Nearly all new mothers appear to know that a pregnant women can transmit HIV to her unborn child, and nine in 10 say they were given information about HIV and AIDS as part of their prenatal care. However, according to information collected postpartum from nearly 1,400 U.S. women, much smaller proportions are aware that HIV can be passed to a child via breast milk (60%) and that medical treatment can prevent mother-to-child transmission (51%). Moreover, many new mothers are reluctant to endorse legal requirements that pregnant women and newborns be tested for HIV: Eighty-four percent believe that all pregnant women should be tested for HIV infection, but only 60% favor a legal requirement that such a test should take place. Finally, a small but sizable proportion believe either that the government is keeping the existence of a cure for AIDS from the general public or that HIV was developed in a laboratory expressly to hurt people.1
Since 1995, the U.S. Public Health Service has recommended that all pregnant women be counseled about HIV infection and be offered voluntary HIV testing. In 1997, to determine the extent of counseling and testing and how women's attitudes affect their willingness to be tested, researchers conducted a cross-sectional survey at seven hospitals--four in North Carolina; one in New Haven, Connecticut; one in Miami, Florida; and one in New York City.
The study participants were selected in slightly different ways. At the four North Carolina facilities, researchers approached all women who had had vaginal deliveries in the previous 24 hours or cesarean deliveries in the preceding 48 hours; a total of 753 women were interviewed. Similarly, at the New Haven hospital, all women who delivered were invited to participate, and 208 completed the survey. Researchers at the New York City hospital approached every other woman who gave birth, and surveyed 201. In Miami, every third new mother was approached, with 200 surveyed. Overall, 43% of women who gave birth were surveyed, and only 10% refused to participate; in no case did the refusal rate surpass 13%.
Respondents provided basic demographic data and indicated whether they received prenatal care and how they paid for it. The women were asked if they had been given information about HIV and AIDS during their prenatal care, whether they had been offered an HIV test and whether they had accepted the offer. Interviewers also sought information about what the women knew or believed about HIV testing, about perinatal transmission of HIV, about the government's involvement in a cure for HIV and about the origins of the virus.
Of the 1,362 women interviewed, 44% were black, 43% were white and 13% were of other races; 12% were Hispanic. Their mean age was 27; 58% were married, 43% had no more than a high school education, 48% had an annual household income of $20,000 or less, and 47% relied on a public source for payment of their prenatal care. Fewer than 1% received no prenatal care. For all but the latter characteristic, there were large differences across study locations. For example, the proportion married ranged from 73% in New Haven to 41% in New York. The researchers used multivariate regression analysis to control for the effects of differences in these variables.
Eighty-nine percent of the women said they received information about HIV and AIDS during prenatal care. This proportion differed significantly by site, ranging from 98% in New York to 83% in Miami. Likewise, most women (88%) said they were offered HIV tests during prenatal care; this proportion ranged from 90-92% in North Carolina and New York to 82% in New Haven. Three-quarters of those who were offered a test chose to have one--95% in Miami, 88% in New York, 72% in North Carolina but just 54% in New Haven.
A large majority of participants (84%) believed that all pregnant women should be tested for HIV infection, ranging from nearly all of those surveyed in Miami to about two-thirds of those in New Haven. Yet only 60% believed there should be a law requiring pregnant women to be tested. (This proportion varied from 45% in New Haven to 84% in Miami.) Similarly, 70% of women felt newborns should be tested for HIV, but just 51% thought there should be a law requiring infants to be tested. Nearly all respondents (95%) said that if the law required newborn testing, they would return for a postnatal visit at which they would learn their infant's test outcome.
Interviewers asked the women five questions to assess their knowledge of perinatal HIV infection. Most participants (95%) knew that an HIV-positive pregnant woman can transmit the virus to her unborn baby, and about three in four (74%) knew that if a newborn tests positive for HIV, that means the mother is infected as well. Seventy percent were aware that not all infants born to HIV-positive women become infected, 60% knew that HIV can be transmitted to an infant through breast milk and 51% understood that a medical treatment can prevent transmission of HIV from mother to infant.
On average, the participants answered 3.5 questions correctly. Twenty percent gave five correct answers, 31% four, 30% three, 15% two and 3% one. A multivariate analysis indicated that women with no more than a high school education were significantly less likely to give four or five correct answers than were more educated women (odds ratio, 0.8).
Small proportions of women reported beliefs that suggested distrust of government and scientists. Seventeen percent said they believe a cure for AIDS exists but is being kept secret by the government, and another 18% reported being unsure whether this is the case. Nine percent agreed that HIV was "invented in a laboratory to hurt people," while another 12% were unsure whether this is true.
Several factors appear related to women's distrust of government and scientists. White women were significantly less likely than nonwhite women to agree with either or both of these statements (odds ratio, 0.4). In addition, less-educated women and those relying on public funds to pay for their prenatal care were significantly more likely to agree with one or both statements (1.8 and 1.7, respectively) than were more educated women and those who used private funds for their prenatal care. Finally, women in Miami, New Haven and New York were significantly more likely than North Carolina women to express distrust (odds ratios, 1.7-2.0).
Additionally, the investigators assessed which factors affected whether the women had been tested for HIV infection during pregnancy. While knowledge was not related to having received an HIV test, testing was somewhat more frequent among those who distrusted the government or scientists than among others (77% vs. 65%). However, a multivariate analysis revealed that the association between distrust and receipt of an HIV test was not statistically significant. Two other factors were significantly related to having had an HIV test: having no more than a high school education (1.4) and relying on public financing for prenatal care (1.8).
While most study participants found routine HIV testing to be acceptable, the investigators observe that "a substantial proportion of new mothers lack rudimentary knowledge about perinatal transmission of HIV." They also note that cli-nicians should be aware that some patients distrust government and scientists regarding HIV. They conclude that while their study found no evidence that lack of knowledge or the presence of distrust reduces pregnant women's willingness to be tested for HIV infection, such factors "might hamper other important prevention components, such as care-seeking behavior for women who are HIV infected." --M. Klitsch
1. Walter EB et al., New mothers' knowledge and attitudes about perinatal human immunodeficiency virus infection, Obstetrics & Gynecology, 2001, 97(1):70-76.