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HIV Testing Among Pregnant Women --- United States and
Canada, 1998--2001 - November 15, 2002 / 51(45);1013-1016.
Since 1994, the availability of increasingly effective antiretroviral
drugs for both the prevention of perinatal human immunodeficiency virus
(HIV) transmission and maternal treatment has resulted in a greater
emphasis on prenatal HIV testing and substantial increases in prenatal
testing rates. In 2000, preliminary data indicated that 766 (93%) of
824 HIV-infected women in 25 states knew their HIV status before delivery
(CDC, unpublished data, 2002). However, an estimated 280--370 perinatal
HIV transmissions continue to occur in the United States each year (1).
The primary strategy to prevent perinatal HIV transmission is to maximize
prenatal HIV testing of pregnant women. States and Canadian provinces
have implemented three different prenatal HIV-testing approaches. To
assess their effectiveness, CDC reviewed prenatal HIV-antibody testing
rates associated with these approaches. Medical record data suggest
that the "opt-in" voluntary testing approach is associated with lower
testing rates than either the "opt-out" voluntary testing approach or
the mandatory newborn HIV testing approach.
Under the opt-in approach, women typically are provided pre-HIV test
counseling and must consent specifically to an HIV-antibody test. Under
the opt-out approach, women are notified that an HIV test will be included
in a standard battery of prenatal tests and procedures and that they
may refuse testing (2). Under mandatory newborn HIV testing,
newborns are tested for HIV, with or without the mother's consent, if
the mother's HIV status is unknown at delivery.
Three methods were used to estimate prenatal testing rates among all
women who delivered, regardless of whether they received prenatal care.
First, eight U.S. areas that participated during 1998--1999 in CDC's
Active Bacterial Core Surveillance/Emerging Infections Program (ABC)
Network assessed HIV testing during prenatal care and <2 days
before delivery by reviewing a stratified random sample of labor and
delivery records and prenatal records forwarded to birthing hospitals
(3); in collaboration with CDC, network staff received a sample
of records from all birthing hospitals in the surveillance areas and
weighted testing rates to represent all live-born infants in those areas.
Second, public health investigators in each of the five Canadian provinces
tallied the number of HIV tests among pregnant women that were submitted
to provincial laboratories and divided the total by an estimate of all
live and stillborn births in each province during the same year. Third,
CDC analyzed weighted data collected in 1999 by interviewers in nine
states for CDC's Pregnancy Risk Assessment Monitoring System (PRAMS)
(an ongoing, population-based survey conducted in 32 states and New
York City among women who have given birth during the preceding 2--6
months [4]),
who had asked women if they had been tested for HIV during pregnancy.
Data on state prenatal HIV-testing policies were obtained from the American
College of Obstetricians and Gynecologists (5).
HIV-testing rates varied depending on which approach to testing was
used. Rates for states using the opt-in approach to prenatal HIV testing
included in the ABC Network ranged from 25% to 69% (Table
1), testing rates in Canada ranged from 54% to 83% (Table
2), and rates derived from PRAMS data ranged from 61% to 81% (Table
3). Two U.S. states (Arkansas and Tennessee) and two Canadian provinces
(Alberta, and Newfoundland and Labrador) reported using an opt-out prenatal
HIV-testing policy. ABC Network data indicated that Tennessee had a
testing rate of 85% (Table
1). Canada's population-based data indicated a 98% testing rate
in Alberta and a 94% testing rate in Newfoundland and Labrador (Table
2). PRAMS interview data indicated a 71% testing rate in Arkansas
(Table
3), compared with a 57% testing rate early in 1997 before the law
was implemented (Arkansas Department of Health, personal communication,
2002). Two states (New York and Connecticut) require HIV testing of
newborns whose mothers were not tested during pregnancy. In New York,
an ABC Network review of medical records in seven counties in the Rochester
area indicated that the proportion of pregnant women who received a
prenatal HIV test increased from 52% of 438 charts during January 1998--July
1999 to 83% of 112 charts during August--December 1999 after New York
required that newborn HIV testing results be made available within 48
hours of specimen collection (Table
1). PRAMS data for 1999 indicated that the proportion of women statewide
who reported having received an HIV test during pregnancy increased
from 69% of 758 women during January--July to 93% of 502 during August--December
(Table
3). In separate, statewide analyses of prenatal testing reported
on newborn metabolic screening forms from all live-born infants, New
York reported prenatal HIV-testing rates of 89% in 2000 and 93% in 2001
(New York State Department of Health, personal communication, 2002).
In Connecticut, an ABC Network review of 668 charts indicated a testing
rate of 31% during January 1998--September 1999, compared with 81% of
93 charts reviewed during October--December 1999 after enactment of
the mandatory newborn testing law (Table
1).
Reported by: A Roome, PhD, J Hadler MD, Connecticut Dept
of Public Health. G Birkhead, MD, AIDS Institute, New York State Dept
of Health. S King, MD, The Hospital for Sick Children, Toronto; C Archibald,
MD, Health Canada. S Schrag, DPhil, Active Bacterial Core Surveillance/Emerging
Infections Program Network, Div of Bacterial and Mycotic Diseases, National
Center for Infectious Diseases; A Lansky, PhD, Pregnancy Risk Assessment
Monitoring System, Div of Reproductive Health, National Center for Chronic
Disease Prevention and Health Promotion; S Sansom, PhD, M Fowler, MD,
I Onorato, MD, J Anderson, PhD, Div of HIV/AIDS Prevention, National
Center for HIV, STD, and TB Prevention, CDC.
Editorial Note:
Prenatal HIV testing affords the best opportunity for the prevention
of perinatal HIV transmission. On the basis of clinical trial data,
perinatal HIV-transmission rates among HIV-infected women who begin
antiretroviral treatment during pregnancy are as low as <2%
(6), compared with 12%--13% early transmission rates among women
who do not begin preventive treatment until labor and delivery or after
birth (7) and 25% among women who receive no preventive treatment
(8).
Among the three prenatal HIV testing approaches assessed in this report,
opt-out voluntary testing and the mandatory testing of newborns appear
to be associated with the highest testing rates. On the basis of the
chart-review methodology, prenatal testing rates were higher in Tennessee,
which uses the opt-out approach, than rates in states using the opt-in
approach and similar to rates achieved with mandatory newborn testing
in New York during the same time period. A similar trend was observed
among Canadian provinces. In New York and Connecticut, mandatory HIV
testing of newborns was associated with increases in prenatal testing
rates. On the basis of PRAMS data, three of seven states using the opt-in
approach achieved lower prenatal HIV-testing rates than states using
the opt-out or mandatory newborn testing approaches.
Increases in prenatal HIV-testing rates were noted in states that shifted
from an opt-in approach to either an opt-out or mandatory newborn testing
approach and were probably associated with a greater likelihood that
woman were offered HIV testing during prenatal care. Data from the Perinatal
Guidelines Project indicated that the majority of women will accept
HIV testing if it is recommended by their health-care provider (9).
Perinatal HIV experts and professional organizations have advocated
streamlining prenatal HIV pre-test counseling and consent procedures
to reduce barriers to the offer of testing by health-care providers
(1,2,10).
The findings in this report are subject to at least seven limitations.
First, testing results for each strategy are for all women, and the
proportion of HIV-positive women who accepted testing under each strategy
is not known. Second, among women who did not receive prenatal testing,
the proportion of women who were not tested because they did not seek
prenatal care is unknown. Third, among women who did not receive prenatal
testing, the proportion of women who were tested at labor and delivery
or whose infants were tested at birth is not known. Fourth, maternal
self-reported data from PRAMS collected 2--6 months after delivery might
be subject to recall bias. Fifth, PRAMS data do not indicate whether
a prenatal-care provider was aware of the woman's HIV status. Sixth,
among the women interviewed in PRAMS, up to 16% (in Arkansas) indicated
they did not know if they had been tested. Finally, chart abstraction
can document only prenatal HIV testing recorded in maternal medical
records; without such documentation, clinicians might not be aware of
the need to offer effective perinatal interventions to infected women
and their HIV-exposed infants.
This report emphasizes the need for better data to assess perinatal
HIV testing rates in the United States. Ongoing, randomized reviews
of prenatal, labor/delivery, and pediatric charts, with a sampling framework
ensuring that the sample is representative of the population of women
delivering, might provide the most valid approach to assessing a state's
progress on perinatal HIV testing and prevention. CDC is working with
states with high HIV prevalence rates among women of childbearing age
and high numbers of pediatric AIDS cases to ensure standardized monitoring
of prenatal testing rates. The data suggest that jurisdictions that
use an opt-in approach and that have low prenatal HIV-testing rates
should reevaluate their approach.
References
- CDC.
Revised recommendations for HIV screening of pregnant women. MMWR
2001;50(No. RR-19).
- Institute of Medicine. Reducing the Odds: Preventing Perinatal Transmission
of HIV in the United States. Washington, DC: National Academy Press,
1998.
- Schrag SJ, Zell ER, Lynfield R, et al. A population-based comparison
of strategies to prevent early-onset group B streptococcal disease
in neonates. N Engl J Med 2002;347:233--9.
- CDC.
Prevalence of selected maternal behaviors and experiences, Pregnancy
Risk Assessment Monitoring System (PRAMS). In: CDC surveillance summaries
(April 26). MMWR 2002;51(No. SS-2).
- American College of Obstetricians and Gynecologists. Survey of state
laws on HIV and pregnant women, 1999--2000. Moore KG, ed. Washington,
DC: American College of Obstetricians and Gynecologists, 2000.
- Dorenbaum A, Cunningham CK, Gelber RD, et al. Two-dose intrapartum/newborn
nevirapine and standard antiretroviral therapy to reduce perinatal
HIV transmission: a randomized trial. JAMA 2002;288:189--98
- Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose
nevirapine compared with zidovudine for prevention of mother-to-child
transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial.
Lancet 1999;354:795--802.
- Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant
transmission of human immunodeficiency virus type 1 with zidovudine
treatment. N Engl J Med 1994; 331:1173--80.
- Fernandez MI, Wilson TE, Ethier KA, et al. Acceptance of HIV testing
during prenatal care. Public Health Rep 2000;115:460--8.
- American College of Obstetricians and Gynecologists. Joint statement
of ACOG/AAP on human immunodeficiency virus screening. ACOG statement
of policy. Washington, DC: American College of Obstetricians and Gynecologists,
1999.
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