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  • Disparities in Prenatal HIV Testing: DISCUSSION

Disparities in Prenatal HIV Testing DISCUSSION

Our study found a substantial level of prenatal HIV (treating HIV infection) counseling and testing six years after the publication of the 1995 PHS guidelines on routine HIV counseling and voluntary testing for pregnant women. In this sample of low-income pregnant and recently postpartum women, a majority were counseled about the HIV test (87.8%) and tested (70.2%) prenatally. Only a small proportion of women reported that they were tested without counseling (5%), and 18% reported that they were counseled about HIV (еreating HIV infection when used in combination with other medicines) but declined testing. Given that a majority of women agreed to voluntary counseling and testing (69%) under Massachusetts’ opt-in approach, our data suggest that mandatory prenatal testing is not needed to achieve substantial levels of HIV testing of pregnant women since most women will accept testing if offered. Still, the fact that only 70% of women were tested overall indicates that more needs to be done to assure that all women do get tested. A strategy to accomplish this should address the fears that women reported about repercussions of getting a positive HIV test. In addition, outreach and education should emphasize that measures can be taken to prevent the spread of HIV to the unborn child but only when the mother knows her status.

Our study is the first to document that site of care and race jointly affect prenatal HIV testing. Relative to black women, white women had less testing in both private and public practice settings. In community health centers and hospital outpatient settings, fewer white women than Hispanic women were tested pre-natally for HIV (treating HIV infection) Only in private practice settings did white women have more testing than Hispanic women (64% versus 45%). These results provide important information concerning healthcare resources needed as HIV counseling and testing services become fully integrated into prenatal care. Research has shown that a physician’s recommendation strongly influences a women decision to accept HIV testing. Practices that serve a Hispanic community may need to evaluate the ratio of bilingual staff to Spanish-speaking patients to ensure that patients can be counseled adequately about HIV and are able to give informed consent or refuse testing without risk.

A strength of this study is that it examined the with-in-group and between-group variation in prenatal HIV testing for low-income black, Hispanic and white women. Our research suggests that being a recent victim of intimate partner violence was associated with less frequent prenatal HIV testing for all women, but the race-specific models indicated that partner-perpetrated violence was significant only for black women. According to PRAMS data for the years 1996-1998, black women were two times as likely to report abuse around the time of pregnancy as white women. Other studies have not found that the prevalence of physical abuse during pregnancy differs by race, except in the 20-24 age group, where black women reported partner violence more frequently than white women.
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For a majority of women, abuse during pregnancy is a continuation of pre-existing abuse. The recurrent nature of intimate partner violence has been attributed, in part, to chronic stressors, such as poverty and unemployment. Although we cannot draw definitive conclusions about the relationship between intimate partner violence and prenatal HIV testing, we hypothesize that black women may have had even less access to economic resources than the other low-income women in our study, potentially increasing black women’s vulnerability to partner violence. This study lends further support to the importance of discussing partner abuse during family planning and prenatal care visits, and consideration of the role of partner abuse in a woman’s decision to be tested.

A compelling reason why women were tested for HIV during their pregnancy was their endorsement of testing to promote the health of mother and child. If our findings were based solely on the results of the unstratified model, we would have missed the finding that beliefs about the efficacy of HIV testing, while important for all women, did not appear to have comparable importance for black and Hispanic women as for white women. For some women, positive beliefs about testing may have been attenuated by fears about the repercussions of getting a positive HIV test, such as the fear of someone finding out about the results or having their children taken. generic wellbutrin SR

Finally, while the national initiative launched in 2003, Advancing HIV Prevention: New Strategies for a Changing Epidemic, calls for healthcare providers to include HIV testing as a routine part of medical care, it de-emphasizes the historic role of HIV counseling. In this study, prenatal HIV counseling had a separate and independent effect on testing, after adjustment for individual-level demographic and pregnancy-related characteristics, suggesting that counseling continues to play an important role in the implementation of testing and should not be disregarded. Counseling also provides an opportunity to ascertain ongoing risk behaviors that may call for interventions and repeated HIV testing during the course of pregnancy.

The findings in this report are subject to at least four limitations. First, although women in our study provided valuable data, this was not a random sample, and the women do not represent the entire population of pregnant and postpartum women (<3 months post delivery) residing in Massachusetts.

Second, women in our study may have under-reported their experiences of partner-perpetrated violence, creating an underestimate of domestic violence. Surveys, including questions on sensitive topics, have been shown to have lower response rates for the specific sensitive items. Assuming comparability in underreporting across racial/ethnic groups, such error would not explain associations for domestic violence with less HIV testing among black women. risperdal medication

Third, our study is also subject to the limitation of recall bias. Comparisons of women’s recall of prenatal testing with documentation of testing in clinical records and hospital laboratory reports have found discrepancies in test reporting. Given the potential for recall bias in our study, our key findings on the proportion of women tested prenatally may be inflated, but racial disparities in testing rates would not change appreciably.

Fourth, we did not determine whether any of the women knew they were HIV-positive or when the women who were tested were informed of their positive or negative HIV status—before, during or after their pregnancy. Hence, knowledge of HIV status, which could be an important predictor of testing, was not included in the models and may have biased our findings. viagra soft tabs online

Continued efforts are needed to improve levels of routine HIV counseling and voluntary prenatal HIV testing. Our data suggest that racial biases may be influencing providers’ approach to testing, rather than the CDC’s 2001 guidelines for HIV screening of pregnant women. Beginning in 2003, provider trainings and performance expectations from the Massachusetts Department of Public Health have emphasized the CDC guidelines for routine prenatal HIV testing and the importance of ongoing risk assessment. This is to ensure that pregnant women who are at risk for HIV have the opportunity to be tested and to receive behavioral interventions if needed while reducing the likelihood of racial bias in clinical decision-making.

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