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Perinatal HIV and Addressing Missed Opportunities through the Texas Consortium for Peirnatal HIV Prevention
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Perinatal HIV and Addressing Missed Opportunities through the Texas Consortium for Peirnatal HIV Prevention


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  • 1. Perinatal HIV in Texas & Addressing Missed Opportunities through the Texas Consortium for Perinatal HIV Prevention (TCPHP) Presenters: Elvia Ledezma, MPH Leslie Conley, L.M.S.W.-I.P.R. Janak Patel, M.D. Judy Levison, M.D.
  • 2. Perinatal HIV in Texas Elvia Ledezma, Epidemiologist HIV/STD Epidemiology and Surveillance Texas Department of State Health Services 512-533-3045
  • 3. Outline Overview of perinatal HIV Steps to prevention of perinatal HIV Preventative factors
  • 4. General Definitions Perinatal Exposure-Any child born to an HIV infected woman • Infected-Any child born to an HIV infected woman and determined to be HIV positive • Uninfected Any child born to an HIV infected woman and determined to be HIV negative • Indeterminate- Any child born to an HIV infected woman with insufficient test history to determine his/her HIV status.
  • 5. HIV Positive Women in Texas 2008 13,751 HIV+ women living in Texas • 8,201 (60%) are women of childbearing age (15-44 years) • 361 (4%) of women gave birth to an infant 2000-2008 9% increase in the number of HIV+ women of childbearing age from 2000 to 2008 • 57% decrease in proportion of infected infants from 2000 to 2008
  • 6. Race/Ethnicity, Texas Black Hispanic White Other/Unknown 70 Percent (%) by Race/Ethnicity 60% 60 50 41% 40 32% 30 22% 22% 20 12% 10 6% 5% 0 HIV+ Women Delivering an HIV+ Women Delivering an Exposed Infant, 2008 Infected Infant, 2005-2008 n=361 n=41
  • 7. Prenatal Care*, Texas 96% of women delivering an infant in Texas received prenatal care, 2008** 92% of HIV positive women delivering an infant received prenatal care, 2008 • 55% (5/9) of HIV positive women delivering an infected infant received no prenatal care, 2008 *Excluding women with unknown receipt of prenatal care **Based on provisional vital statistics birth data for year 2008
  • 8. Perinatal HIV in Texas, 2008 361 HIV+ women delivered 364 infants • Uninfected: 122 • Indeterminate: 233 • Infected: 9
  • 9. Perinatally Exposed and Infected Children, Texas, 1999-2008 450 8 Exposures Infected 400 7 No. of Perinatal Exposures 350 n=21 6 n=21 n=22 Percent Infected 300 5 250 n=20 n=13 4 200 n=12 n=13 3 150 n=9 2 100 n=8 n=7 50 1 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year of Birth
  • 10. No. Exposed=3,593 % of Total Births= Numerator: No. of HIV Exposed Births by County Denominator: No. of HIV Exposed Births for the State
  • 11. No. Exposed=3,593 No. Infected=146 % of Total Births= Numerator: No. of HIV Exposed Births by County Denominator: No. of HIV Exposed Births for the State
  • 12. Steps to Prevention Success Woman receives prenatal care Tested for HIV Diagnosed before delivery Receives ARV therapy at all three recommended timings Pregnancy Labor and delivery Neonatally
  • 13. Prevention of Perinatal HIV Transmission, TX, 2005-2008, cont. No. of Women=1,461 Step 1: Missed Prenatal Care (N=1461) No. of Infected Infants=41 Opportunity Infected=10 No Yes Unknown No Infected (9%) n=113 (8%) n=1276 (87%) n=72 (5%) Infants HIV Diagnosis Before Delivery Step 2: Missed (N=1276) Opportunity Infected=6 No Yes Unknown No Infected (10%) n=61 (5%) n=1211 (95%) n=4 (<1%) Infants Any Prenatal Antiretroviral Step 3: Missed (ARV) Therapy (N=1211) Opportunity Infected=6 No (None or IP No Infected (9%) and/or Yes Unknown Infants Neonatal, yes): n=1124 (93%) n=22 (2%) n=65 (5%) Any ARV Therapy Regimens (N=1185)
  • 14. Prevention of Perinatal HIV Transmission, TX, 2005-2008, cont. Among deliveries with prenatal care, HIV diagnosis before delivery, and any ARV regimens No. of Women=1,461 N=1185 No. of Infected Infants=41 Incomplete Prevention 1-2 arm ART 3 arm ART Unknown No Infected Infected=7 n=103 (9%) n=1082 (91%) n=0 (0%) Infants (7%) Infected Uninfected Indeterminate n=18 (2%) n=615 (57%) n=449 (41%) 56% (23/41) had at least one missed opportunity 45% (18/41) had no missed opportunities
  • 15. Prevention of Perinatal HIV Transmission Receipt of prenatal care Timing of HIV diagnosis Receipt of antiretroviral therapy (ARV)
  • 16. Prenatal Care among HIV+ Women Delivering* and Proportion of Infected Children, Texas, 2008 350 20% n=307 No. of HIV+ Women Delivering 18% 18% 300 16% % of Children Infected 250 Infected: 56% 14% (5/9) received 12% 200 no prenatal care 10% 150 8% 100 6% 4% 50 n=28 1% 2% 0 0% Any Prenatal Care No Prenatal Care Women Infected Children (n=9) *Excluding women with unknown receipt of prenatal care
  • 17. Timing of HIV Diagnosis among HIV+ Women Delivering* and Proportion of Infected Children, Texas, 2008 250 n=229 14% No. of HIV+ Women Delivering 13% 12% % of Children Infected 200 Infected: 33% 10% 150 (3/9) diagnosed at delivery 8% n=105 100 6% 3% 4% 50 n=24 2% 0% 0 0% Prior to Pregnancy During Pregnancy At Delivery Women Infected Children (n=9) *Excluding women with unknown timing of diagnosis
  • 18. Receipt of ARV* among HIV+ Women Delivering** and Proportion of Infected Children, Texas, 2008 350 12% No. of HIV+ Women Delivering 300 n=286 10% 10% % of Children Infected 250 Infected: 78% 8% (7/9) received 200 incomplete ARV 6% 150 4% 100 n=67 50 1% 2% 0 0% All 3 Intervals None or 1-2 Intervals Births Infected Children (n=9) *ARV-Antiretroviral Therapy **Excluding women with unknown receipt of ARV
  • 19. Summary Decrease in proportion of perinatal HIV transmission from 2000 to 2008 Among HIV+ women delivering an infected infant: • Hispanic and White women were disproportionately affected (2005-2008) • Women predominantly received no prenatal care and received incomplete ARV therapy (2008) Perinatally HIV infected and exposed children are distributed throughout Texas (2005-2008)
  • 20. Summary Missed opportunities continue to occur (2005-2008) Earlier encounters with HIV positive pregnant women decreases the likelihood of perinatally infected children • Early diagnosis of HIV • Ensure ARV therapy intake • Counseling on breastfeeding practices
  • 21. Addressing Missed Opportunities through the Texas Consortium for Perinatal HIV Prevention (TCPHP) Leslie Conley, L.M.S.W.-I.P.R. Janak Patel, M.D. Judy Levison, M.D.
  • 22. Examples of Perinatally HIV Infected Cases Leslie Conley, L.M.S.W.-I.P.R. Case Manager/Inpatient Liaison Parkland Health and Hospital System
  • 23. Case #1 • 20yo BF, G1P0 • Chlamydia positive, HIV negative in April 2009 • Presented to ER in July 2009 (27 w EGA) – Abdominal pain – No previous prenatal care – HIV positive diagnosis • Presented for prenatal care in August 2009 (34 w EGA) – Late entry into prenatal care *** 1st – Refused HAART *** 2nd
  • 24. Case #1 Continued • Presented to private OB (August-October 2009) – No HIV test *** 3rd • Presented to rural hospital in October 2009 – 39 w EGA, C-section – HIV diagnosis not disclosed *** 4th – No HIV results at delivery (send out test) *** 5th – Breastfeeding – HIV positive results not known until after discharge Baby’s initial PCR—HIV+, VL on 2/4/10 = 4,300,000 copies/ml Baby is INFECTED with HIV.
  • 25. Case #2 • HIV negative in July 2005 • Presented for OB care in August 2006 (14 w EGA) – Positive trichomonas, chlamydia, and HIV – Referred to UTMB Maternal-Child HIV Clinic • Presented to hospital in Texas City in Sept 2006 – Miscarriage – No subsequent HIV care
  • 26. Case #2 Continued • Presented to same hospital in February 2008 – Active labor – HIV diagnosis not disclosed, but seen in medical record from previous visit *** 1st – No prenatal care or HAART during pregnancy *** 2nd – No IV zidovudine in stock for mother *** 3rd – No oral zidovudine in stock for baby until > 24 hrs of age *** 4th – Delay in obtaining zidovudine for discharge *** 5th Baby’s initial VL at 10 days = 1,569 copies/ml, confirmed with repeat tests. Baby is INFECTED with HIV.
  • 27. Overview of the TCPHP Janak Patel, M.D. Professor, Department of Pediatrics Director, Pediatric Infectious Disease and Immunology University of Texas Medical Branch
  • 28. What is the purpose of the TCPHP? Reduce or prevent perinatal HIV transmission in Texas through the collaborative efforts of Perinatal HIV champions 28
  • 29. Who makes up the TCPHP? Hospitals/Clinics • Maternal and pediatric HIV providers • Administrators and case managers DSHS departments • Office of Title V and Family Health • Mental Health and Substance Abuse Services • HIV/STD Comprehensive Services Branch • TB/HIV/STD Epidemiology and Surveillance Branch HIV education/outreach/prevention agencies • AIDS Education and Training Center • Houston Regional HIV/AIDS Resource Group • International AIDS Empowerment Local health departments • Surveillance staff
  • 30. Project Components/Work Groups Leadership Standards of Care Education Outreach 30
  • 31. Project Components/Work Groups Leadership • List of perinatal experts • Identified gaps in membership Standards of Care • Guidelines for care for HIV+ pregnant women Education • In progress Outreach • In progress 31
  • 32. Standards of Care Component Products
  • 33. Goal 1: Objective and Product Goal 1: To improve access to necessary components for perinatal HIV prevention • Objective: Identify labor and delivery hospitals with access to ARV therapy for mother and child • Rational: – 11% of women received no ARV at L&D (2005-2007) – 1% of infants received no ARV at birth (2005-2007) • Product: Developed a survey instrument for pharmacy staff – 76 hospitals surveyed – 15-20% do not stock IV AZT or oral AZT
  • 34. Goal 2: Objectives Goal 2: Improve SOC through enhanced communication, knowledge, and cultural competency among statewide stakeholders to prevent perinatal HIV transmission • Objective 1: Developed guidelines for care • Objective 2: Develop prenatal HIV testing recommendations to harmonize with national testing guidelines 34
  • 35. Obj. 1: Product (Guidelines for Care) Pre-conceptual counseling • Counseling/education Antepartum, intrapartum, and neonatal postnatal care • Recommendations for ARV drugs during pregnancy, labor & delivery and neonatally by the child Breastfeeding practices • Refrain from breastfeeding 35
  • 36. Obj. 1: Product (Guidelines for Care) Mode of delivery • Recommendations based on RNA levels Postnatal care • Referral to an HIV specialist Access to HIV medication • Familiarity with medication resources • Stock IV AZT and liquid AZT • 6 week course of AZT for the infant
  • 37. Obj. 2: Product (Testing Recommendations) Universal opt-out screening of all pregnant women Timing of tests for pregnant women and infant • 1st test at first health care visit • 2nd test at 32-36 weeks gestation • At labor and delivery (if no documentation of 2nd test) • Infant testing (if mother’s HIV status is unknown) Results available within 6 hours of collection 37
  • 38. New Law-Amendments to 81.090 (Effective January 1, 2010) Second test in third trimester Sample of woman’s blood or other appropriate specimen Test at labor and delivery if no documentation of test in 3rd trimester • Make results available within 6 hours of collection Test infant if no documentation of maternal test in 3rd trimester or not tested prior to delivery • Test infant w/in 2 hours after birth and results made available w/in 6 hours of collection
  • 39. Doing the Right Thing… The Process Judy Levison, M.D. Associate Professor, Department of Obstetrics and Gynecology; Department of Family and Community Medicine Baylor College of Medicine
  • 40. How we got started
  • 41. Texas Law until 1/1/2010 Offer HIV testing to all pregnant women early in pregnancy and in Labor and Delivery So, all of us have been doing that but most clinicians and institutions have been using the standard ELISA Works great for those who get prenatal care; with treatment, HIV transmission drops from 25% to <1% Yet we are left with missed opportunities: those women with no prenatal care AND those who seroconvert during pregnancy
  • 42. True Scenario A woman presented to a local hospital in labor and had had no prenatal care. Routine HIV testing (ELISA=enzyme-linked immunosorbent assay) was done. Results tend to return in 24-48 hours and many labs do not report the results before a confirmatory Western blot is done, which may take 2-5 days.
  • 43. True Scenario, cont. The pediatricians were notified of this woman’s positive ELISA and WB 5 days after the baby was born, after the mother—who was breastfeeding—was sent home.
  • 44. A Missed Opportunity… The majority of HIV transmission occurs at the time of labor and delivery. This baby had a 25% chance of being infected with HIV. This mother’s risk of transmitting HIV to her baby--if diagnosed as late as labor-- could have been reduced to 10% or less.
  • 45. Some History 2007 Texas Department of State Health Services funded the TRIAD project TRIAD = Texas Rapid-testing Implementation At Delivery Goal was to educate physicians; midwives; labor and delivery nurses; hospital labs, pharmacies, risk management about their role in the prevention of mother to child transmission of HIV—with a focus on rapid HIV testing in Labor & Delivery
  • 46. Why rapid testing? If a woman has HIV, the rapid test is more likely to be positive than the ELISA (higher sensitivity) If a woman does not have HIV, the rapid test is more likely to be negative than the ELISA (higher specificity) Results are available immediately (20 minutes on site/60 minutes in our lab) Although confirmation is needed (Western blot), the results are accurate enough to warrant action, i.e. treating mother and baby
  • 47. Why rapid testing? (cont.) 2006 CDC updated recommendations state: • “A second HIV test during the third trimester, preferably <36 weeks of gestation, is cost-effective even in areas of low HIV prevalence” Wouldn’t it make sense to maximize obtaining test results during pregnancy and use rapid tests for those who did not get a third trimester test?
  • 48. So how do you change a law? Start early… the Texas legislature meets from January until June every two years Find a sponsor… in this case Senator Rodney Ellis of Houston had proposed a number of bills related to routine HIV testing Work with sponsor’s office
  • 49. Changing Laws Watch where the bill is in the process of review… Senate bill proposal filed and sent to appropriate committee for review, witnesses on each side testify, financial impact is reviewed, and suggested improvements are made If passed in the Senate, then the bill is sent to the House where similar process occurs; if decision is made to attach the bill to another bill, then the two must be relevant to one another We watched “our” bill come to life and die several times
  • 50. House Bill 1795 Part 1: “Greyson’s Law” • Expands newborn screening for enzyme deficiencies as recommended by the American College of Medical Genetics in 2005
  • 51. House Bill 1795 Part 2: Perinatal HIV screening • Test at first prenatal visit for syphilis, HIV, and hepatitis B (as before) • Perform the second test for HIV in the third trimester (a change) • Do expedited testing for HIV in Labor and Delivery (results available within 6 hours) IF no third trimester results available (a change) • Test baby within 2 hours after birth if mother did not get tested (a change)
  • 52. Where are we now? On June 1, 2009, the last day of the 2009 official legislative session, the Texas legislature voted to change Texas law related to HIV screening in pregnancy Amends Section 81.090 of the Texas Health and Safety Code
  • 53. What does this mean to health care providers? Test twice in pregnancy—as we had been doing Do second test at 32-36 weeks, e.g. when you do GBS testing at 35 weeks. If positive, you have time to start treatment and make decisions about the most appropriate mode of delivery If a woman presents in labor before the second test has been done, then do rapid testing in Labor and Delivery
  • 54. What now? Educate physicians, office staff, and hospital staff about new law Correct misconceptions Lectures to groups vs. computer modules available to all providers/institutions Make proper prenatal HIV testing a quality indicator Research the factors that contributed/barriers that existed for the mothers whose babies were born HIV+ in last 5 years, e.g. why no prenatal care, why incorrect test ordered in L&D, why + test in L&D not acted on
  • 55. Questions/Suggestions