|HIV Screening for Pregnant Women||Percentage of pregnant women who were screened for HIV infection during the first or second prenatal care visit||Number of women from the denominator who were screened for HIV infection during the first or second prenatal care visit||All patients seen for two prenatal visits during the measurement year||AMA|
|National Quality Forum|
Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) are leading causes of illness and death in the United States and only 40 percent of the United States population has been tested. (1) One of the major ways in which children become HIV-infected is via perinatal transmission from the infected mother to her fetus. By targeting pregnant women for screening, this mode of transmission can be reduced through monitoring and treatment of HIV-infectesd pregnant women. Without antiretroviral therapy, approximately 25 percent of pregnant women infected with HIV in the United States will transmit the virus to their child.(2) Appropriate health care management of women with HIV during pregnancy and delivery, as well as care for infants promptly after delivery, can reduce the rate of HIV transmission to less than two percent.(2) Regularly testing pregnant women for HIV and providing pregnancy appropriate antiretroviral drugs, if they are infected, has dramatically reduced the number of children born with HIV. Recommendations for HIV Testing for Pregnant Women in Health Care Settings can be found on the Center for Disease Control and Prevention (CDC) Web site.
Perinatal HIV transmission accounts for nearly all pediatric AIDS cases. In Figure 1.1, the graph shows that the number of perinatally-acquired AIDS cases decreased dramatically recommendations for perinatal treatment and prenatal HIV testing were introduced. Data also indicates that perinatal HIV transmission can be prevented when appropriate antiretroviral medications are given during pregnancy, labor and delivery, and after birth. The risk of transmission can be reduced to less than 2 percent compared to approximately 25 percent when no interventions are given. (3)
On a national level, HIV/AIDS surveillance and other studies continue to demonstrate that perinatal HIV prevention efforts are making a difference. Between 1991 and 2004, the number of new perinatally-acquired HIV cases in the United States declined more than 80 percent from an estimated 1,650 (4) to an estimated 96 to 186 cases. (5) Between 1992 and 2005, perinatally-acquired AIDS cases declined 93 percent in the United States from 855 to 57 cases. (6) It is, therefore, vital that an HIV infection in a mother is identified during the early stages of pregnancy to provide an opportunity to reduce the risk of transmission to her baby. Early screening even prior to conception is ideal, but in practice, screening at any time is better than none. Although this measure focuses on early screening it is important to emphasize that intervention to reduce mother-to-child transmission can be successful even during labor and in the immediate postpartum period.
Offering HIV screening for pregnant women is the standard of care in the United States. The CDC recommends that all pregnant women in the United States be tested for HIV infection. Health care providers should recommend HIV testing to all of their pregnant patients, pointing out the substantial benefit of knowledge of HIV status for the health of women and their infants. HIV screening should be a routine part of prenatal care for all women. (7) Universal HIV testing with patient notification and opt-out options should, however, be in accordance with current State laws. (8,9) HIV Testing for Mothers and Newborns is a resource for current laws for HIV screening by State.
Since 1994, the availability of increasingly effective antiretroviral drugs for both the prevention of perinatal HIV transmission and maternal treatment has resulted in a greater emphasis on prenatal HIV testing and substantial increases in prenatal testing rates. In 2000, preliminary data indicated that 766 of 824 HIV-infected women (93 percent) in 25 States knew their HIV status before delivery (CDC, unpublished data, 2002). However, about 100 to 200 infants in the United States are infected with HIV annually. Many of these infections involve women who were not tested early enough in pregnancy or who did not receive prevention services. (1) The primary strategy to prevent perinatal HIV transmission is to maximize prenatal HIV testing of pregnant women. States and Canadian provinces have implemented three different prenatal HIV-testing approaches. To assess their effectiveness, CDC reviewed prenatal HIV-antibody testing rates associated with these approaches. Medical record data suggests that the opt-in voluntary testing approach is associated with lower testing rates than either the opt-out voluntary testing approach or the mandatory newborn HIV-testing approach.
According to the United States Preventive Services Task Force (USPSTF), clinicians should screen all pregnant women for HIV. The task force categorizes this as A Recommendation, which indicates that there is good evidence to support the practice. It cites evidence that both standard and FDA-approved rapid screening tests accurately detect HIV infection in pregnant women, and there is fair evidence that introduction of universal prenatal counseling and voluntary testing increase the proportion of HIV-infected women who are diagnosed and treated before delivery. (7)
Monitoring the percentage of pregnant women screened for HIV during the first or second prenatal care visit assists an organization in its efforts to improve care and provide optimal outcomes for mothers and babies.
The HIV Screening for Pregnant Women measure is designed to measure screening of pregnant patients for HIV. The goal for improvement for HIV Screening for Pregnant Women is to minimize perinatal transmission of HIV infection through early diagnosis and treatment of HIV-infected pregnant women. (10) The ultimate goal is to decrease the number of children perinatally infected with HIV.
Consider the characteristics of a good performance measure and the IOM framework, Envisioning the National Healthcare Quality Report:
To ensure that a performance measure has these characteristics, it is often based on, or aligned with, an organization's existing and proven measures.
The HIV Screening for Pregnant Women measure aligns with measures endorsed by the American Medical Association (AMA) and is supported by recommendations and guidelines by National Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics, American College of Obstetricians and Gynecologists (ACOG), and U.S. Preventive Services Task Force (USPSTF) sponsored by the Agency for Healthcare Research and Quality (AHRQ). Similar measures also exist in the national measure set for Healthy People 2020 as shown in Figure 1.2. Measures are also available as part of the Advancing HIV Prevention Program (AHP) from the CDC, Strategy 4: Further Decrease Mother-to-Child HIV Transmission. The AHP initiative represents a multi-agency collaboration within the Department of Health and Human Services (DHHS). Strategy 4 states that treatment of pregnant women and their infants can substantially reduce the number of babies born with HIV infection. (11)
Reduce the number of new cases of perinatally-acquired HIV/AIDS diagnosed each year and perinatally-acquired AIDS. (11)
Data Source: HIV/AIDS Surveillance System, CDC, NCHHSTP
Status: Retained Healthy People 2020 Objective 8-17
HRSA Core Clinical Measure: HIV Screening for Pregnant Women
As with all performance measures, paying close attention to specifications, such as, inclusions, exclusions, and clarifications are required to ensure that an organization collects and reports data consistently. This consistency allows an organization using the measure to compare itself with others. Detailed specifications for the measure, with descriptions of inclusion and exclusion criteria, are found in the section, Part 3: Data Infrastructure: HIV Screening for Pregnant Women.
Improvement Experience: HIV Screening for Pregnant Women
In 2002, the CDC reviewed the HIV-testing rates for pregnant women for the period of 1998 to 2001. (13) A variety of data sources were used to determine rates, including interviews with patients, large-scale research studies, and regional databases. The CDC study found that HIV- testing rates for pregnant women varied widely and that a relatively high proportion of women of child-bearing age were unaware that treatment is available to reduce the risk of perinatal transmission. (14) Additionally, the CDC found that rates varied with different approaches to testing. Locations that used the opt-out approach presented HIV screening as part of the routine prenatal testing panel and informed the woman that she had the right to refuse HIV testing. Locations that used the opt-in approach provided HIV pre-test counseling and required specific consent from the patient. Mandatory newborn testing, which tested newborns whose mothers' HIV status was unknown at the time of birth, was also reviewed. The opt-out approach resulted in higher screening rates of 71 to 98 percent than the opt-in approach, which resulted in screening rates of 25 to 83 percent, or mandatory newborn testing. In addition, it was found that locations that transitioned from the opt-in to the opt-out approach saw an increase in screening rates and the likelihood that HIV testing was offered to pregnant patients. A limitation of the study was noted to be the lack of a standardized national database. (13)
As depicted in Figure 1.3, a study of HIV testing showed 69 percent of the 748 women who had a completed pregnancy during the 12 months before participating in the 2002 National Survey of Family Growth reported that they had been tested during prenatal care. This percentage is consistent with the range of values found in a number of State and local studies, including follow-back surveys of recent mothers and chart review studies, and was applied to the 5.5 million pregnancies completed in the past year in the same 2002 study. (17,18)
A large U.S. survey found that overall prenatal testing rates increased from 41 percent in 1995 (when recommendations for universal prenatal HIV counseling and testing were issued) to 60 percent in 1998 (prior to the revision recommending the opt-out approach). (18) Other studies have found higher screening rates when the provider endorses testing and when testing is offered routinely to all pregnant patients. (19)
A lack of data related to prenatal HIV testing has proven to be a problem in defining national goals. Healthy People 2010 Objective 25-17 is defined as: Increase the proportion of pregnant females screened for sexually transmitted diseases (including HIV infection and bacterial vaginosis) during prenatal health care visits, according to recognized standards. This objective was deleted at the Healthy People 2010 Midcourse Review because a national data source was unavailable.
Indirect data, however, supports the impact of the dramatic increase in perinatal HIV screening. According to 2004 data, HIV counseling and testing of pregnant women and the use of appropriate antiretroviral therapy on HIV-infected women during pregnancy have saved lives and resources. The number of children diagnosed with AIDS, who had been perinatally exposed to HIV, declined from 122 in the year 2000 to 47 in 2004.(14/20) Additionally, it was reported that perinatal transmission of HIV peaked in 1991 and has continued to decline. This decline is attributed primarily to practices that have increased the identification of HIV-positive women during pregnancy, allowing for appropriate interventions to be implemented. (13)
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