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ORIGINAL RESEARCH |
From the Departments of Public Health, Community Health Services, and Obstetrics and Gynecology, Denver Health and Hospital Authority; and the Departments of Medicine (Division of Infectious Diseases), Family Medicine, and Obstetrics and Gynecology, University of Colorado Health Science Center, Denver, Colorado.
Address reprint requests to: William Burman, MD, 605 Bannock Street, Denver, CO 80204; e-mail: bburman{at}dhha.org.
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ABSTRACT |
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METHODS: This was a retrospective cohort study of pregnancies resulting in delivery from 1998 through 2001 at Denver Health Medical Center, an urban public hospital. The main outcome measure was the proportion of documented HIV screening within 9 months before the delivery date.
RESULTS: Of 12,221 pregnancies resulting in delivery, HIV screening was completed in 12,000 (98.2%, 95% confidence interval 97.9–98.4%). Of the 221 women not screened for HIV, only 24 (10.9% of those not screened, 0.2% of all women in the study) were documented as refusing HIV testing. Patients not screened for HIV presented late in pregnancy, a median of 1 day before delivery, compared with a median of 176 days for those who were screened (P < .001).
CONCLUSION: A verbal opt-out system was very effective in promoting HIV screening during pregnancy. Late presentation in pregnancy was associated with not having HIV screening performed.
LEVEL OF EVIDENCE: II-3
Previous studies have reported marked differences in the use of HIV-screening programs during pregnancy, with rates ranging from 25% to 98%.6,7 Rates of HIV screening during pregnancy have increased with time but remained less than 70% in 1999 in a nationwide study.6 Identification of factors that affect perinatal screening rates would have important public health implications. Therefore, we evaluated a program for screening for HIV during pregnancy in a large urban public health care system using the verbal opt-out system for obtaining permission for HIV testing. We hypothesized that use of the verbal opt-out system would result in a high rate of HIV screening.
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MATERIALS AND METHODS |
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Denver Health uses a verbal opt-out system for HIV screening during pregnancy. During the initial prenatal visit, pregnant women are told that a screening test for HIV is recommended during all pregnancies because treatment can markedly decrease the rate of perinatal transmission. This information can be presented by a Denver Health physician, nurse, or health care partner. There is no attempt to obtain a detailed risk assessment of the likelihood of prior HIV exposure. Patients are given an opportunity to refuse HIV testing; those who give verbal permission have an HIV test obtained at that same time that other standard prenatal laboratory tests are obtained. Because Spanish is commonly spoken in our patient population, bilingual staff is widely available. In addition, patients are given written information on HIV screening; this information is provided in Spanish and English and is written at the 5th-grade reading level. During the study period, all HIV testing was performed by using conventional enzyme-linked immunosorbent assay and Western blot testing; no rapid test was available.
Deliveries at Denver Health Medical Center from January 1, 1998, through December 31, 2001, were identified from a computer data set containing discharge diagnosis codes. We then matched this cohort to billing information from another computer data set to determine whether a screening test for HIV (enzyme-linked immunosorbent assay) had been obtained during a 270-day period before hospitalization for delivery. The accuracy of using billing data to determine screening status was assessed in 2 ways. First, we reviewed charts for 100 pregnancies selected at random from those with a charge for HIV testing in the billing file. The sample size of 100 was chosen to provide a narrow 95% confidence interval (CI) around the estimate of the accuracy of the billing data. Second, we reviewed charts of all pregnancies for which there was not a charge for HIV testing. To be counted as having been screened for HIV infection during pregnancy, we required that a copy of the HIV test be available in the selected patient's medical record; a chart notation indicating that HIV screening had taken place but without further documentation was not accepted. Finally, we evaluated the duration of prenatal care (time from the first appointment for pregnancy care to delivery date) for 100 randomly selected women who did and 100 randomly selected women who did not have HIV screening during pregnancy (women who refused HIV testing were not included in this sample).
Data from chart reviews were entered into a Microsoft Excel spreadsheet (Microsoft, Renton, WA) and analyzed by using the SAS statistical package (SAS Institute, Inc, Cary, NC). Dichotomous variables were compared by using the 
2 test. The distribution of continuous variables was assessed by using the Shapiro–Wilk test for normality. Normally distributed variables were compared by using the Student t test; nonnormally distributed variables were evaluated by using the Wilcoxon rank sum test.
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RESULTS |
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Women who were not screened for HIV during pregnancy were more often of African-American or Caucasian race/ethnicity, more often spoke English as a primary language, and were more often U.S. citizens than were women who were screened during pregnancy (Table 1). The most notable difference between women not screened for HIV versus those who had screening was in the estimated duration of prenatal care. The median time from diagnosis of pregnancy to delivery was only 1 day (interquartile range, 0–83 days) among the 100 randomly selected women not screened for HIV compared with 176 days (interquartile range, 121–199 days) among the 100 randomly selected women who were screened for HIV (P < .001, Wilcoxon rank-sum test).
Nine women were diagnosed with HIV as a result of screening during pregnancy; therefore, the yield of screening was 0.08%. An additional 11 women with a prior diagnosis of HIV infection delivered during the study period. The rate of perinatal HIV transmission was 5% (1/20), with the only known case of perinatal HIV transmission involving a woman who presented very late in pregnancy without any identified risk factors for HIV exposure. Because of her late presentation for medical care, the results of her positive HIV test did not return until after delivery.
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DISCUSSION |
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Recent studies have shown a correlation between HIV-screening rates and the way in which HIV screening is presented to pregnant women. Programs that require specific counseling and written consent ("opt-in") have substantially lower rates of HIV screening (25–83%) than do programs recommending HIV testing as a standard practice for all pregnancies, or "opt-out" (85–98%).7 Our study confirms the effectiveness of the opt-out testing strategy in a large urban hospital providing care for a diverse patient population. Although an HIV-screening rate during pregnancy of 98% is notable, it should be possible to improve this rate. The use of the recently approved rapid HIV test may improve the overall effectiveness of our screening system8,9 because the most common reason for lack of screening appeared to be lack of prenatal care and presentation during labor.
The major limitation of this study was the inability of a retrospective study based on computer and medical records to clearly delineate the reasons screening was not performed. Given the retrospective nature of this study, we were unable to ascertain whether failure to complete screening was caused by a failure to offer HIV testing or by refusal of testing that was not documented in the medical record. We did not attempt to assess attitudes among patients or care providers toward HIV screening. The chart review may have underestimated the rate of refusal of HIV screening if care providers did not document refusal in the medical record.
Despite limitations, this study demonstrated the effectiveness of the verbal opt-out system. Additional research is needed to clarify reasons for lack of HIV screening using the verbal opt-out system, but our results suggest that patient refusal of testing is a very uncommon reason. Further work should focus on improving HIV screening among women who present very late in pregnancy.
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Footnotes |
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Presented in part at the National HIV Prevention Conference, July 2003, Atlanta, Georgia.
10.1097/01.AOG.0000129957.35105.d4
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REFERENCES |
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2. Cooper ER, Charurat M, Burns DN, Blattner W, Hoff R. Trends in antiretroviral therapy and mother-infant transmission of HIV: The Women and Infants Transmission Study Group. J Acquir Immune Defic Syndr 2000;24:45–7.[Medline]
3. Lindegren ML, Byers RH Jr, Thomas P, Davis SF, Caldwell B, Rogers M, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999;282:531–8.
4. Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50:63–85.
5. Peters V, Liu KL, Dominguez K, Frederick T, Melville S, Hsu HW, et al. Missed opportunities for perinatal HIV prevention among HIV-exposed infants born 1996–2000, pediatric spectrum of HIV disease cohort. Pediatrics 2003;111:1186–91.
6. Lansky A, Jones JL, Frey RL, Lindegren ML. Trends in HIV testing among pregnant women: United States, 1994–1999. Am J Public Health 2001;91:1291–3.
7. Centers for Disease Control and Prevention. HIV testing among pregnant women—United States and Canada, 1998–2001. MMWR 2002;51:1013–6.[Medline]
8. Cohen MH, Olszewski Y, Branson B, Robey M, Love F, Jamieson DJ, et al. Using point-of-care testing to make rapid HIV-1 tests in labor really rapid. AIDS 2003;17:2121–4.[Medline]
9. Minkoff H, O'Sullivan MJ. The case for rapid HIV testing during labor. JAMA 1998;279:1743–4.
This article has been cited by other articles:
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  A. D. Gray, R. Carlson, M. A. Morgan, D. Hawks, and J. Schulkin Obstetrician Gynecologists' Knowledge and Practice Regarding Human Immunodeficiency Virus Screening Obstet. Gynecol., November 1, 2007; 110(5): 1019 - 1026. [Abstract] [Full Text] [PDF]
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M. H. Yudin, C. Moravac, and R. R. Shah Influence of an "Opt-Out" Test Strategy and Patient Factors on Human Immunodeficiency Virus Screening in Pregnancy Obstet. Gynecol., July 1, 2007; 110(1): 81 - 86. [Abstract] [Full Text] [PDF]
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