Data Highlights | References | Tables

Background

Pregnant women can enhance birth outcomes and infant health by engaging in healthy behaviors and avoiding risky ones around the time of pregnancy. Annually in the United States, an estimated 6,000–7,000 women who are infected with the human immunodeficiency virus (HIV) give birth, and an estimated 280–370 HIV-infected infants are born.¹ To reduce perinatal HIV transmission, the U.S. Preventive Services Task Force (USPSTF),² the American College of Obstetricians and Gynecologists (ACOG),^3,4 the American Academy of Pediatricians (AAP),⁴ and the U.S. Public Health Service (PHS)⁵ recommend universal HIV counseling and voluntary testing as part of routine prenatal care. Diagnosis early in pregnancy gives infected women the opportunity to receive antiretroviral drugs that protect her health and lower her chances of transmitting the virus to her unborn infant.⁵ Early diagnosis also allows infected women to learn about and make decisions that reduce the risk of transmitting the virus during labor and delivery.⁵

About 84% of pregnant women who have a live birth begin prenatal care in their first trimester,⁶ placing prenatal care providers in a unique position to discuss HIV and offer testing early in pregnancy. Data from the Enhanced Perinatal Surveillance (EPS) system show that 88% of HIV-infected women received some prenatal care and 82% had 3 or more prenatal visits in 1999–2001.¹ Studies show, however, that the proportions of HIV-infected women who receive early and adequate care are much lower than those in the general population, resulting in missed opportunities to prevent perinatal HIV transmission.^7–9

Transmission of HIV from an infected woman to her fetus or newborn can occur during pregnancy, delivery (intrapartum), or after delivery through breastfeeding. From the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic through 2004, 93% of all reported AIDS cases among children in the United States have been due to perinatal transmission of HIV.¹⁰ In the absence of antiretroviral prophylaxis, perinatal transmission rates in developed countries have been found to range from 14% to 25%.¹¹ In 1994, a multicenter, placebo-controlled clinical trial demonstrated that administering zidovudine (ZDV) therapy to a selected group of HIV-infected women during pregnancy, labor, and delivery and to their newborns reduced the risk of perinatal HIV transmission by approximately two-thirds.¹² Subsequent clinical trials have added further support to the efficacy of prenatal ZDV therapy, including support for substantially lower transmission rates when mothers start antiretroviral therapy during pregnancy (2% or less) instead of at the time of labor and delivery or after birth (12%–13%).¹³

In 1995, PHS announced guidelines recommending universal HIV counseling and voluntary testing for all pregnant women during routine prenatal care and treatment for those infected with HIV.¹⁴ Widespread adoption of the 1995 guidelines and acceptance of treatment among HIV-infected women are credited with sharp declines in perinatal transmission rates during 1995–2000.⁵ The guidelines also led to increases in prenatal care discussions about HIV testing,¹⁵ actual HIV testing,^15,16 and diagnosis of HIV-infected women before delivery.⁸ In 2001, PHS issued revised recommendations for HIV screening of pregnant women.⁵

Despite recommendations from federal and professional health agencies, many health care providers still do not discuss HIV testing or offer testing to pregnant women during prenatal care.^15–17 For example, a study using 1997 PRAMS data in 14 states found that between 63.4% and 86.7% of mothers reported discussing HIV testing with their prenatal care provider, and between 58.0% and 80.7% were tested.¹⁵ EPS data show that 91% of HIV-infected women giving birth during 1999–2001 were tested for HIV before either pregnancy or labor.¹ Concerns about the quality and comprehensiveness of prenatal counseling about HIV testing have also been raised.¹⁸

PRAMS collects data from women on whether any health care provider or worker talked to them about getting tested for HIV during a prenatal care visit. States and professional organizations can use these data to monitor counseling practices and to improve the quality of prenatal care counseling on HIV prevention and transmission.

Data Highlights

• In 2002, the proportion of women who reported that their prenatal care counseling included a discussion of HIV testing ranged from 56.6% (Utah) to 91.4% (New York).
  
  
• During 2000–2002, the proportion of women who reported that prenatal care counseling included a discussion of HIV testing increased in 2 states (New Mexico and South Carolina) and decreased in 3 states (Arkansas, Hawaii, and New York).

References

1. Centers for Disease Control and Prevention. Enhanced Perinatal Surveillance—United States, 1999–2001. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2004. (HIV/AIDS Special Surveillance Report, No.4).
   
   
2. U.S. Preventive Services Task Force. Screening for HIV: Recommendation Statement. Rockville, MD: Agency for Healthcare Research and Policy; 2005.
   
   
3. American College of Obstetricians and Gynecologists (ACOG). Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. (ACOG committee opinion number 304.) Obstetrics and Gynecology 2004;104(5 Part 1):1119–1124.
   
   
4. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Human immunodeficiency virus screening. Joint statement of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Pediatrics 1999;104(1):128.
   
   
5. Centers for Disease Control and Prevention. Revised recommendations for HIV screening of pregnant women. MMWR Recommendations and Reports 2001;50(RR-19):59–86.
   
   
6. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. National Vital Statistics Reports 2003;52(10):1–113.
   
   
7. Wilson TE, Ickovics JR, Royce R, Fernandez MI, Lampe M, Koenig LJ. Prenatal care utilization and the implementation of prophylaxis to prevent perinatal HIV-1 transmission. Maternal and Child Health Journal 2004;8(1):13–18.
   
   
8. Centers for Disease Control and Prevention. Success in implementing Public Health Service guidelines to reduce perinatal transmission of HIV—Louisiana, Michigan, New Jersey, and South Carolina, 1993, 1995, and 1996. MMWR 1998;47(33):688–691.
   
   
9. Peters V, Liu KL, Dominguez K, Frederick T, Melville S, Hsu HW, Ortiz I, Rakusan T, Gill B, Thomas P. Missed opportunities for perinatal HIV prevention among HIV–exposed infants born 1996–2000, Pediatric Spectrum of HIV Disease Cohort. Pediatrics 2003;11(5):1186–1191.
   
   
10. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2005 (Vol. 16).
    
    
11. Chou R, Smits AK, Huffman LH, Fu R, Korthuis PT. Prenatal screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine 2005;143(1):38–54.
    
    
12. 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. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. The New England Journal of Medicine 1994;331(18):1173–1180.
    
    
13. Centers for Disease Control and Prevention. HIV testing among pregnant women—United States and Canada, 1998–2001. MMWR 2002;51(45):1013–1016.
    
    
14. Centers for Disease Control and Prevention. U.S. Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR Recommendations and Reports 1995;44(RR-7):1–15.
    
    
15. Centers for Disease Control and Prevention. Prenatal discussion of HIV testing and maternal HIV testing—14 states, 1996–1997. MMWR 1999;48(19):401–404.
    
    
16. Lansky A, Jones JL, Frey RL, Lindegren ML. Trends in HIV testing among pregnant women: United States, 1994–1999. American Journal of Public Health 2001;91(8):1291–1293.
    
    
17. Joo E, Carmack A, Garcia-Bunuel E, Kelly CJ. Implementation of guidelines for HIV counseling and voluntary HIV testing of pregnant women. American Journal of Public Health 2000;90(2):273–276.
    
    
18. Ruiz JD, Molitor F, Prussing E, Peck L, Grasso P. Prenatal HIV counseling and testing in California: women's experiences and providers' practices. AIDS Education and Prevention 2002;14(3):190–195.

 

Prevalence of Prenatal Care Discussion of HIV Testing, 2002

State	Respondents	Percent†	Standard Error	95% CI‡
Alabama	1,506	79.3	1.3	76.6–81.7
Alaska	1,584	84.2	1.1	82.1–86.2
Arkansas	1,896	73.0	1.4	70.2–75.7
Colorado	2,229	75.8	1.2	73.4–78.0
Florida	1,980	88.5	1.1	86.1–90.5
Hawaii	1,769	80.8	1.2	78.4–83.0
Illinois	1,885	79.8	1.0	77.8–81.7
Louisiana	1,641	84.3	1.0	82.2–86.1
Maine	1,120	80.1	1.3	77.3–82.6
Maryland	1,437	83.5	1.4	80.5–86.2
Michigan	1,524	86.0	1.0	83.9–87.8
Minnesotaa	1,108	75.6	1.6	72.3–78.7
Montana	1,029	73.3	1.4	70.4–75.9
Nebraska	1,826	75.4	1.2	72.9–77.7
New Jerseyb	912	81.3	1.5	78.1–84.1
New Mexico	1,518	82.8	1.0	80.7–84.7
New Yorkc	1,186	91.4	1.1	89.1–93.3
North Carolina	1,508	88.0	1.0	85.8–89.9
North Dakota	890	73.1	1.5	70.2–75.9
Ohio	1,349	79.6	1.4	76.7–82.3
Oklahoma	1,813	74.0	1.6	70.8–77.0
Rhode Island	1,382	78.8	1.3	76.1–81.2
South Carolina	1,344	83.5	1.6	80.1–86.4
Utah	1,540	56.6	1.6	53.4–59.7
Vermont	1,088	81.6	1.2	79.2–83.7
Washington	1,488	85.8	1.3	83.1–88.2
West Virginia	1,651	79.9	1.4	77.0–82.5
All PRAMS states§	40,203	82.2	0.3	81.6–82.8
† 2002 state range is 56.6–91.4%. ‡ Confidence interval. § Aggregate of the 27 PRAMS states. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City.

 

Prevalence of Prenatal Care Discussion of HIV Testing, 2002

 

Prevalence of Prenatal Care Discussion of HIV Testing, 2000–2002

State	2000 (%)	2001 (%)	2002 (%)	P value for trend#
Alabama	79.0	79.0	79.3	0.893
Alaska	82.8	81.1	84.2	0.366
Arkansas	78.1	73.0	73.0	0.012*
Colorado	77.3	76.8	75.8	0.365
Florida	86.1	86.1	88.5	0.139
Hawaii	84.1	84.3	80.8	0.022*
Illinois	77.5	81.1	79.8	0.096
Louisiana	85.4	85.6	84.3	0.399
Maine	78.8	75.7	80.1	0.502
Maryland	—	83.9d	83.5	# #
Michigan	—	86.5e	86.0	# #
Minnesota	—	—	75.6a	# #
Montana	—	—	73.3	# #
Nebraska	72.4	74.5	75.4	0.086
New Jersey	—	—	81.3b	# #
New Mexico	78.5	80.8	82.8	0.004*
New Yorkc	95.8	95.0	91.4	0.001**
North Carolina	87.6	84.5	88.0	0.829
North Dakota	—	—	73.1	# #
Ohio	77.1	79.0	79.6	0.211
Oklahoma	73.2	75.2	74.0	0.729
Rhode Island	—	—	78.8	# #
South Carolina	78.7	81.3	83.5	0.038*
Utah	57.7	56.4	56.6	0.630
Vermont	—f	80.0f	81.6	# #
Washington	83.8	86.0	85.8	0.271
West Virginia	81.9	81.6	79.9	0.298
# Based on a test for linear trend using logistic regression. * p value is less than 0.05. ** p value is less than 0.001. # # < 3 years of data available; test for linear trend not applicable. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City. d Data represent Maryland births from February–December 2001. e Data represent Michigan births from July–December 2001. f Data represent Vermont births from October 2000–December 2001.