The maternal and child health sites' practices regarding HIV education, counseling, and testing of women of reproductive age in Chicago: barriers to universal implementation

Why don't physicians test for HIV? A review of the US literature

OBJECTIVE

In its 2006 HIV testing guidelines, the Centers for Disease Control and Prevention (CDC) recommended routine testing in all US medical settings. Given that many physicians do not routinely test for HIV, the objective of this study was to summarize our current understanding of why US physicians do not offer HIV testing.

DESIGN

A comprehensive review of the published and unpublished literature on HIV testing barriers was conducted.

METHODS

A literature search was conducted in Pubmed using defined search terms. Other sources included Google, recent conference abstracts, and experts in the field. Studies were divided into three categories: prenatal; emergency department; and other medical settings. These categories were chosen because of differences in physician training, practice environment, and patient populations. Barriers identified in these sources were summarized separately for the three practice settings and compared.

RESULTS

Forty-one barriers were identified from 17 reports. Twenty-four barriers were named in the prenatal setting, 20 in the emergency department setting, and 23 in other medical settings. Eight barriers were identified in all three categories: insufficient time; burdensome consent process; lack of knowledge/training; lack of patient acceptance; pretest counselling requirements; competing priorities; and inadequate reimbursement.

CONCLUSION

US physicians experience many policy-based, logistical, and educational barriers to HIV testing. Although some barriers are exclusive to the practice setting studied, substantial overlap was found across practice settings. Some or all of these barriers must be addressed before the CDC recommendation for routine HIV testing can be realized in all US medical settings.

The "Six T's": barriers to screening teens for substance abuse in primary care

PURPOSE

To identify barriers to adolescent substance abuse screening in primary care.

METHODS

Focus groups were held at six primary care sites with a total of 38 providers. Providers brainstormed a list of barriers, collectively grouped similar barriers, and voted to produce a final ranked list. Two investigators qualitatively analyzed field notes and transcripts to triangulate findings, ranked the barriers across all sites by the number of groups identifying the barrier, then calculated a mean ranking (MR) for each.

RESULTS

The most commonly identified barrier was insufficient time (MR 1.8). Lack of training in how to manage a positive screen was ranked second (MR 1.7), but was linked to the first. Providers reported they had enough time to administer a short screen, but insufficient time to manage a positive result during the well care visit. The need to triage competing problems (MR 3.0), lack of treatment resources (MR 3.3), tenacious parents who would not leave the room for a confidential discussion (MR 2.5), and unfamiliarity with screening tools (MR 3.0) were also noted by more than one group.

CONCLUSIONS

Insufficient time and lack of training in how to manage positive screens are the greatest barriers to screening adolescents for substance abuse. This suggests that some providers might differentially avoid screening youth who they suspect will screen positive, yet these patients would benefit most from early recognition. More research is needed on effective ways to manage positive substance abuse screens in primary care.

Testing practices and knowledge of HIV among prenatal care providers in a low seroprevalence state

As the prevalence of heterosexually transmitted HIV increases among women of childbearing age in the United States, so too does the potential for vertical transmission from mother to child. Early maternal diagnosis and appropriate management are critical to minimizing the risk of perinatal infection. We designed a study to evaluate current prenatal care provider testing practices and knowledge of HIV as it relates to pregnancy in a low seroprevalence state. A written questionnaire was mailed to 642 prenatal care providers in Kentucky. Responses were compared to a similar survey conducted in 1998 and to current federal guidelines for HIV management. Nearly all respondents reported to offer HIV testing to all prenatal patients, demonstrating a marked improvement since 1998 (p < 0.001). However, clinicians did not report adequate follow-up when testing is refused and appear to have limited knowledge of the disease as it relates to pregnancy. Only 9.3% of respondents demonstrated proficiency on two knowledge assessment questions. Those with previous experience treating prenatal patients with HIV were more likely to respond correctly (odds ratio [OR] 3.03; 95% confidence interval [CI] 1.08-8.50). Providers with little experience treating patients with HIV may not possess the basic knowledge required to manage the disease during pregnancy. Additional educational interventions are needed in low seroprevalence areas to ensure the appropriate treatment of all HIV-positive pregnant patients and to minimize the risk of preventable perinatal transmission.

A faculty trainer model: increasing knowledge and changing practice to improve perinatal HIV prevention and care

Although routine counseling and HIV testing of pregnant women is recommended, it is not yet universally offered. This paper reports on a project that trained health care providers from 2000 to 2002 using a faculty trainer (or train-the-trainer) model. The goals of the projects were to increase knowledge and change practice, increase HIV counseling and testing in prenatal care, and improve management of HIV in pregnant women. In four jurisdictions of the southeastern United States, 193 health care providers attended faculty trainer workshops using a standardized curriculum. Eighteen providers used the curriculum to train an additional 545 health care providers over 2 years. Participants in both faculty trainer workshops and trainerled seminars reported significant increases in perceived knowledge in all content areas and the intention to change clinical practice. The number of providers who became faculty trainers and then led seminars varied widely among the jurisdictions. Six-month follow-up of faculty trainers, although limited by a 63% response rate, found that over 90% of respondents reported the workshop had a positive impact on their care of women with and at risk for HIV. Our findings indicate the faculty trainer model is an effective way to educate practicing clinicians. Key elements to successful implementation were: ongoing support of faculty trainers by acquired immune deficiency syndrome (AIDS) educators, involvement of local HIV experts as trainers and resource persons, and use of a standardized curriculum based on national guidelines.

Unique challenges to preventing perinatal HIV transmission among Hispanic women in California: results of a needs assessment

To identify rates and factors associated with timely prenatal care (PNC) initiation, HIV test counseling, test offering, and test offer acceptance, we conducted a semistructured survey of a convenience sample of pregnant/recently delivered Hispanic women (n=453, 418 with analyzable data) in four California counties in 2000. Only 68.4% and 43.5% of Hispanic women reported receiving an HIV test offer and counseling, respectively, though 88.8% of those offered a test accepted. After controlling for the effects of age, education, years lived in the United States, health insurance coverage, delivery status, and parity, Hispanic women who initiated prenatal care in the first trimester were 1.7 times more likely to be offered an HIV test and almost 3 times more likely to receive counseling than women with a later prenatal care start or no prenatal care. Factors associated with timely PNC initiation on multivariate analysis were private/HMO insurance (OR=10.7, p < .001), Medi-Cal insurance (OR = 4.32, p < .001), being 25-30 years old (OR = 3.0, p = .008), and completion of high school (OR = 2.07, p = .01). Key opportunities to prevent perinatal HIV transmission are being lost for Hispanic women in California. Interventions to increase timely PNC initiation, and to improve test offering by health care providers, may help to improve counseling and testing rates for this population.

Implementation of guidelines for HIV counseling and voluntary HIV testing of pregnant women

OBJECTIVES

This study assessed HIV counseling and testing among pregnant women.

METHODS

A survey was administered to 9115 women who gave birth at 66 Chicago-area hospitals in 1997 and 1998.

RESULTS

Fifty-eight percent of the women received HIV counseling, and 65% were offered testing. Fifty-six percent were tested for HIV. Among the women tested, 88% were given their test result. Women were more likely to be tested if they received HIV counseling and were more likely to be offered testing if they received such counseling.

CONCLUSIONS

Rates of HIV counseling for, and offers of testing to, pregnant women need to be increased.