HIV Testing Among U.S. Women During Prenatal Care: Findings from the 2002 National Survey of Family Growth

HIV testing among pregnant women with prenatal care in the United States: An analysis of the 2011-2017 National Survey of Family Growth

Although there has been significant progress in reducing perinatal human immunodeficiency virus (HIV) transmission, the United States is yet to meet the proposed elimination goal of less than one infection per 100,000 live births. Failure to screen all pregnant women for HIV as recommended by the Centers for Disease Control and Prevention can result in missed opportunities for preventing vertical transmission of HIV with antiretroviral drugs. Using the 2011-2017 National Survey of Family Growth, this study examined HIV testing among pregnant women during prenatal care. We estimated the weighted proportion of self-reported HIV testing among women whose last pregnancy ended within 12 months prior to the interview. Logistic regression models were used to determine the factors associated with HIV testing. Of the 1566 women included in the study, 76.4% (95% confidence intervals [CI] = 72.8-80.0) reported receiving an HIV test during prenatal care. In the multivariable regression model, high school diploma (adjusted odds ratio [aOR] = 1.9, 95% CI = 1.1-3.1), two completed pregnancies (aOR = 1.7, 95% CI = 1.1-2.7), health insurance coverage in the last 12 months (aOR = 1.6, 95% CI = 1.0-2.6), Hispanic race/ethnicity (aOR = 2.8, 95% CI = 1.8-4.4), and non-Hispanic black race/ethnicity (aOR = 2.2, 95% CI = 1.3-3.8) were associated with higher odds of reporting being tested for HIV. However, household income of 300% or more of the federal poverty level (aOR = 0.6, 95% CI = 0.3-0.9) and urban residence (aOR = 0.5, 95% CI = 0.3-0.9) were associated with lower odds of reporting HIV testing. These findings suggest that HIV testing among pregnant women during prenatal care is not universal and may affect achieving the goal of elimination of mother-to-child transmission of HIV in the United States.

Self-efficacy and HIV testing among Latino emerging adults: examining the moderating effects of distress tolerance and sexual risk behaviors

Latino emerging adults in the United States are at a high risk of HIV and have a low prevalence of HIV testing. This study examined the association between self-efficacy for HIV testing, distress tolerance and lifetime history of HIV testing, and tested the moderating effect of distress tolerance and sexual risk behaviors on the association between self-efficacy and lifetime history of HIV testing. Data were collected from a cross-sectional sample of 157 Latino emerging adults aged 18-25 using an online survey and were analyzed using hierarchical logistic regression and moderation analyses. We found that 62.8% of those engaging in sexual risk behaviors had ever been tested for HIV. Participants that reported higher levels of self-efficacy (aOR=3.49, 95%CI: 1.78-6.83) were more likely to have ever been tested for HIV in their lifetime. There was a statistically significant three-way interaction among self-efficacy for HIV testing, distress tolerance and sexual risk behaviors (b=2.76, 95%CI: .52, 5.00, p=.016). This interaction suggests that among those that reported any sexual risk behaviors, higher levels of self-efficacy were associated with lifetime history of HIV testing only at higher levels of distress tolerance. Further research is warranted to determine how self-efficacy and distress tolerance work together among high-risk groups to promote HIV testing.

Characteristics associated with lack of HIV testing during pregnancy and delivery in 36 U.S. states, 2004-2013

The Centers for Disease Control and Prevention and the American Congress of Obstetricians and Gynecologists recommend universal prenatal HIV testing to prevent perinatal HIV transmission in the U.S.; since the 1990s perinatal HIV transmission has declined. In 2006, 74% of women with a recent live birth reported testing for HIV prenatally or at delivery. We used Pregnancy Risk Assessment Monitoring System data from 36 states and New York City from 2004 to 2013 (N = 387,424) to assess characteristics associated with lack of self-reported testing and state-to-state variability in these associations. Overall, 75.2% (95% confidence interval [CI] 75.0-75.5) of women with a recent live birth reported an HIV test. There were significant differences in testing prevalence by state, ranging from 91.8% (95% CI 91.0-92.6) in New York to 42.3% (95% CI 41.7-43.5) in Utah. In adjusted analysis, characteristics associated with no reported testing included being married, white, non-Hispanic, multiparous, not smoking during pregnancy, and having neither Medicaid nor Special Supplemental Nutritional Program for Women, Infants, and Children. White married women were 57% (adjusted prevalence ratio [aPR] 1.57, 95% CI 1.52-1.63) more likely to report no test compared to white unmarried women. Multiparous married women were 57% (aPR 1.57, 95% CI 1.51-1.64) more likely to report no test compared to multiparous unmarried women. Women who were married, white, non-Hispanic, and multiparous women were 23% less likely to be tested than other women combined. Marital status was significantly associated with lower prevalence of testing in 35 of the 37 reporting areas, and race was significant in 30 of 35 states with race information. The prevalence of reported HIV testing during pregnancy or at delivery remains below 80%. Opportunities exist to increase HIV testing among pregnant women, particularly among certain subpopulations.

Estimated Perinatal HIV Infection Among Infants Born in the United States, 2002-2013

Importance

Perinatal transmission of human immunodeficiency virus (HIV) can be reduced through services including antiretroviral treatment and prophylaxis. Data on the national incidence of perinatal HIV transmission and missed prevention opportunities are needed to monitor progress toward elimination of mother-to-child HIV transmission.

Objective

To estimate the number of perinatal HIV cases among infants born in the United States.

Design, Setting, and Participants

Data were obtained from the National HIV Surveillance System on infants with HIV born in the United States (including the District of Columbia) and their mothers between 2002 and 2013 (reported through December 31, 2015). Estimates were adjusted for delay in diagnosis and reporting by weighting each reported case based on a model incorporating time from birth to diagnosis and report. Analysis was performed from April 1 to August 15, 2016.

Exposures

Maternal HIV infection and antiretroviral medication, including maternal receipt prenatally or during labor/delivery and infant receipt postnatally.

Main Outcomes and Measures

Diagnosis of perinatally acquired HIV infection in infants born in the United States. Infant and maternal characteristics, including receipt of perinatal HIV testing, treatment, and prophylaxis.

Results

The estimated annual number of perinatally infected infants born in the United States decreased from 216 (95% CI, 206-230) in 2002 to 69 (95% CI, 60-83) in 2013. Among perinatally HIV-infected children born in 2002-2013, 836 (63.0%) of the mothers identified as black or African American and 243 (18.3%) as Hispanic or Latino. A total of 236 (37.5%) of the mothers had HIV infection diagnosed before pregnancy in 2002-2005 compared with 120 (51.5%) in 2010-2013; the proportion of mother-infant pairs receiving all 3 recommended arms of antiretroviral prophylaxis or treatment (prenatal, intrapartum, and postnatal) was 22.4% in 2002-2005 and 31.8% in 2010-2013, with approximately 179 (28.4%) (2002-2005) and 94 (40.3%) (2010-2013) receiving antiretroviral prophylaxis or treatment during pregnancy. Five Southern states (Florida, Texas, Georgia, Louisiana, and Maryland) accounted for 687 (38.0%) of infants born with HIV infection in the United States during the overall period. According to national data for live births, the incidence of perinatal HIV infection among infants born in the United States in 2013 was 1.75 per 100 000 live births.

Conclusions and Relevance

Despite reduced perinatal HIV infection in the United States, missed opportunities for prevention were common among infected infants and their mothers in recent years. As of 2013, the incidence of perinatal HIV infection remained 1.75 times the proposed Centers for Disease Control and Prevention elimination of mother-to-child HIV transmission goal of 1 per 100 000 live births.

Percentage and determinants of missed HIV testing in pregnancy: a survey of women delivering in the Lazio region, Italy

HIV testing is recommended as part of routine preconception and prenatal care but some cases of vertical transmission still occur because of missed HIV testing in pregnancy. We estimated the percentage of women missing HIV testing before delivery, and we evaluated factors related with it. An anonymous survey was distributed to women giving birth during a two-week period in the maternity units of hospitals in the Lazio region of Italy in 2011. Among the 1568 women who filled out the questionnaire, only 33.6% had an HIV test prior to conception, while 88.2% were tested during pregnancy; main reasons reported for missed testing were: not requested by the gynaecologist (57.0%), performed previously (20.7%), requested by the gynaecologist but not done (13.3%) and structural/organisational barriers (4.4%). The percentage of women who missed the HIV test as part of preconception care or during pregnancy was 9.1% (95% confidence interval, CI: 7.7-10.6). Multivariate analysis showed that those with missed test were younger (p = 0.05), of lower education level (p < 0.01), with a lower HIV-knowledge score (p < 0.01) and with fewer visits during pregnancy (p < 0.01). Around 10% of delivering women were not tested for HIV during pregnancy or as part of preconception care. Absence of a specific request by the gynaecologist was the most frequent reason given. The association of missed HIV testing with poor sociocultural level and limited maternal HIV knowledge emphasise the importance of promoting HIV information among women and prenatal care providers. Strategies to increase routine testing may include the adoption of an opt-out approach. Finally, availability of rapid HIV testing in the delivery room should be encouraged.

Medical care of pregnant women in eastern North Carolina with human immunodeficiency virus

OBJECTIVES

To assess the time lag between the diagnosis of human immunodeficiency virus (HIV) and the initiation of antiretroviral therapy (ART) in pregnant women.

METHODS

A retrospective chart review of 105 deliveries from HIV-positive women from January 2001 to June 2009 was undertaken.

RESULTS

One hundred five HIV-infected pregnant women were identified and studied. Forty-eight women were diagnosed during the prenatal visit: 21 in the first trimester, 17 in the second trimester, and 10 in the third trimester. Forty-five had undetectable viral loads at delivery. The time lag between diagnosis of HIV and initiation of ART was 1 month for 31% and 3 months for 28.5%.

CONCLUSIONS

The time lag between diagnosis of HIV and initiation of ART was more than 1 month in 69% of the expectant mothers, which may have contributed to the failure in viral suppression. Implementation of HIV screening and a more effective means of communication between prenatal and HIV clinics are required to help reduce vertical transmission of the virus to neonates.

Antenatal sexually transmitted infection screening in private and indigent clinics in a community hospital system

OBJECTIVE

To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics.

STUDY DESIGN

One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types.

RESULTS

Compliance was found to be different between clinic types (P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7-8], 7 [7-7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P < .001).

CONCLUSION

Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.

Routine prenatal HIV testing: women's concerns and their strategies for addressing concerns

The purpose of this exploratory study was to solicit women’s opinions about the process of routine prenatal HIV testing to identify strategies for routine testing that will address women’s concerns, increase their level of comfort with testing, and support universal prenatal HIV testing. A convenience sample of English-speaking women between 18 and 45 years of age who were HIV-negative or of unknown HIV status were recruited for focus groups at four diverse community sites in four states. Focus group discussion questions addressed health care provider approaches and actions that would make a woman feel more comfortable with the process of routine prenatal HIV testing. Twenty-five women agreed to participate; most women (64%) were of Black, non-Hispanic race/ethnicity; 44% were 25–34 years of age. Thematic analysis of women’s concerns about routine prenatal HIV testing fell into the following categories: fear, protecting the baby, protecting the woman, confidentiality, and stigma. Women’s strategies for addressing these concerns were related to themes of education and information, normalizing HIV testing, patient–provider relationships, systems, and private communication. Participants offered numerous insightful and practical suggestions for addressing their concerns thereby supporting universal routine prenatal HIV testing. The themes that arose in this study support the conclusion that women will be more comfortable with routine prenatal HIV testing if they are fully informed and knowledgeable about the rationale for HIV testing during pregnancy and their right to decline, and if testing is carried out in a confidential and supportive health care environment.

A review of missed opportunities for prenatal HIV screening in a nationwide sample of health facilities in the Indian Health Service

To better serve our patients, we sought to identify missed opportunities for prenatal HIV screening across Indian Health Service and potential ways to increase screening. Twenty-seven of 161 Federal or Tribal IHS health facilities were randomly selected. Each facility received a standardized set of commands to identify the charts of prenatal patients who were not screened for HIV according to the national Health Information Technology (HIT) platform. We reviewed 598 records at 27 sites of prenatal patients who were identified as not screened for HIV during their pregnancy. According to on-site chart review, nearly half (267/598, 45%) had been screened for HIV, and a slight majority (331/598, 55%) had not been screened. Among the 331 pregnant women not screened for HIV, about half had no HIV screening despite having had ≥2 prenatal care encounters and no screening exclusions (167/331, 50%). A majority of missed opportunities (118/167, 71%) had prenatal testing for other infectious diseases. Based on these results, the National HIV/AIDS program has encouraged increased bundling of HIV with infectious disease tests in prenatal laboratory panels. Improvements in documentation of HIV screening are expected with the IHS transition to electronic health records.

Acquired rectovaginal fistula in babies of unknown and asymptomatic retroviral positive mothers

BACKGROUND

Acquired rectovaginal fistulae managed in three babies of asymptomatic mothers not known to be retroviral positive are presented to heighten clinician suspicion of HIV infection in babies with unexplained cause of acquired rectogenital fistula in regions where routine antenatal HIV screening is not adopted.

CASES

Between 2004 and 2008, three babies aged 6, 10, and 11 months with rectovaginal fistula secondary to perinatal HIV transfer from unknown and asymptomatic positive mothers were managed at the University of Benin Teaching Hospital, Nigeria. Screening of the mothers confirmed the infection, and multidisciplinary approach to treatment, prompt antiretroviral regimen, use of broad spectrum antibiotics, and surgical management gave encouraging results.

CONCLUSION

Routine antenatal screening and suspicion of HIV infection in babies with unexplained cause of acquired rectovaginal fistula is advocated.

Universal prenatal HIV screening: are we there yet?

The objectives of this study were to determine the prevalence of and factors associated with prenatal HIV screening and the availability of HIV test results in medical records in Pittsburgh, PA, USA. Three hundred postpartum women were surveyed about demographics and prenatal care provider(s) and practice setting and were asked to recall prenatal HIV screening and reasons for accepting or declining a HIV test. Medical records were reviewed for documentation of HIV results. Overall, 65% of women reported screening. White race, higher annual household income and fewer lifetime sexual partners were independently associated with decreased likelihood of prenatal HIV screening. Provider presentation of screening as standard practice and provider encouragement were associated with prenatal HIV screening. Only 38% of medical records contained HIV results at the time of labour. Universal and routine offering of prenatal HIV screening as standard practice, in conjunction with encouragement from health-care providers, may increase patient acceptability and the uptake of prenatal HIV screening.

False-positive human immunodeficiency virus enzyme immunoassay results in pregnant women

OBJECTIVE

Examine whether false-positive HIV enzyme immunoassay (EIA) test results occur more frequently among pregnant women than among women who are not pregnant and men (others).

DESIGN

To obtain a large number of pregnant women and others tested for HIV, we identified specimens tested at a national laboratory using Genetic Systems HIV-1/HIV-2 Plus O EIA from July 2007 to June 2008.

METHODS

Specimens with EIA repeatedly reactive and Western blot-negative or indeterminate results were considered EIA false-positive. We compared the false-positive rate among uninfected pregnant women and others, adjusting for HIV prevalence. Among all reactive EIAs, we evaluated the proportion of false-positives, positive predictive value (PPV), and Western blot bands among indeterminates, by pregnancy status.

RESULTS

HIV prevalence was 0.06% among 921,438 pregnant women and 1.34% among 1,103,961 others. The false-positive rate was lower for pregnant women than others (0.14% vs. 0.21%, odds ratio 0.65 [95% confidence interval 0.61, 0.70]). Pregnant women with reactive EIAs were more likely than others (p<0.01) to have Western blot-negative (52.9% vs. 9.8%) and indeterminate results (17.0% vs. 3.7%) and lower PPV (30% vs. 87%). The p24 band was detected more often among pregnant women (p<0.01).

CONCLUSIONS

False-positive HIV EIA results were rare and occurred less frequently among pregnant women than others. Pregnant women with reactive EIAs were more likely to have negative and indeterminate Western blot results due to lower HIV prevalence and higher p24 reactivity, respectively. Indeterminate results may complicate clinical management during pregnancy. Alternative methods are needed to rule out infection in persons with reactive EIAs from low prevalence populations.

Pregnancy and HIV infection in young women in North Carolina

OBJECTIVES

We described young women in North Carolina (NC) who were pregnant at the time of diagnosis with human immunodeficiency virus (HIV) infection to identify an at-risk population that could be targeted for increased HIV screening. We investigated the combined effect of partner counseling and referral services (PCRS) and comprehensive prenatal HIV screening.

METHODS

We conducted a retrospective review of PCRS charts on young women newly diagnosed with HIV in NC between 2002 and 2005. We determined the prevalence of pregnancy in the study sample and conducted bivariate analyses to assess predictors of pregnancy at the time of HIV diagnosis, calculating prevalence ratios (PRs) with 95% confidence intervals (CIs). We analyzed results of partner notification efforts, including timing and stage of diagnosis of HIV-positive partners.

RESULTS

During the four-year period, 551 women aged 18-30 years were newly diagnosed with HIV; 30% were pregnant at the time of HIV diagnosis. Pregnant women were more likely to be Hispanic (PR=1.58, 95% CI 1.15, 2.17) and not report typical risk factors. Fourteen percent of pregnant women's partners had an undiagnosed infection compared with slightly more than 8% of nonpregnant women's partners (p<0.01).

CONCLUSIONS

Ethnic differences in co-diagnosis of pregnancy and HIV suggest that young Hispanic women may have differential access to and acceptance of routine HIV screening. Comprehensive prenatal screening combined with partner notification can be effective in reaching infected male partners who are undiagnosed.

A review of nucleoside reverse transcriptase inhibitor use to prevent perinatal transmission of HIV

Worldwide, women comprise > 50% of all people living with HIV and the vast majority of these women are of childbearing age. In fact, a significant proportion of these women are identified as HIV-infected during pregnancy. Preventing perinatal transmission has been one of the greatest prevention successes of the HIV epidemic with < 2% of live births resulting in an HIV-infected infant. The strategic use of combination antiretroviral therapy has been a critical component of this reduction. With more antiretroviral agents available for HIV, the appropriate selection of therapy is often based on provider familiarity with the various agents. Although benefits of antiretroviral use in pregnancy tremendously outweigh the risks, concerns regarding short- and long-term toxicity in mothers and their children, in addition to the risk of the development of HIV resistance, remain subjects of discussion. The choice of antiretroviral 'backbone' is supported by extensive data showing efficacy in the prevention of HIV vertical transmission. Co-formulated zidovudine/lamivudine is the most commonly used combination in pregnancy. Long-term consequences of in utero exposure to antiretroviral agents are not fully understood. In this article, we review the data regarding nucleoside reverse transcriptase inhibitors with a focus on tenofovir.

Unawareness of HIV status in pregnancy, delay in testing and conflict between information on antenatal card and interview in Recife, Brazil

Overall HIV test coverage among pregnant women in Brazil is 62%, but only 41% in northeastern Brazil. We aimed to identify risk factors for unawareness of HIV status among pregnant women and determine test coverage up to 14th week of pregnancy. We conducted a case-control study in a reference maternity hospital for high-risk pregnancy in Recife, where 485 puerperae were interviewed about their knowledge of results of HIV testing, biological, sociodemographic and healthcare data. Cases were those who were not aware of their HIV status and controls were those who were. Only 21.65% stated that they were unaware of their HIV status during pregnancy (78.35% coverage); however, test results were recorded on an antenatal card in only 48.35%. Only 22% received the result by the 14th week of pregnancy. Unawareness was associated with low schooling (odds ratio [OR] = 2.92; P = 0.006); living outside the state capital's metropolitan region (OR = 4.11; P = 0.001); test performed in the third trimester (OR = 11.6; P = 0.000); and lack of counselling (OR = 2.31; P = 0.022) in multivariate analysis. In conclusion, there has been a considerable delay in having an HIV test. Conflict of Information obtained by interview and that on the antenatal card raises questions about deficiencies in antenatal care or lack of comprehension about the HIV test.

Experiences of women in obtaining human immunodeficiency virus testing and healthcare services

PURPOSE

Over a decade ago, the U.S. Public Health Service recommended routine human immunodeficiency virus (HIV) testing for pregnant women. Despite this recommendation, nearly 30% of pregnant women report not being tested. The purpose of this qualitative study was to describe personal experiences of women in obtaining HIV testing and healthcare services in east Texas.

DATA SOURCES

A secondary data analysis was conducted using audiotapes and transcriptions from structured group interview data obtained from HIV-positive and high-risk negative women residing in east Texas (n = 64).

CONCLUSIONS

Content analysis revealed three patterns: living with stigma; struggling to be healthy; and getting along, day by day. Additional findings indicated that women are more likely to access HIV testing if they are assured of confidentiality and women living with HIV are more likely to remain in the healthcare system if healthcare professionals are supportive, knowledgeable, and nonjudgmental.

IMPLICATIONS FOR PRACTICE

Healthcare professionals must engage in self-reflection to conscientiously uncover their true feelings related to caring for women with or at risk for HIV disease. Once providers acknowledge that their beliefs and values differ from their clients, they will be able to minimize personal biases that interfere with HIV testing and healthcare services.

Testing for HIV infection in the United States

The process by which HIV-infected individuals are tested and identified has changed with the evolving HIV epidemic and public health response. In this review, we discuss the rationale for increased HIV testing as well as the current standards in HIV diagnostics and their inherent limitations. Current policy guidelines for routine HIV testing from the U.S. Preventive Services Task Force and the U.S. Centers for Disease Control and Prevention are divergent. However, national momentum toward the implementation of routine HIV testing programs continues based on the efficacy and feasibility of these programs in terms of HIV case identification and on recent reports of their cost-effectiveness. As routine, voluntary HIV screening programs are established, issues surrounding consent, reporting, and stigma still persist, as does the challenge of effectively linking detected HIV cases to care.