Impact of Rapid HIV Test Utilization Protocol in a Hospital Clinical Setting

1. Rapid HIV test utilization: The impact of the administration a hospital clinical protocol Sunanda Gaur, MD, Patricia Whitley-Williams,MD, Roseann Marone,RN, BSN, MPH, Anna Petrova, MD, Charlene Flash, MD, Tanushree Dutta, BS, Emanuel Jimenez, MD, Amisha Malhotra, MD*, Kathy Mahoney, APN** *UMDNJ/Robert Wood Johnson Medical School **Robert Wood Johnson University Hospital, New Brunswick, NJ • ABSTRACT • Background: • Unknown maternal HIV status is the major risk factor of mother-to-child HIV transmission. • Objectives: • To evaluate the impact of the implementation of the Rapid HIV test utilization protocol and to identify factors that may • affect physician compliance with hospital policy. • Methods: • A retrospective analysis of randomly selected medical records of deliveries occurring six months before and six months after implementation of the new Rapid HIV test policy at the Robert Wood Johnson University Hospital was utilized. • Results: • Analysis of medical records of the 732 women showed that 150 women (20.5%) presented in labor with unknown HIV status • (21.9%, 92/422 before and 18.8% 58/307after). Overall, the women in labor with unknown HIV status were more likely to have private medical insurance (71.5% vs. 47.6%), to be older (30.7+/-6.0 yrs vs. 28.2 +/-6.4 yrs), to be married (77.5% vs. 59.7%), white, non Hispanic (61.6% vs. 23.1%), and college educated (62.9% vs. 44.5%). The Rapid HIV test was utilized in 7.6% of eligible women before and 12.1% after the implementation of the new hospital policy (OR=1.67 95%CI 0.55, 5.03). The HIV tested women were more likely to have had no prenatal care, no insurance, be unmarried, black or Hispanic and drug using as compared with eligible but not tested women. • Conclusion: • Low compliance and disparity in the utilization of Rapid HIV testing dictates the need for education of OB providers in order • to achieve successful implementation of the current CDC recommendations regarding HIV testing for women presenting in labor with unknown HIV status. • Rational of this Study • The CDC facilitated the development and the states’ implementation of protocols for HIV testing during labor and delivery for women with unknown HIV status (results not documented in the prenatal medical record) • In January 2005, a new protocol for intra-partum HIV testing for women with unknown HIV prenatal status was implemented at RWJUH. • The goal was to evaluate the impact of the protocol implementation of the HIV rapid test utilization among mothers with unknown HIV status during delivery. • Specific Aims • Determine the proportion of women with unknown HIV status prior to delivery before and after implementation of the new clinical protocol • Evaluate demographic characteristics of women with unknown HIV status prior to delivery before and after implementation of the new clinical protocol. • Identify maternal, social, demographic, and other possible factors that may effect physician’s compliance regarding the hospital recommendations. • Study Design • Retrospective cohort study was designed to investigate the impact of a hospital-implemented protocol for the rapid HIV testing of women with unknown HIV status prior to delivery. • The study comprised two consecutive samples of all term and preterm deliveries from July 1, 2004 to Dec 31, 2004 and from Feb 1, 2005 to Aug 31, 2005. One month (January) was designated for implementation of the new clinical protocol. • Exposure variables: Implemented clinical protocol • Outcome variable: Utilization of rapid HIV testing prior to delivery for pregnant women with unknown HIV status before and after implementation of new protocol. • Statistical Analysis • 1. Analysis of variance (for comparison continuous variables) • 2. Chi-square test (for comparison categorical variables) • 3. Phi test or Cramer's V for estimation of how strong related categorical variables • 4. Odds Ratio and 95% Confidence Interval (OR, 95%CI) to identify the association Comparison of the HIV testing activities among eligible (with unknown HIV status) women during delivery before and after intervention • Results • 422 medical records before and 309 after implementation of the HIV testing policy at RWJUH were reviewed. • No differences in demographic and pregnancy characteristics, type of insurance, PCP type of practice were found. OR=1.67 95%CI 0.55, 5.03 Offering of HIV testing during pregnancy (%) Eligible (with unknown HIV status) n=150 Tested n=14 (9.3%) Not tested n=136 (90.7%) 1. Offered 2. Not offered 3. Unknown status HIV testing accepted during pregnancy (%) Characteristics of women eligible for the Rapid HIV testing during delivery who were tested and not tested HIV + 1.2% (n=4) HIV + 0 P< 0.0001 (52.5%) P< 0.0007 (31.2%) P< 0.002 (25.4%) 1. Accepted 2. Not accepted 3. Unknown status A total number of 150 women (20.5%) with unknown HIV status during pregnancy were eligible for HIV testing during delivery: 92 (21.9%) among women admitted before implementation of HIV testing protocol 58 (18.8%) among women admitted after implementation of HIV testing protocol • Women eligible for Rapid HIV testing who were tested prior to delivery were more likely to: • have no prenatal care during pregnancy • have no insurance • be married • be black or Hispanic • have a history of drug use Women with HIV unknown status during pregnancy because: • HIV test not offered • HIV test offered but not accepted • HIV test performed but result not recorded in the medical record CONCLUSION The post-intervention outcome evaluation is important for identification of the educational needs and development of new strategies to improve the compliance of rapid HIV testing for women with unknown HIV status prior to delivery • Reference: • * A Practical Guide and Model Protocol for the Rapid HIV-1 Antibody Testing during Labor and Delivery for Women of Unknown HIV Status (CDC, 2004 Anna Petrova MD, PhD MPH Associate Professor of Pediatrics Phone:732-235-7319 E-mail: petroran@umdnj.edu Roseann Marone, RN, BSN, MPH Instructor of Pediatrics Phone: 732-235-7383 Email: maronero@umdnj.edu • Women with unknown HIV status during pregnancy are more likely to: • have received prenatal care from OB in private practices • have coverage from private insurances • be older • be married • be white and English speaking