Factors associated with declining a rapid human immunodeficiency virus test in labor and delivery.

The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend routine rapid HIV testing in labor and delivery (L&D) for women with undocumented HIV status using an opt-out approach. Identifying factors associated with declining a rapid HIV test in L&D will be helpful in developing strategies to improve rapid HIV testing uptake. Data from the Mother-Infant Rapid Intervention at Delivery study were analyzed. Women ≥24 weeks gestation, in labor, with undocumented HIV status were offered rapid HIV testing using informed consent. Women who declined rapid HIV testing (decliners) but agreed to be interviewed were compared to women who accepted testing (acceptors). 102 decliners and 478 acceptors met inclusion criteria for analysis. Decliners of rapid HIV testing were more likely to have had prenatal care (PNC), after adjusting for age, Hispanic ethnicity, high-school education and city of enrollment (adjusted OR 2.4, 95% CI 1.06-5.58). Having had PNC was collinear with prior HIV education and previous offer of an HIV test during the current pregnancy, so these factors were not part of the model. During PNC, standard informed consent may involve discussions that negatively affect later uptake of testing in L&D. Therefore an opt-out approach to testing may improve testing rates. Furthermore, decliners may have felt that testing in L&D was redundant because of previous testing during PNC; however, if previous testing occurred, this was undocumented at L&D. Documentation and timely communication of HIV status is critical to provide appropriate HIV prophylaxis.

Rapid human immunodeficiency virus testing in obstetric outpatient settings: the MIRIAD study.

OBJECTIVE: To evaluate the acceptability and feasibility of rapid human immunodeficiency virus testing in obstetric outpatient settings. STUDY DESIGN: The Mother-Infant Rapid Intervention at Delivery (MIRIAD) study was a prospective, multicenter study. Women were offered rapid and conventional human immunodeficiency virus testing if they presented to outpatient settings late in pregnancy with undocumented human immunodeficiency virus status. We compared median times between conventional and rapid testing and between rapid point-of-care and rapid laboratory-based testing. RESULTS: Among eligible women who were offered participation, 90% accepted testing. The median time from blood draw to result available was faster for rapid testing (25 minutes) than conventional testing (23 hours; P < .0001). For rapid tests, point-of-care testing was faster than laboratory-based testing (24 minutes vs 35 minutes; P < .0001). Almost 96% of rapid test results were available within 1 hour. CONCLUSION: Rapid human immunodeficiency virus testing is acceptable, feasible, and provides results far sooner than conventional testing in obstetric outpatient settings.

Primary human immunodeficiency virus infection during pregnancy detected by repeat testing.

OBJECTIVE: The purpose of this study was to describe characteristics of pregnant women with newly acquired human immunodeficiency virus (HIV) infection that was identified by repeat testing. STUDY DESIGN: The Centers for Disease Control and Prevention-sponsored Mother-Infant Rapid Intervention at Delivery (MIRIAD) study, which was conducted in 6 US cities, encouraged repeat HIV testing during pregnancy to identify primary infections. RESULTS: Fifty-four HIV-infected women were identified. Four primary HIV infections were recognized, with median estimated seroconversion at 22 weeks of gestation. All 4 women denied new sex partners, alcohol, and illegal drug use during pregnancy. Three of the 4 mother-infant pairs received antiretroviral medications. One infant was infected perinatally, with positive HIV DNA polymerase chain reaction at birth. Questionnaire data identified 2 additional women with HIV that was likely acquired during pregnancy (identified by rapid testing at labor and delivery), which suggests that 6 of 54 HIV-infected women (11%) in the MIRIAD study had primary infection during pregnancy. CONCLUSION: Repeat HIV testing in pregnancy can identify opportunities for antiretroviral prophylaxis and should be used in areas of high HIV prevalence.

Rapid human immunodeficiency virus-1 testing on labor and delivery in 17 US hospitals: the MIRIAD experience.

The objective of the study was to evaluate the feasibility, acceptability, and accuracy of rapid human immunodeficiency virus (HIV) testing during labor. The Mother-Infant Rapid Intervention at Delivery (MIRIAD) study was a prospective, multicenter study that offered voluntary, rapid HIV testing to women with undocumented HIV status at 17 hospitals in 6 cities. Of 12,481 eligible women, 74% were approached for participation and 85.5% of those approached accepted rapid HIV testing. Among 7753 women tested, MIRIAD identified 52 (0.7%) HIV-infected women. The time between obtaining the blood sample for the rapid test and reporting the results to the health care provider was shorter for hospitals utilizing point-of-care testing than in hospitals utilizing laboratory-based testing (30 minutes vs 68 minutes; P < .0001), and point-of-care testing strategies were 14 times more likely to have a short turnaround as laboratory testing strategies. Routine rapid testing during labor provides a feasible, acceptable, and accurate way to identify HIV-infected women before delivery.

Premastication as a route of pediatric HIV transmission: case-control and cross-sectional investigations.

BACKGROUND: Three cases of pediatric HIV transmission attributed to the feeding practice of premasticating food for children have been reported. The degree of risk that premastication poses for pediatric HIV transmission and the prevalence of this behavior among HIV-infected caregivers is unknown. METHODS: During December 2009 to February 2010, we conducted a case-control investigation of late-diagnosed HIV infection in children at 6 HIV clinics using in-person and telephone interviews. A cross-sectional investigation of premastication was conducted in concert with this case-control investigation. RESULTS: We compared 11 case-patients to 35 HIV-exposed controls of similar age. Sixteen (35%) of 46 children were fed premasticated food, 10 (22%) by an HIV-infected caregiver. Twenty-seven percent of case-patients received premasticated food from an HIV-infected caregiver compared with 20% of controls (odds ratio = 1.5; 95% confidence interval = 0.3 to 7.1). In the cross-sectional investigation, 48 (31%) of 154 primary caregivers of children aged ≥6 months reported the children received premasticated food from themselves or someone else. The prevalence of premastication decreased with increasing caregiver age and had been used to feed children aged 1-36 months. CONCLUSIONS: Premastication, a potential route of HIV transmission to children, was a common practice of caregivers. Public health officials and health care providers should educate the public about the potential risk of disease transmission via premastication.

Factors associated with prenatal care use among peripartum women in the Mother-Infant Rapid Intervention at Delivery study.

OBJECTIVE: To evaluate factors associated with receiving prenatal care among women who present in labor without human immunodeficiency virus documentation using the results of a previous study, Mother-Infant Rapid Intervention at Delivery. DESIGN: Prospective, multicenter study. SETTING: Eighteen hospitals in the United States. PARTICIPANTS: The present analysis is based on 667 peripartum women who completed a face-to-face interview after delivery. For purposes of this analysis, human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women were considered together as the "study group." METHODS: The original study, Mother-Infant Rapid Intervention at Delivery, offered rapid human immunodeficiency virus testing to women in labor without human immunodeficiency virus testing documentation at 18 hospitals in the United States. This secondary study evaluated factors related to prenatal care, among participants who agreed to an interview after delivery. RESULTS: Interviews were completed by 667 women. Of these, 26.8% reported no prenatal care before admission to labor and delivery. These women were more likely to have been born in the United States, have other children, used alcohol, and reported being unhappy. Those who reported receiving prenatal care were more likely to have had Medicaid, stronger social support, and reported good health. CONCLUSION: Women who are unlikely to receive prenatal care lack social support and are more likely to have additional social stressors. Medicaid may provide an important safety net to enhance access to care, because those with Medicaid were more likely to receive prenatal care. Further research is necessary to identify nontraditional models of care to enhance outreach to women at risk for no prenatal care.

Women identified with HIV at labor and delivery: testing, disclosing and linking to care challenges.

OBJECTIVE: To determine if women with undocumented HIV status in late pregnancy or at labor and delivery who are rapidly tested and identified as HIV infected have high-risk behaviors and psychosocial obstacles hindering postpartum follow-up. METHODS: Consenting participants (women with undocumented HIV status and > or =24 weeks gestational age (GA) and imminent delivery or > or =34 weeks GA) in 6 cities were rapidly tested and interviewed. HIV-positive women were offered follow-up. RESULTS: From 2001-2005, 54 HIV-infected women were identified: median age 26 years; 91% African American; 11 (20%) lost custody of their infants; 30 (56%) knew they or their partner were HIV-infected, but had no antenatal HIV care; 25 met criteria for starting antiretroviral therapy. Comparison between 48 HIV-infected and 130 HIV-negative women, tested and interviewed at the same hospitals, showed HIV-infected women more likely to be African American (P < .01) and report no prenatal care (P < .001), use street drugs (P < .01), have unstable residency (P < .05), not live with the father of their infant (P < .001), and have children in foster care (P < .01). Sixteen women (30%) and 17 (31%) infants did not remain in follow-up study due to relocation, child protective custody, and psychosocial issues including frequent substance use. CONCLUSION: Over half of HIV-infected women knew they or their partner were infected with HIV, but did not initially disclose their status. Increased support services and substance abuse treatment are critical to facilitate better continuity of care for these socially marginalized women.