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Human Immunodeficiency Virus Counseling and Testing Practices Among North Carolina Providers

From The American College of Obstetricians and Gynecologists, Washington, DC; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and North Carolina Department of Health and Human Services, Raleigh, North Carolina.

Address reprint requests to: Karen Troccoli, MPH, 4701 Chestnut Street, Bethesda, MD 20814; E-mail: ktroccoli{at}teenpregnancy.org.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
OBJECTIVE: To estimate the percentage of prenatal care providers who offer human immunodeficiency virus (HIV) testing to pregnant women, investigate how strongly testing is encouraged, and explore testing barriers.

METHODS: Between January 2001 and March 2001, we sent surveys to 1381 prenatal care providers in North Carolina, comprised of obstetricians, family physicians who practice obstetrics, and nurse-midwives. A total of 653 questionnaires were returned.

RESULTS: Overall, 95.5% of providers who responded reported recommending HIV testing to all pregnant patients. Only 69.2% strongly recommend testing, with obstetricians (73.4%) and family physicians (70.1%) doing so at higher rates than nurse-midwives (55.9%). Almost all respondents (96.9%) strongly recommend testing for women they perceive to be high risk, whereas 39.7% strongly recommend testing to women who have had an HIV test in the past 6 months. When women refuse testing, 48.1% of practitioners inquire about the reason, and 28.2% reoffer the test at a future prenatal appointment. The most significant testing barriers were treating an HIV-positive woman (18.4%) and informing a patient she is HIV positive (14.8%). Respondents report that low literacy and culturally appropriate patient education materials would be most helpful to them.

CONCLUSION: Among respondents, most prenatal care providers report that they recommend HIV testing to all pregnant women. However, many respondents base their decision about how strongly to recommend HIV testing on an assessment of the woman’s risk for HIV exposure. Significant barriers to offering HIV testing were associated with managing an HIV-positive patient. Providers were most in need of patient education materials.

In 1994, results of the Pediatric AIDS Clinical Trials Group 076 study demonstrated that administering zidovudine to women infected with human immunodeficiency virus (HIV) during pregnancy and to their newborns reduced the risk of perinatal transmission by approximately two-thirds, from 25.5% to 8.3%.¹ Recognizing that successful implementation of this regimen required that prenatal care providers determine the HIV infectious status of all pregnant women, the US Public Health Service issued guidelines in 1995 that, for the first time, recommended all pregnant women, regardless of risk, be offered HIV counseling and testing.²

The state of North Carolina responded by amending its state code in 1995 to recommend that every pregnant woman in the state have HIV pretest counseling by her attending physician as early in the pregnancy as possible and be encouraged to have an HIV test. When informed consent was obtained, the health care provider would then test the woman as early in the pregnancy as possible.³ Subsequent research found the percentage of pregnant women who were counseled and offered HIV testing increased in North Carolina.⁴ However, studies also have determined that many North Carolina prenatal care providers still offer HIV counseling and testing based on assessment of the woman’s risk of HIV exposure, rather than to all women as a routine part of prenatal care.^5,6 Moreover, research indicates that pregnant women who receive prenatal care from private sector providers⁵ or who have private insurance for prenatal care^5,6 are less likely to be tested for HIV.

In an effort to bolster HIV counseling and testing rates in North Carolina, particularly among private providers, a group of public and private sector women’s health care providers, agency leaders, academics, and other stakeholders convened in 1999 to form the North Carolina Providers Partnership on Perinatal HIV. The group collectively agreed to explore in more depth the barriers to HIV counseling and testing that providers were facing and solicit input from practitioners about the kinds of support and materials that would help them. To that end, the Partnership developed a survey that was sent to all obstetricians, nurse-midwives, and family physicians who practice obstetrics in North Carolina. The objective of this study was to estimate the percentage of prenatal care providers who offer HIV testing to pregnant women, investigate how strongly testing is encouraged, and explore testing barriers.

	MATERIALS AND METHODS

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In January 2001, the Partnership mailed a 14-question, self-administered questionnaire to 1381 North Carolina prenatal care providers. Mailing lists of all prenatal care providers in the state were provided by the membership organization for each practitioner group: The American College of Obstetricians and Gynecologists (ACOG), the North Carolina Academy of Family Physicians, and the American College of Nurse-Midwives’ North Carolina Chapter. Surveys were mailed to 913 obstetricians, 238 family physicians who practice obstetrics, and 230 nurse-midwives.

The questionnaires were accompanied by a cover letter jointly signed by the Assistant Secretary of Health in the North Carolina Department of Health and Human Services, the Chair of the North Carolina Section of ACOG, the President of the North Carolina Academy of Family Physicians, and the Chair of the North Carolina Chapter of the American College of Nurse-Midwives. In March 2001, the questionnaire was resent to those who had not yet returned their surveys.

The survey contained primarily multiple-choice questions pertaining to prenatal care providers’ practice procedures and experiences with HIV testing during pregnancy. The questionnaire included items about practitioners’ HIV testing recommendations, information they provide patients, actions taken when patients refuse testing, documentation practices, perceived barriers to HIV testing, and questions about information that might be helpful to prenatal care providers in their practices. Some questions were written in a yes-no format, whereas others were in a Likert-type format. For instance, strength of testing recommendation included strongly/moderately/not strongly/don’t recommend; significance of barriers to testing included significant/moderate/not a barrier; and usefulness of various materials included very/somewhat/not helpful.

Data were analyzed according to practice type (obstetricians, family physicians, and nurse-midwives), gender, practice setting (solo practice, multispecialty, or single-specialty group, health maintenance organization, Health Department, or University faculty) and location (rural or urban). Finally, practitioners were grouped into the number of "years in practice" by 1–7, 8–14, and 15 years or more. These groupings were chosen to correspond with significant developments in perinatal HIV. Seven years before the survey (1994), results of 076 were reported, followed almost immediately by the North Carolina HIV testing law being amended, as described previously. The 8–14-year group covers years when the proportion of total AIDS cases that comprised women began to increase significantly, and the number of perinatal HIV cases peaked in the United States (1992).⁷ The category of 15 years or more captured all prior years. Data were analyzed using the personal computer statistical package SPSS 10.0 (SPSS Inc., Chicago, IL). Descriptive statistics were computed for measures used in the analyses. Group differences on categoric measures were assessed using ².

	RESULTS

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A total of 653 questionnaires were returned (47.3% response rate). Response rates of obstetricians (45.9%), family physicians (39.2%), and nurse-midwives (55.2%) were significantly different (² = 12.33, P = 002). Of the respondents who practice obstetrics, 65.2% were obstetricians, 13.1% were family practitioners, and 21.7% were nurse-midwives. Approximately 49% of respondents were men, and 51.1% were women. Most respondents (54.1%) were members of a single-specialty group practice.

Almost all respondents (95.5%) recommend HIV testing to all pregnant patients. However, only 69.2% "strongly recommend" testing to all pregnant patients (see Figure 1). Significantly fewer nurse-midwives (55.9%) "strongly recommend" testing than do family physicians (70.1%) and obstetricians (73.4%) (² = 11.4, P = .003). When asked about HIV testing recommendations for pregnant women "at high risk" for HIV, almost all respondents (96.9%) "strongly recommend" testing. Comparatively, only 39.7% of practitioners "strongly recommend" testing for those who have had an HIV test in the past 6 months. Years in practice was related to strength of test recommendation. Fewer respondents who had been in practice for 8–14 years (93.4%) "strongly recommend" HIV testing for those at high risk than those in practice for 1–7 years (98.6%) and for 15 years or more (97.2%) (² = 6.62, P = .037). Also, more of those with 15 years or more in practice (49.3%) recommend testing for those who have had a test in the past 6 months than those with 1–7 years (35.3%) and those with 8–14 years (34.0%) in practice (² = 12.94, P = .044).

View larger version (46K): [in this window] [in a new window]   Figure 1. Proportion of practitioners who recommend human immunodeficiency virus testing to all pregnant patients, high-risk pregnant patients, and pregnant patients who have been tested in the previous 6 months. Troccoli. Prenatal HIV Testing Practices. Obstet Gynecol 2002.

When asked what steps they take when a patient refuses HIV testing, most (83.4%) document patients’ refusal of testing in their medical records, 48.1% inquire as to why patient refused testing, 33.2% request patient signature on a patient refusal of testing form, 28.2% reoffer the test at a later appointment, and 8.2% take no further action. Nearly all practitioners in practice 15 years or more (97.2%) document patients’ refusal in their medical charts, which is higher than those in practice 8–14 years (92.5%) and 1–7 years (90.4%) (² = 6.27, P = .044). More nurse-midwives (43.2%) have patients sign a refusal of testing form than obstetricians (33.0%) and family physicians (17.9%) (² = 12.1, P = .002).

Figure 2 illustrates that more nurse-midwives and family physicians are likely to inquire as to the reason for the patient’s refusal than obstetrician-gynecologists (² = 22.1, P = .001). Additionally, more family physicians reoffer the test at a later date than nurse-midwives and obstetricians (² = 14.78, P = .001). More Health Department practitioners (46.7%) reoffer the test than those in other practice types (² = 13.84, P = .017).

View larger version (66K): [in this window] [in a new window]   Figure 2. Responses of obstetrician-gynecologists, family physicians, and nurse-midwives to patient refusal of human immunodeficiency virus testing. Significant differences between the three practitioner types emerged for "patient signature on refusal to test form" (P = .002), "inquire as to why" (P < .001), and "reoffer at later appointment" (P = .001). Troccoli. Prenatal HIV Testing Practices. Obstet Gynecol 2002.

View larger version (54K): [in this window] [in a new window]   Figure 3. Percent of obstetrician-gynecologists, family physicians, and nurse-midwives who screen for sexually transmitted diseases (STD) and human immunodeficiency virus (HIV) during the third trimester of pregnancy. Troccoli. Prenatal HIV Testing Practices. Obstet Gynecol 2002.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

Nearly all North Carolina prenatal care providers who responded to the survey reported that they offer HIV testing, and strongly agree that providers should recommend testing, to all pregnant patients. However, the survey responses suggest that some North Carolina providers base their recommendations on assessment of HIV exposure risk instead of uniformly recommending testing to all pregnant women. These findings replicate an earlier survey of North Carolina providers’ HIV counseling and testing practices.⁵ Similar findings were reported for obstetricians and family physicians in Minnesota; 90% agreed with universal prenatal counseling and voluntary HIV screening in pregnancy, and only 43% actually practiced this policy.⁸

Our survey explored differences in HIV test recommendation among several types of prenatal care providers. The study found that nurse-midwives were less likely than obstetricians or family physicians to strongly recommend testing to all pregnant patients and least likely to strongly agree that prenatal care providers should universally recommend HIV testing to all pregnant women. The reason for this is not clear; lack of familiarity with policies and regulations on this issue may contribute. We learned that nearly one-third of practitioners were unfamiliar with the North Carolina law that requires providers to offer the test to all pregnant patients, but we found no significant difference in how the three provider groups answered this question. All three of the practitioners’ medical associations have positions or policies that resemble the North Carolina law. Universal HIV testing with patient notification is advocated by the Institute of Medicine,⁹ ACOG, and the American Academy of Pediatrics,¹⁰ as well as the American Academy of Family Physicians.¹¹ The American College of Nurse-Midwives’ position states that "following counseling, all women should be offered HIV testing with informed consent."¹² More aggressive promotion of these policies may help change provider behavior, particularly among nurse-midwives.

Policies and laws that encourage universal testing are important because this strategy identifies more HIV-positive women than does risk-based counseling and testing.¹³ Risk-based approaches result in greater likelihood that HIV infection will go unrecognized.⁵ Moreover, when prenatal care providers use risk assessment to decide which pregnant women to counsel and test for HIV, their assessments tend to be inaccurate.¹³ Routine recommendation of HIV testing to all pregnant patients addresses both of those findings.

Pregnant patients are strongly influenced by their health care providers’ opinions about HIV testing.^6,9 Our findings suggest that many pregnant women, particularly those who were tested for HIV in the past 6 months, will likely go untested in their current pregnancies either because they are not offered the test or because their provider does not strongly recommend testing. This could result in missed opportunities to identify and treat HIV-positive pregnant women, including women who seroconvert during pregnancy.

Another missed opportunity arises when practitioners do incomplete follow-up with a woman who refuses an HIV test. In our survey, less than half inquire as to the reason, and only one-third offer the test at a subsequent appointment. In both instances, obstetricians are least likely to follow-up. Although it may seem that women who refuse testing would be those who perceive themselves to be at low risk, their reluctance may actually signal a fear of learning HIV status because of high-risk situations such as domestic violence or drug use.

In Reducing the Odds, the Institute of Medicine cited HIV counseling and testing barriers such as lack of provider time, legal requirements of counseling informed consent, the need for confidential record keeping, lack of perceived risk, lack of awareness of effective treatment among pregnant women, and fear of offending or embarrassing the patient by offering an HIV test.⁹ Our study found that the top two "most significant" barriers were both associated with managing an HIV-positive patient. This suggests that providers are not as deterred by the process of offering and administering the test and the concomitant requirements of counseling and obtaining informed consent as they are by the prospect of having to respond to a patient’s positive test result. Interestingly, respondents indicated that patient-oriented rather than provider-oriented materials would be most helpful to them in their practices. These providers want resources that facilitate communication with patients about HIV more than they want materials that enable them to be "experts" in treating HIV-positive patients.

Although the focus of this survey was HIV, it also provided an opportunity to explore provider practices around screening for other STDs. North Carolina law states that all pregnant women be tested for syphilis and gonorrhea early in pregnancy and in the third trimester.¹⁴ According to the survey respondents, less than one-fourth screen for these STDs in the third trimester. Respondents may be unaware of the state regulation or they may be only retesting those patients they perceive to be "at risk" for contracting an STD. The latter would suggest the same type of risk assessment that is being used for HIV testing.

The survey found that those providers who offer testing to all pregnant women do so with varying degrees of encouragement. Although this study did not attempt to correlate how the test is offered with the percentage of women who agree to testing, other studies have found an association. This suggests that all prenatal care providers should strongly recommend testing to all their pregnant patients as part of standard clinical practice. Our survey also found differences among the three provider groups in several areas, including offering of HIV testing, follow-up for declined tests, and STD testing in pregnancy. Practitioners who were in practice fewer years (1–7 years) were least familiar with the state law on HIV counseling and testing during pregnancy.

Medical associations can use this information from our survey to develop tools to help practitioners integrate universal HIV testing and STD screening into their practices. The North Carolina Providers Partnership on Perinatal HIV used the survey findings to develop a resource packet on perinatal HIV that was mailed to all prenatal care providers in the state.

	Footnotes

 
The authors would like to acknowledge the contributions of all the members of the North Carolina Providers Partnership on Perinatal HIV to this statewide effort to increase rates of HIV testing in pregnancy, particularly Judy Owen-O’Dowd, NC Department of Health and Human Services, Libby Anderson, NC Academy of Family Physicians, and Louann Alexovich, CNM, American College of Nurse-Midwives’ NC Chapter. We also appreciate the assistance of Andrea Carpentieri, American College of Obstetricians and Gynecologists, and acknowledge the federal Maternal and Child Health Bureau, Health Resources and Services Administration, for their support of the Providers Partnership.

PII S0029-7844(02)02120-8

Received December 18, 2001. Received in revised form April 1, 2002. Accepted April 11, 2002.

	REFERENCES

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
1. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994;331:1173–80.[Abstract/Free Full Text]

2. US Public Health Service. Recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR 1995;44(RR-1):1–15.[Medline]

3. Katz VL, Lim W. HIV infection in pregnancy: A review of current developments. NC Med J 1995;56:102–4.

4. Fiscus SA, Adimora AA, Schoenbach VJ, McKinney R, Lim W, Rupar D, et al. Trends in human immunodeficiency virus (HIV) counseling, testing, and antiretroviral treatment of HIV-infected women and perinatal transmission in North Carolina. J Infect Dis 1999;180:99–105.[Medline]

5. Walter EB, Lampe MA, Livingston E, Royce RA. How do North Carolina prenatal care providers counsel and test pregnant women for HIV? NC Med J 1998;59:105–9.

6. Royce RA, Walter EB, Fernandez MI, Wilson TE, Ickovics JR, Simonds RJ. Barriers to universal prenatal HIV testing in 4 US locations in 1997. Am J Public Health 2001;91:727–33.[Abstract]

7. Lindegren ML, Byers RH Jr, Thomas P, Davis SF, Caldwell B, Rogers B, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999;282:531–8.[Abstract/Free Full Text]

8. Mills WA, Martin DL, Bertrand JR, Belongia EA. Physicians’ practices and opinions regarding prenatal screening for human immunodeficiency virus and other sexually transmitted diseases. Sex Transm Dis 1998;25:169–75.[Medline]

9. Institute of Medicine. Reducing the odds: Preventing perinatal transmission of HIV in the United States. Washington, DC: National Academy Press, 1999.

10. American College of Obstetricians and Gynecologists and American Academy of Pediatrics. Joint statement of ACOG/AAP on human immunodeficiency virus screening. Washington, DC: American College of Obstetricians and Gynecologists, 1999.

11. American Academy of Family Physicians. Policy on HIV infection: Counseling and testing. AAFP policies/position papers, Appendix B. Leawood, Kansas: AAFP, 1999.

12. American College of Nurse-Midwives. Statement on HIV/ AIDS. Washington, DC: American College of Nurse-Midwives, 1998.

13. Barbacci M, Repke JT, Chaisson RE. Routine prenatal screening for HIV infection. Lancet 1991:337:709–11.[Medline]

14. 15A North Carolina Administrative Code 19A.0204. Control measures—sexually transmitted diseases. Amended July 1, 1993.

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