Patterns of treatment for HIV infection and substance abuse among pregnant, low-income women with HIV infection or AIDS are likely to change during the months before and after childbirth.1 In an analysis of matched data from Medicaid records and an HIV/AIDS registry in New Jersey, the odds of using antiretroviral drugs among pregnant women with HIV or AIDS were elevated in the six months before delivery (odds ratio, 1.8), and the odds of obtaining treatment for substance abuse among those who had misused drugs or alcohol were elevated in the six months after delivery (1.5). Women who received obstetric and gynecologic care were more likely than those who did not to receive antiretroviral therapy or substance abuse treatment, regardless of the timing of care relative to delivery (1.5-1.9).
Using matched data from paid Medicaid claims and the New Jersey HIV/AIDS registry, researchers identified women with HIV or AIDS who had given birth between 1992 and 1998, and investigated how their receipt of any antiretroviral regimen, substance abuse treatment (among those with a history of substance abuse), and obstetric and gynecologic care varied in the six months before and after delivery. The analysis included women who had HIV infection or AIDS diagnosed before becoming pregnant, but not before 1992 or 1991, respectively; and who had filed a Medicaid claim between diagnosis and the end of 1998. The researchers classified women as having a history of substance abuse if they had Medicaid records of drug or alcohol abuse or dependence, drug withdrawal syndrome, hepatitis, opiate poisoning, drug or alcohol detoxification, or referral for rehabilitation from drug addiction. In addition, women who had contracted HIV through injection-drug use were assumed to have a history of substance abuse. To predict the likelihood of receiving antiretroviral therapy or substance abuse treatment during each month, the analysts converted data to person-months and performed multivariate logistic regressions that controlled for the time taken to enroll in Medicaid, demographic characteristics, year of diagnosis, initial diagnosis (HIV infection or AIDS), residence in a county with high HIV and AIDS prevalence, and receipt of obstetric and gynecologic care.
In all, 346 women gave birth during the study period. Some 67% of women were black, 21% Hispanic and 11% white. Roughly one-half were aged 21-29 at the time of delivery (52%) and diagnosis (53%). Seventy-eight percent of women had HIV infection as their primary diagnosis, whereas the remainder had AIDS. Nearly one-half (46%) of women had a history of substance abuse.
The proportion of women who were receiving antiretroviral therapy was significantly higher in the six months before delivery than in the six months after (45% vs. 37%). Similarly, the receipt of obstetric and gynecologic care was more common before delivery than after (71% vs. 38%). Substance abuse was less common before childbirth than after (20% vs. 25%), although the proportion of women with a history of substance abuse who obtained relevant treatment remained at roughly one-quarter.
In a logistic regression limited to women who had ever misused drugs or alcohol, the odds of treatment for substance abuse were 50% higher during a postpartum month than during a month outside the year surrounding a delivery (odds ratio, 1.5). The odds of treatment in a given month were also elevated among women older than 29 and those who received obstetric and gynecologic care (4.2 and 1.5, respectively). Black women were less likely than white women to be treated for substance abuse (0.4). All of these findings were essentially unchanged in a regression that also tested whether the timing of obstetric and gynecologic care relative to delivery was associated with the receipt of substance abuse treatment.
In a separate logistic regression that included all women and controlled for substance abuse, timing of obstetric and gynecologic care and substance abuse treatment, and months in which women had no history of substance abuse, the odds of receiving antiretroviral therapy were higher in an antepartum month than in a month outside the year surrounding a delivery (odds ratio, 1.8). In addition, women who received diagnoses after 1993 and those with AIDS rather than HIV infection had elevated odds of obtaining antiretroviral treatment (2.0-2.3). Black women and those who had never misused drugs or alcohol had a reduced likelihood of using antiretroviral drugs (0.5-0.6). However, not misusing drugs or alcohol during the six months before and after a delivery was positively associated with receipt of antiretroviral treatment (2.1-2.4). Finally, the likelihood of using antiretroviral drugs in a given month was higher among women who received obstetric and gynecologic care than among those who did not, and among women with a history of substance abuse who obtained treatment for this problem than among those with a similar history who did not obtain treatment (1.9 for each). However, the timing of obstetric and gynecologic care and of treatment for substance abuse did not predict whether women received antiretroviral therapy.
Concluding that "patterns of care before and after delivery are distinct" among pregnant, low-income women with HIV or AIDS, the researchers suggest that receipt of antiretroviral therapy may be greater before childbirth than after because of ongoing efforts to reduce mother-to-child HIV transmission, and that receipt of substance abuse treatment may be greater after childbirth because of efforts to reduce substance abuse during pregnancy and to minimize fetal exposure to drugs used in substance abuse therapy. The analysts also note that postpartum stress and depression may contribute to the decreased adherence to antiretroviral regimens, as well as to a "relapse to drug abuse for women with drug abuse histories." Citing the association between obstetric and gynecologic care and the increased likelihood of treatment for HIV or AIDS and substance abuse, the investigators suggest that providers of obstetric and gynecologic care may have "untapped opportunities" to educate pregnant women with HIV or AIDS about anti-retroviral therapy and to make referrals for substance abuse treatment when needed.
1. Warner LA et al., Ante- and postpartum substance abuse treatment and antiretroviral therapy among HIV-infected women on Medicaid, Journal of the American Medical Women's Association, 2003, 58(3):143-153.