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

Prevalence of Repeat Prenatal HIV Screening in New York State

Description: New York State Department of Health (NYSDOH) recommends that all pregnant patients receive human immunodeficiency virus (HIV) screening during pregnancy. This study assessed the prevalence of repeat prenatal HIV testing and factors associated with receipt of the recommended tests. Methods: Data from the NYSDOH newborn screening program were used to randomly select pregnant persons without HIV who delivered a liveborn infant in 2017. Receipt of repeat testing was defined as an initial HIV test in the first or second trimesters and the final in the third trimester (relaxed); or an initial test in the first trimester and the final in the third trimester (strict). Relative risks (RRs) and 95% confidence intervals were calculated in bivariate analyses. Adjusted RRs were calculated to determine associations between demographic and clinical factors and receipt of repeat HIV testing. Results: The cohort included 2,225 individuals. Roughly one quarter (24%) received the recommended tests in the first or second and third trimesters and 17% received them in the first and third trimesters. Individuals who reported Hispanic or Asian race/ethnicities, had government-funded insurance, started prenatal care in the first trimester, delivered in New York City, or received prenatal hepatitis C virus screening were significantly more likely to receive repeat testing using either definition. Conclusions: Despite the benefits and cost-effectiveness, the prevalence of repeat prenatal HIV screening during the third trimester remains persistently low. Improved messaging and targeted education and resources to assist prenatal providers could reinforce the importance of repeat testing and reduce residual perinatal HIV transmission.

HIV testing among women of reproductive age in 28 sub-Saharan African countries: a multilevel modelling

BACKGROUND

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) remains one of the most significant public health challenges globally, particularly in sub-Saharan Africa (SSA). Although HIV testing is a vital step for both prevention and treatment, its uptake is still low in SSA. We therefore examined HIV testing in SSA and its individual/household and community factors among women of reproductive age groups (15-49 y).

METHODS

Demographic and Health Survey data collected between 2010 and 2020 from 28 SSA countries were used for this analysis. We analysed the coverage of HIV testing and individual/household and community factors on 384 416 women in the reproductive age groups (15-49 y). Bivariate and multivariable multilevel binary logistic regression analysis were conducted to select candidate variables and to identify significant explanatory variables associated with HIV testing and the results were presented using adjusted odd ratios (AORs) at 95% confidence intervals (CIs).

RESULTS

The pooled prevalence of HIV testing among women of reproductive age in SSA was 56.1% (95% CI 53.7 to 58.4), with the highest coverage found in Zambia (86.9%) and the lowest in Chad (6.1%). Age (45-49 y; AOR 0.30 [95% CI 0.15 to 0.62]), women's education level (secondary; AOR 1.97 [95% CI 1.36 to 2.84]) and economic status (richest; AOR 2.78 [95% CI 1.40 to 5.51]) were some of the individual/household factors associated with HIV testing. Similarly, religion (no religion; AOR 0.58 [95% CI 0.34 to 0.97]), marital status (married; AOR 0.69 [95% CI 0.50 to 0.95]) and comprehensive knowledge of HIV (yes; AOR 2.01 [95% CI 1.53 to 2.64]) were significantly associated individual/household factors for HIV testing. Meanwhile, place of residence (rural; AOR 0.65 [95% CI 0.45 to 0.94]) was found to be a significant community-level factor.

CONCLUSION

More than half of married women in SSA have been tested for HIV, with between-country variations. Both individual/household factors were associated with HIV testing. Stakeholders should therefore consider all above-mentioned factors to plan an integrated approach to enhancing HIV testing through health education, sensitization, counselling and empowering older and married women, those with no formal education, those who do not have comprehensive HIV/AIDS knowledge and those in rural areas.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV’s vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

HIV testing during pregnancy among women with a recent live birth-Seven US States, 2016-2019

BACKGROUND

Although the United States has made progress in reducing the transmission of HIV from mother-to-child, it has not yet met the goal of reducing such transmissions to 70%. Self-reported HIV testing varied by state of residence. Approximately, two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

OBJECTIVES

The aim of this study was (1) to examine the prevalence of receipt of an HIV test during pregnancy and (2) to examine differences in HIV testing during pregnancy by race/ethnicity, state of residence, and other sociodemographic characteristics.

DESIGN

Population-based surveillance of women with a recent live birth from seven US states. Individuals were sampled from birth certificate records 2-6 months postpartum and surveyed about their behaviors and experiences before, during, and shortly after pregnancy.

METHODS

Data from the Pregnancy Risk Assessment Monitoring System, a large, population-based survey, were used to estimate the prevalence of HIV testing during pregnancy during 2016-2019. Weighted prevalence estimates and 95% confidence intervals were calculated overall and by demographic and other selected characteristics.

RESULTS

Approximately two-thirds of women (66.1%) self-reported having a test for HIV during pregnancy. Prevalence varied by maternal characteristics and was highest among women who were non-Hispanic Black (80.7%) and among women who were aged ⩽ 24 years, had a high school education or less, were unmarried, or had Medicaid or no insurance for prenatal care (each > 70%). Self-reported HIV testing varied by state of residence. Approximately two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

CONCLUSION

About one in three Pregnancy Risk Assessment Monitoring System respondents did not report an HIV test during pregnancy. Health care providers can help educate pregnant patients about the importance of HIV testing and ensure universal testing to help identify individuals needing treatment and reduce the rates of mother-to-child HIV transmission.

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.

Women's healthcare decision-making capacity and HIV testing in sub-Saharan Africa: a multi-country analysis of demographic and health surveys

BACKGROUND

Global commitment to stop Human Immunodeficiency Virus (HIV) and ensure access to HIV treatment calls for women empowerment, as these efforts play major roles in mother-to-child transmission. We examined the association between women's healthcare decision-making capacity and uptake of HIV testing in sub-Saharan Africa.

METHODS

We used data from the current Demographic and Health Surveys (DHS) of 28 countries in sub-Saharan Africa, conducted between January 1, 2010 and December 31, 2018. At the descriptive level, we calculated the prevalence of HIV testing in each of the countries. This was followed by the distribution of HIV testing across the socio-demographic characteristics of women. Finally, we used binary logistic regression assess the likelihood of HIV testing uptake by women's health care decision-making capacity and socio-demographic characteristics. The results were presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals signifying precision. Statistical significance was set at p-value < 0.05.

RESULTS

We found that prevalence of HIV testing uptake in the 28 sub-Saharan African countries was 64.4%, with Congo DR having the least (20.2%) and the highest occurred in Rwanda (97.4%). Women who took healthcare decisions alone [COR = 3.183, CI = 2.880-3.519] or with their partners [COR = 2.577, CI = 2.335-2.844] were more likely to test for HIV, compared to those whose healthcare decisions were taken by others, and this persisted after controlling for significant covariates: [AOR = 1.507, CI = 1.321-1.720] and [AOR = 1.518, CI = 1.334-1.728] respectively.

CONCLUSION

Sub-Saharan African countries intending to improve HIV testing need to incorporate women's healthcare decision-making capacity strategies. These strategies can include education and counselling. This is essential because our study indicates that the capacity of women to make healthcare decisions has an association with decision to test for their HIV status.

Examination of a Canadian provincial prenatal HIV screening program: 2010 to 2014

OBJECTIVES

Universal prenatal screening in the Canadian province of Alberta employs an 'opt-out' HIV screening strategy. We examined all women giving birth in the province and determined the frequency and characteristics of women having and not having HIV screening.

METHODS

All livebirths in Alberta from January 1, 2010 to December 31, 2014 were compiled from the Vital Statistics database and linked to HIV screening data to determine maternal demographic and prenatal care characteristics. Correlates associated with prenatal HIV screening, opting out of HIV screening, and not having any prenatal communicable disease screening were determined by multivariable statistics.

RESULTS

Of the 256,280 live births, 94.2% had prenatal HIV screening, 1.9% declined prenatal HIV screening, and 3.9% had no record of any prenatal communicable disease testing. Compared with those who had HIV screening, those who opted out of prenatal HIV screening were more likely to be over 40 years of age (adjusted odds ratio (AOR), 2.83 [2.12-3.78]) and less likely to be single (AOR, 0.67 [0.62-0.73]) and First Nations (AOR, 0.67 [0.56-0.82]). Those who received no prenatal communicable disease screening were less likely to be over 40 years of age (AOR, 0.81 [0.69-0.95]) and more likely to be single (AOR, 1.27 [1.21-1.33]) and have received no prenatal care (AOR, 6.78 [6.40-7.19]). Both the HIV decliners and prenatal non-testers were more likely to have used a midwife (AOR, 4.52 [3.83-5.35] and AOR, 2.44 [2.03-2.92], respectively).

CONCLUSION

Demographic and prenatal care characteristics differ by a pregnant woman's prenatal screening status. Policies to improve HIV screening coverage should take these variations into account.

Hepatitis C Screening in an Underserved U.S. Cohort of Reproductive Age Women

The opioid epidemic has recently increased the rates of hepatitis C virus (HCV) infection among young women. We therefore aimed to characterize the cascade of HCV care in a cohort of underserved women of reproductive age. Medical records of 19,121 women between the ages of 15 and 44 years, receiving primary care in the San Francisco safety‐net health care system, were reviewed. Cohort characteristics were as follows: median age 33 years (interquartile range 26‐38), 18% white (12% black, 46% Latina, 22% Asian, 2% other race), 1.3% hepatitis B surface antigen (HBsAg)‐positive, and 0.9% human immunodeficiency virus (HIV) co‐infection. HCV antibody (HCVAb) testing occurred in 38.7% (n = 7,406), of whom 2.8% (n = 206) were HCVAb‐positive and 2.4% (n = 177) had a detectable HCV viral load. Of the 5% (n = 1,017) with a history of pregnancy, 61% (n = 615) had HCVAb testing (2.6% were positive). On multivariable analysis, HBsAg testing (odds ratio [OR] 8.25 [95% confidence interval (CI)] 6.80‐10.01]; P < 0.001), HIV infection (OR 5.98 [95% CI 1.86‐19.20]; P = 0.003), and log alanine aminotransferase (ALT) (OR 1.30 [95% CI 1.16‐1.45]; P < 0.001) were associated with HCV screening. Compared with whites, women of Latina (OR 0.45 [95% CI 0.37‐0.55]; P < 0.001) and Asian (OR 0.74 [95% CI 0.58‐0.94]; P = 0.01) race were less likely to receive HCV screening. Age (OR 1.80 per decade [95% CI 1.26‐2.57]; P = 0.001), white race (versus non‐white; OR 10.48 [95% CI 7.22‐15.21]; P < 0.001), HIV infection (OR 3.25 [95% CI 1.40‐7.55]; P = 0.006), and log ALT (OR 1.93 [95% CI 1.49‐2.49]; P < 0.001) were associated with HCVAb positivity. Conclusion: Most (>60%) underserved women of reproductive age were not tested for HCV. Moreover, women of Latina and Asian race were less likely to receive HCV screening. Given the known high HCV risk in the underserved population, targeted interventions, especially for racial minority women of reproductive age, are needed to enhance HCV screening in those at risk.