Those receiving prenatal care and antiviral treatments already were more likely to get AZT
How well are medical advances translated into the community practice? In the case of HIV-infected pregnant women, where they get their care may matter the most.
In 1994, researchers were stunned when they found that the anti-HIV drug AZT, taken during the second and third trimester, could reduce mother-newborn transmission of AIDS by as much as two-thirds. Along with national educational efforts, New York State mounted an information campaign, sending letters to physicians and other health care specialists, even conducting marketing campaigns to high-risk groups.
Researchers at Jefferson Medical College asked, how quickly would community practitioners, notoriously slow to change, adopt new practices to treat their often poor, pregnant, HIV-infected patients? What's more, which patients would benefit?
While community physicians in New York State responded rapidly to the findings, patients in certain health care settings benefited more than others. The researchers found that women who were more likely to receive antiretroviral treatment during pregnancy were those who already were being treated at a medical center that performed HIV clinical trials, those who were being treated at sites paid by the state to deliver a range of specific HIV-focused services to persons enrolled on Medicaid, those who were receiving prenatal care, or those receiving methadone.
"Where women get their medical care plays a major role in getting access to important medical advances," says Barbara Turner, M.D., professor of medicine at Thomas Jefferson University in Philadelphia, who led the study.
Dr. Turner, who is Director of Health Care Research at the Jefferson Center for Research and Medical Education in Health Care, and her co-workers report their findings June 15 in the Annals of Internal Medicine.
The study involved the results of the Pediatric AIDS Clinical Trials Group protocol 076, arguably the biggest advance in HIV prevention yet, according to Dr. Turner. The trial was halted early and its results, announced in February, showed AIDS transmission could be substantially reduced during delivery by giving AZT to the pregnant women during the last two trimesters of pregnancy, during delivery, and to the baby the first six months of life. But because the findings were not published for nine months, she says, "the news was by word through news releases and educational programs for lay persons and professionals as well as direct mailings to doctors."
In the Annals paper, Dr. Turner and her colleagues examined three time periods: January 1993 until the announcement; nine months from announcement to publication; and after publication until September 1996. They looked at the treatment records of 2607 HIV-infected women who delivered live children. They found that after accounting statistically for patient and health care delivery factors, these Medicaid enrolled women had a 21 percent increase per month in their likelihood of receiving antiretroviral therapy during pregnancy. After publication, the rate increased more slowly.
"We found that certain women were more likely to be treated," says Dr. Turner, such as those already receiving care at centers of excellence. New York State has identified centers and physicians who would contract to deliver a range of HIV-related services, such as nutritional care and treat special medical complications, for example.
"If a woman was treated at one of these sites, they were more likely to be treated with antiretroviral therapy," she says. "Even if you have a doctor in an area trained in management of HIV infections, such as in infectious diseases, hematology or selected generalists, you're also more likely to get treated with antiretrovirals.
"If a woman was treated at a site that was part of the 076 trial, after the trial ended, they were 50 to 70 percent more likely to get treated with antiretroviral therapy," she says. "That argues for care from medical centers that offer special services, including clinical trials."
Dr. Turner sees several lessons from her team's study, which was funded by the National Institute on Drug Abuse, including the possible need for a "direct marketing program for some dramatic finding such as the 067 trial. The adoption of medical advances in private practice has been generally far slower than in academic medical centers." Dr. Turner and her co-workers are following the data on the women through 1998 to see who gets antiretroviral therapy up to two years after they gave birth.
Editors: This information is embargoed for release on June 14 at 5 p.m. EDT
Journal
Annals of Internal Medicine