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Obstetrics & Gynecology 2004;103:165-168
© 2004 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Women’s Knowledge About Treatment to Prevent Mother-to-Child Human Immunodeficiency Virus Transmission

John E. Anderson, PhD, Shahul H. Ebrahim, MD, PhD and Stephanie Sansom, PhD

From the Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia.

Address reprint requests to: John E. Anderson, PhD, Division of HIV/AIDS Prevention, CDC/MS E-46, Atlanta GA 30333; e-mail: jea1{at}cdc.gov.


   ABSTRACT
TOP
ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: To provide national estimates of knowledge about treatments available to reduce mother-to-infant human immunodeficiency virus (HIV) transmission among U.S. women of childbearing age.

METHODS: We used data from 55,712 women aged 18 to 44 years who responded to questions on antiretroviral treatment in the 2001 Behavioral Risk Factor Surveillance System. We obtained the percentage of women who correctly answered a question on treatment to prevent mother-to-child transmission of HIV and determined factors independently associated with such knowledge using a multiple logistic regression model.

RESULTS: Overall, the percentage of women who correctly stated that treatment existed to help prevent mother-to-child transmission of HIV was 58.6% (95% confidence interval 57.9, 59.3). In the multiple logistic regression model that controlled for sociodemographics, having correct knowledge about treatment to prevent mother-to-child HIV transmission was independently associated with being black, younger age (18–34 years), college level education, and having been tested for HIV. Current pregnancy was not an independent predictor of having knowledge about the availability of treatment to prevent mother-to-child transmission.

CONCLUSION: Among US women of childbearing age, just over one half had correct knowledge of effective perinatal HIV prevention strategies. Increasing the awareness of these treatments may lead to greater uptake of HIV testing among pregnant women.

LEVEL OF EVIDENCE: III

The availability of effective interventions to prevent the transmission of human immunodeficiency virus (HIV) from infected mothers to their newborns has reduced the incidence of perinatal HIV transmission in the United States from an estimated 1,000 to 2,000 cases a year in the early 1990s to an estimated 280 to 370 cases in 2000.1 The ability to prevent most perinatal transmission has led to recommendations that all pregnant women receive an HIV test as early as possible during prenatal care to allow infected women to begin receiving treatment when it most effectively prevents transmission.1 Despite the recommendation of universal, voluntary prenatal HIV testing, however, many pregnant women are untested.2 Pregnant women may be untested for a variety of reasons: the prenatal care provider may not offer testing or strongly recommend it or women may decline testing when it is offered.3–5 A key factor associated with women’s acceptance of a prenatal HIV test is the belief that testing is beneficial for her and her baby’s health.6 To assess knowledge of the availability of HIV treatments, questions on this topic were included in the 2001 Behavioral Risk Factor Surveillance System. In this report, we present national estimates of knowledge among U.S. women of childbearing age about treatments to prevent perinatal mother-to-child transmission of HIV.


   MATERIALS AND METHODS
TOP
ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The Behavioral Risk Factor Surveillance System is an ongoing, state-based telephone survey that gathers information about modifiable risk behaviors for the non-institutionalized, civilian population aged 18 years or older in each state.7 The Behavioral Risk Factor Surveillance System survey was reviewed by the Centers for Disease Control and Prevention office on human subjects. Samples are selected using a stratified design based on random-digit-dialing methodology (http://www.cdc.gov/brfss/surveydata/2001/overview_01.rtf, accessed August 22, 2003). Sample sizes are based on adequate numbers to estimate a variety of health-related indicators in each state, and range from 1,888 to 8,628 total respondents. The estimates presented here are based on weighting factors designed to produce unbiased estimates for the adult population of each state, and when aggregated, of the United States. Pregnancy status of the respondents is obtained by using the question "To your knowledge are you now pregnant?" The cooperation rate for all states in the 2001 Behavioral Risk Factor Surveillance System (the percentage of completed interviews among identified eligible respondents) was 67.2%.

We analyzed the responses of women aged 18 to 44 years for two separate "true/false" questions about the availability of treatment for HIV/acquired immunodeficiency syndrome (AIDS) which were read to the respondents. First, "A pregnant woman with HIV can get treatment to help reduce the chances that she will pass the virus to her baby," and second, for comparison, a more general question on HIV treatment, "There are medical treatments available that are intended to help a person who is infected with HIV to live longer." We computed the percentage of women aged 18 to 44 years who answered correctly for population subgroups (sociodemographic categories, self-reported pregnancy status, and self-reported HIV testing status). We also developed a multiple logistic regression model to determine which factors were independently associated with knowledge about treatments to prevent of perinatal HIV transmission. We used SUDAAN software to adjust estimates and statistical tests for the complex sample design (SUDAAN 7; Research Triangle Institute, Research Triangle Park, NC; 1996).


   RESULTS
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Of the 55,712 women aged 18 to 44 years (representative of 53.3 million U.S. women) who responded to the survey in 2001, we excluded 516 respondents for whom data on knowledge about HIV treatments were missing. The sociodemographic distribution of the respondents (Table 1Go) is comparable with those of the U.S. population (http://www.census.gov/population/projections/nation/summary/np-t4-b.txt, accessed August 22, 2003). Among those surveyed, 4.3% (95% confidence interval 4.0%, 4.6%) reported that they were pregnant at the time of interview, and 58.3% (95% confidence interval 57.6%, 59.0%) reported ever having been tested for HIV.


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  		Table 1. Knowledge of Treatment to Prevent Mother-to-Child Transmission,* U.S. Women Aged 18–44 Years, 2001
 
The percentage of women who correctly stated that treatment existed to help prevent mother-to-child transmission (58.6%) was substantially lower than the percentage of women who stated that treatment existed to help HIV-infected persons live longer (87.6%) (Table 2Go).


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  		Table 2. Knowledge of the Availability of Treatment for HIV Infected Persons U.S. Women Aged 18–44 Years, 2001
 
Among the population groups studied, the percentage of women who correctly stated that treatment existed to help prevent mother-to-child transmission varied between 50.4% and 65.8% (Table 1Go). The multivariate model, which contained all of the categories shown in Table 1Go, indicated that knowledge about treatment to prevent mother-to-child HIV transmission was independently associated with being black, younger age (18–34 years), college level education, ever having been tested for HIV, and living outside the midwest or south regions.

Although knowledge rate among pregnant women was higher than average (64.7%), pregnancy at the time of interview was not an independent predictor of having knowledge about treatment to prevent mother-to-child transmission. Although this survey collects information on history of HIV testing, such questions are not specific to pregnancy-related HIV testing. State-specific estimates indicate that there was considerable variation in knowledge among states (Figure 1Go).



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  		Figure 1. Percent with correct knowledge of treatment to prevent mother-to-child human immunodeficiency virus (HIV) transmission of women aged 18–44 years, Behavioral Risk Factor Surveillance System.

Anderson. Knowledge of Perinatal HIV Prevention. Obstet Gynecol 2004.

 

   DISCUSSION
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This survey of a nationally representative sample of women of childbearing age in the United States indicates that more than 40% of them are unaware that preventive treatment exists to prevent mother-to-child transmission of HIV. Even among pregnant women who, according to Centers for Disease Control and Prevention guidelines, should be receiving counseling and the offer of HIV testing as early as possible in prenatal care,1 only 64.7% were aware that effective treatment exists to prevent perinatal HIV transmission.

Among women surveyed who reported themselves pregnant, no data were collected on whether the woman was receiving prenatal care. The proportion of pregnant women in our analysis who knew about preventive treatment was within the 51–66% range reported by studies conducted in a few states.8,9

Our analysis indicates a positive and statistically significant association among childbearing-aged women between knowledge of treatment to prevent perinatal HIV transmission and ever having been tested for HIV. Other studies have suggested that knowledge of the benefits of testing influence women to obtain a prenatal HIV test.6,9,10 The Behavioral Risk Factors Surveillance System data are subject to coverage and reporting errors that affect survey data. Persons who are institutionalized or who lack home telephones are excluded from the survey, for example. Despite its limitations, these data shed light on one of the important factors associated with accessing and utilizing HIV prevention services.

Despite recommendations that all pregnant women be tested for HIV, studies have suggested that testing is not universal. For example, data from representative samples of the medical charts of pregnant women in 8 states indicated that the percentage tested in 1998 and 1999 ranged from 25% in Oregon to 85% in Tennessee.2 Reasons for low percentages tested include barriers to the offer of testing by prenatal care providers, poor documentation of testing in the medical record, and refusal of testing by pregnant women.3–5

Increased awareness of the very low transmission rates achievable with appropriate interventions may lead more pregnant women to accept HIV testing. Clinicians who provide care to pregnant women can play an important role in improving awareness about treatment to reduce mother-to-child HIV transmission. Public health efforts to increase acceptance with HIV testing among pregnant women should focus also on increasing awareness among women of childbearing years that highly effective interventions exist to prevent the transmission of HIV from mother to infant. Social marketing efforts by publicly and privately funded HIV prevention programs to increase women’s knowledge of the benefits of prenatal HIV testing and availability of treatments could increase HIV test acceptance. Systematic reviews of maternal medical charts, with regular feedback to delivery hospitals, could lead to improved documentation of prenatal HIV testing. Our data suggest that women of child bearing age in all states, particularly those of lower education and socioeconomic status, could benefit from more education about the effectiveness of perinatal HIV transmission interventions.


   Footnotes
 
doi:10.1097/01.AOG.0000101285.25133.5A

Received June 19, 2003. Received in revised form September 12, 2003. Accepted October 1, 2003.


   REFERENCES
TOP
ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR Recomm Rep 2001;50(RR-19):63–85.[Medline]

2. Centers for Disease Control and Prevention. HIV testing among pregnant women: United States and Canada, 1998–2001. MMWR Morb Mortal Wkly Rep 2002;51: 1013–6.[Medline]

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

4. 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]

5. Ruiz JD, Molitor F, Prussing E, Peck L, Grasso P. Prenatal HIV counseling and testing in California: women’s experiences and providers’ practices. AIDS Educ Prev 2002;14:190–5.[Medline]

6. Fernandez MI, Wilson TE, Ethier KA, Walter EB, Gay CL, Moore J. Acceptance of HIV testing during prenatal care. Public Health Rep 2000;115:460–8.[Medline]

7. Aluwalia IB, Mack KA, Murphy W, Mokdad AH, Bales VS. State-specific prevalence of selected chronic disease-related characteristics: Behavioral Risk Factor Surveillance System, 2001. MMWR Surveill Summ 2003;52(8):1–80.[Medline]

8. Walter EB, Royce RA, Fernandez MI, DeHovitz J, Ickovics JR, Lampe MA. New mothers’ knowledge and attitudes about perinatal human immunodeficiency virus infection. Obstet Gynecol 2001;97(1):70–6.[Abstract/Free Full Text]

9. Ruiz JD, Molitor F. Knowledge of treatment to reduce perinatal human immunodeficiency virus (HIV) transmission and likelihood of testing for HIV: results from two surveys of women of childbearing age. Matern Child Health J 1998;2:117–22.[Medline]

10. McKinney MM, McSpirit S, Pomeroy C. Prenatal HIV prevention practices in a low seroprevalence state. AIDS Educ Prev 2000;12:252–62.[Medline]





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