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  20th Conference on Retroviruses and
Opportunistic Infections
Atlanta, GA March 3 - 6, 2013
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One Quarter of US Pregnant Insured Women Not Tested for HIV, Despite CDC Advice
  20th Conference on Retroviruses and Opportunistic Infections, March 3-6, 2013, Atlanta
Mark Mascolini
One quarter of pregnant, insured US women who delivered live infants in 2009-2010 did not get tested for HIV, as the CDC recommends [1]. Testing rates did inch up from 2008 through 2010 and greatly exceeded the CDC's most recent overall estimate of HIV testing rates in pregnant women [2].
In 2006 the CDC recommended opt-out HIV testing for all pregnant women in the United States. With opt-out testing, people are told they will be tested unless they sign a form declining testing. A study of US women who delivered live infants in 2008 found that 73.8% had been tested for HIV. Using the MarketScan Commercial Claims and Encounters database, CDC researchers and collaborators updated that analysis for 2009 and 2010.
The investigators initially limited the analysis to women with 24 months of continuous enrollment in the same health plan before delivery. Later they refined the analysis to include women with continuous enrollment during pregnancy, or about 40 weeks before delivery. They used ICD-9 codes and Current Procedural Terminology codes to calculate deliveries resulting in live births. They relied on MarketScan data to figure how many women filed claims for HIV testing.
The MarketScan insurance claims database included 17,020,206 women 13 or older in 2009 and 19,164,445 in 2010. About half of the women in both years were under 40 years old. Women from the southern United States accounted for 46% of the MarketScan sample in 2009 and 40% in 2010. About two thirds of women in both years had Preferred Provider Organization insurance.
Among 233,531 women with live-birth deliveries in 2009, 175,605 (75.2%) filed a claim for HIV testing in the 293 days before delivery. Among 228,438 women with live-birth deliveries in 2010, 173,368 (75.9%) filed claims for HIV testing in the 293 days before delivery. Most HIV testing claims (79%) were filed in gestation week 10 to 24. Claims peaked in the 14th week of pregnancy then fell steeply and steadily until week 29, after which claims rose to another small peak at week 33 (see Figure 3 in poster linked below).
When the researchers divided women's ages into 5-year brackets, a slightly lower proportion of women under 20 than 20 or older filed claims in 2009 (71.1%) and 2010 (70.3%), but claim rates varied little in the other age groups. The proportion of women who filed two or more claims during the same pregnancy vaulted from 8.7% in 2009 to 15.9% in 2010.
The CDC investigators noted that the study group, though large, may not represent all women in the United States because MarketScan covers only women enrolled in large health plans. In addition, basic demographic data such as race/ethnicity and marriage status are not available from the database. (The researchers did not go on to state an intuitive implication of these limitations--that the study group underrepresents poor black women, who account for a disproportionate share of HIV infections among women in the United States.) The researchers also cautioned that an insurance claim does not mean an HIV test was completed, and some women may have been tested without filing a claim.
With these caveats in mind, the CDC team concluded that about one quarter of commercially insured women in this database who delivered a live infant in 2009 and 2010 did not file a claim for HIV testing during pregnancy. This finding, the researchers stressed, "highlights a continuing missed opportunity for perinatal HIV prevention among this population of stably insured women." Also, fewer than 20% of women filed claims for repeat testing late in pregnancy, even though 63% of women in this sample live in states where late testing is recommended.
In a report on HIV testing in the past decade [2], the CDC calculated a much lower overall testing rate during pregnancy, and that rate fell nonsignificantly from 59.3% in 2000 to 53.7% in 2010 (P = 0.66). In this report, the proportion of pregnant women tested in the last 12 months did not change significantly among whites or blacks from 2000 to 2011 but did rise significantly among Hispanic women. Over those years, the testing rate during pregnancy did not change significantly in any age group analyzed: 18 to 24, 25 to 34, or 35 to 44.
In 2009 rates of perinatal transmission in the United States were 9.9 per 100,000 live births among blacks, 1.7 among Hispanics, and 0.1 among whites [3].
1. Taylor A, Furtado M, Hall L, Nesheim S. HIV testing among commercially insured pregnant women: US, 2009-2010. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 904. http://www.retroconference.org/2013b/PDFs/904.pdf
2. Centers for Disease Control and Prevention. HIV testing trends in the United States, 2000-2011. January 2013. http://www.cdc.gov/hiv/topics/testing/resources/reports/pdf/Testing%20Trends_cleared_01282013.pdf
13. Centers for Disease Control and Prevention. HIV among pregnant women, infants and children in the United States. December 2012. http://www.cdc.gov/hiv/topics/perinatal/index.htm