70 percent or higher. Out of 20 states that were collecting data, 17 had data available and met the response rate criteria. All 17 states had data for 1999, and nine of the states had data for the entire period of 1996 through 1999. A *T-test was used to determine any trend for the time period. The map indicates the 17 states that participated in PRAMS from 1996 to 1999 and the nine states in orange are those with trend data. So we’ll be able to look at their data from ’96 through ’99. Here, looking at the trend data, we’re looking at the prevalence of discussion of HIV testing from ’96 through ’99. And these six states experienced significant increases in the prevalence of discussion of HIV testing during the time period under consideration. The largest increases in prevalence occurred in New York, Oklahoma, and West Virginia. New York experienced a 23 percent increase in prevalence from 1996 to 1999; in Oklahoma, there was a 13 percent increase in prevalence; and in West Virginia, there was a 10 percent increase in prevalence.
Now, we’ll look at the other three states that had trend data from ’96 to ’99, but these states had no real change in prevalence. Interestingly, these states were high in prevalence in 1996. They all were above 75 percent. They show little change, but they remain high through 1999. We do see slight decreases from 1998 to 1999 for Florida and Washington, but we must note that it is difficult to get significant increases once prevalence rates are already high. Now, we’ll switch gears and look at 1999 data alone for the 17 states, and here we see the prevalence of discussion of HIV testing by state. And the state range in prevalence is from 47 percent in Utah to 88.4 percent in New York. And Lois kind of talked about why the prevalence in Utah is so low. They are a low incident state, so not much discussion or counseling is going on there.
About three states had prevalences above 80 percent, and those are Florida, New York, and North Carolina. The next few slides will show the range of prevalence of HIV counseling during prenatal care by select demographics. And again, this is 1999 data and for the 17 states. Here, we examine maternal age. In most states in 1999, as maternal age increased, HIV counseling decreased. So if you look at the teens, you see that the range is from 74 percent to 96 percent. And if you look at the women that are 35 and older, their range is 34.4 up to almost 85 percent. Here, we look at the range of prevalence by race, and we see that Black women were more likely than White women and women of other races to report HIV counseling during prenatal care. The prevalence among Black women ranged from about 76 percent to 93 percent. Here, we’re looking at maternal education. And women with less than a high school education were more likely than other women to report HIV counseling, and we see that as education level increases, the HIV counseling decreases. And here, we see that Medicaid recipients were more likely than non-Medicaid recipients to report discussion of HIV testing during prenatal care.
To conclude, in six states, there was a significant increasing trend in the discussion of HIV testing during prenatal care from 1996 to 1999. For three states without an increase, the initial prevalence was high; it was above 75 percent. And report of HIV discussion during prenatal care is more prevalent among women who are younger, Black, those that were less educated, and those that were Medicaid recipients. These data indicate that by 1999, several states had made progress in implementing the 1995 recommendations for prenatal HIV counseling. The demographic differences in prevalence of prenatal HIV counseling support CDC’s initiative to make HIV testing a routine part of prenatal care. This recommendation is one of many milestones in prenatal HIV testing that have come about since 1999. In 2001, the U.S. Public Health Service Guidelines were updated to recommend simplifying the testing process so that pretest counseling is not a barrier to HIV testing. Another recommendation was to make the consent process more flexible to allow for various types of informed consent.
In 2003, CDC’s “Advancing HIV Prevention: New Strategies for a Changing Epidemic” was released, and this plan consists of four key strategies that include further decreasing perinatal HIV transmission by promoting guidance for routine HIV testing of all pregnant women, and as a safety net, for the routine screening of any infant whose mother was not screened. A collaboration between PRAMS and the division of HIV/AIDS prevention has been formed for 2003 through 2007, as indicated by a new HIV testing question being added to the PRAM Phase Five Core survey. On the Phase Five Core survey, we’ll now ask, “At any time during your most recent pregnancy or delivery did you have a test for HIV?” In addition, this partnership will provide opportunities for collaboration on analyses with CDC and the PRAM states. Thank you.