The Philadelphia Department of Public Health's Kathleen Brady presented on Philadelphia's Fetal Infant Mortality Rate (FIMR) process at the January 2015 meeting of the Philadelphia Ryan White Part A Planning Council.
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Philadelphia HIV Fetal Infant Mortality Review (FIMR)
1. Philadelphia FIMR-HIV
Overview for the Office of
HIV Planning
January 8, 2015
Kathleen Brady, MD
Medical Director / Medical Epidemiologist
AIDS Activities Coordinating Office
Philadelphia Department of Public Health
2. Agenda
Epidemiology Overview re: Perinatal HIV
FIMR-HIV Background and Overview
Philadelphia FIMR-HIV Processes, Key Findings
and Recommendations
Example of CRT>>CAT>>Action Step>>Outcome
Ongoing Issues and Next Steps
3. Perinatal Prevention Cascade
Missed Opportunities Data Needs
HIV transmission rate and
number of infected infants
HIV-infected woman
Become Pregnant
Inadequate Prenatal Care
No (or late) HIV Test
No ARV Prophylaxis
Child Infected
% of HIV+ women with ARV
prophylaxis in pregnancy
% of all women (and HIV+)
tested in pregnancy
Number of HIV-infected women of
childbearing age by state,
race/ethnicity
Number of HIV-infected women
giving birth (or exposed infants)
% of all women (and HIV+) with
adequate prenatal care
8. Quick Facts on HIV Pregnant Women
in Philadelphia
• Racial disparities – 80% of
pregnant women are black, 12%
Latina
• 90% acquired HIV through
Heterosexual transmission, 7%
IDU
• Age distribution
– 50% of deliveries occur in women
25-34
– 25% each in women 16-24 and >35
• HIV Diagnosis
– 74% diagnosed prior to pregnancy
– 22% diagnosed during pregnancy
– 2% diagnosed at delivery or within
1 month of birth
• Prenatal Care
– 39% adequately engaged in
prenatal care
– 38% intermediately engaged in
prenatal care
– 23% inadequately in prenatal care
• Prenatal ART use
– 89% in women diagnosed prior to
pregnancy
– 73% in women diagnosed during
pregnancy
• Viral suppression
– 73% suppressed prior to delivery in
women diagnosed prior to
pregnancy
– 46% suppressed prior to delivery in
women diagnosed during
pregnancy
9. Missed Opportunities for Perinatal HIV Prevention
Enhanced Perinatal Surveillance
Philadelphia, 2005-2011
Missed Opportunity HIV Exposed infants
(N=815)
HIV Infected infants
(N=17)
HIV Uninfected
infants (N=651)
No prenatal care 71 (8.7%) 7 (41.2%) 596 (7.8%)
No maternal HIV
test
19 (2.3%) 4 (23.5%) 10 (1.5%)
No prenatal ART 108 (13.3%) 10 (58.8%) 81 (12.4%)
No L&D ART 80 (9.8%) 6 (35.3%) 57 (8.8%)
>1 missed
opportunity
188 (23.1%) 11 (64.7%) 141 (21.2%)
Additional Missed Opportunity - Only 48% of HIV-infected women with a viral load
>1,000 prior to delivery receive a schedule C-section.
10. HIV Care Continuum for HIV-infected women who gave birth
to a live infant postpartum 2005-2011 (n=695)
Source: Enhanced Perinatal Surveillance System (EPS) and HIV/AIDS Reporting System (eHARS)
AIDS Activities Coordinating Office, Philadelphia Department of Public Health
Percentage of
postpartum women
11. HIV Care Continuum by year for HIV-infected women
who gave birth to a live infant up to two years postpartum
(n=695), 2005-2011- Philadelphia
Source: Enhanced Perinatal Surveillance System (EPS) and HIV/AIDS Reporting System (eHARS)
AIDS Activities Coordinating Office, Philadelphia Department of Public Health
12. Philadelphia FIMR-HIV Background
One of 8 sites funded by CityMatCH/ACOG/CDC
Starting December 2009, implementation
planning began (unfunded)
Case abstractions began Summer 2010
First CRT meeting held in September 2010
Funding began 10/2010, ended 9/2012
Project continues via HFP and AACO staffing
Graduate student intern support key to project
13. Leadership
AACO, Philadelphia Department of Public
Health
Kathleen Brady, MD
Medical Director and Epidemiologist
Health Federation of Philadelphia
Debra D’Alessandro, MPH
Public Health Project Manager
14. Crime Stoppers Model for Prevention of Perinatal Transmission of HIV
Decreasing
amount of virus
and time for it to
get in
Decrease virus
by high dose IV
Last chance to kill
virus that made it
through before
infection
established
AZT
Treatment
Prevention
Pre-natal care
and HIV testing
HIV testing in
labor and delivery
and for baby
Ensure safe harbor
for baby, HIV
testing, early
treatment for
positives
J. Foster, 9/09
15. Elimination of Perinatal HIV—
Why?
It is feasible
We know how
We have the tools
Missed opportunities account for most remaining
transmissions
Cost reductions of approximately $25,000,000/yr
Discounted lifetime medical care cost for an HIV-infected child= $250,000
> 100 perinatal infections per year remaining
It is the right thing to do
16. Elimination of Perinatal HIV Transmission
Proposed Goals:
Achieve:
1) an incidence of <1 HIV-infected infant per
100,000 live births
(< 40 cases annually among a 4 million birth cohort)
and
2) a transmission rate of < 1%
[e.g., < 87 cases in 2006 (8700 HIV-exposed births) ]
Represents a decrease in >100 annual cases
17. What is FIMR?
The Fetal and Infant Mortality Review (FIMR)
“is an action-oriented community process that
continually assesses, monitors, and works to
improve service systems and community
resources for women, infants, and families. A
fetal or infant death is the event that begins
the process.”
18. What is FIMR?
Key Facts
Introduced in the late 1980’s
ACOG and MCHB at HRSA were co-leads
Approximately 220 FIMR programs in 40
states
Funding sources vary from community to
community
20. What is FIMR-HIV?
The FIMR-HIV process, like the FIMR process,
emphasizes broad community buy-in and
involvement (e.g. providers, business groups,
community advocacy groups, consumers,
agencies providing services and resources for
women, infants and families, etc.).
21. Overview of the FIMR-HIV Process
Case Identification and Selection
Case Definition: Exposed infant/fetus ≥ 24 weeks
gestation
Purposeful, not random selection
Cases selected based on an indication of system gap:
HIV-infected infant
Late maternal HIV diagnosis
Inadequate or absence of prenatal care
Lack of maternal treatment or poor viral
suppression
Lack of antiretroviral prophylaxis during labor and
delivery (as applicable)
22. Overview of the FIMR-HIV Process
Case Data Abstraction
All available medical, hospital, CM records
Info collected: prenatal care, labor and delivery
care, post-partum/reproductive health care,
maternal HIV care, newborn care, birth certificate
and pediatric care
De-identified (case and health care setting)
Maternal interview
Critical to the process
Information not available in the medical record
Obtain the woman’s unique perspective
23. Case Review
Multidisciplinary case review team
MCH, HIV/AIDS, community, advocates,
professional organizations, private agencies
Perinatal HIV prevention clinical experts
Regularly scheduled case reviews
Strengths, opportunities for improvements,
general systems issues identified
Recommendations to improve systems
24. Community Action
Community Action Team: Initiate systems change
based on findings and recommendations
“Champions” within the community are important
Include a broad-based, multi-partner range of
agencies and people (e.g. families, CBOs,
consumer advocates, etc.) that represent the
diverse ethnic and cultural groups in the
community
Inclusive of HIV and MCH expertise
Community leaders
25. CAT Purpose
The community action team (CAT) is charged with
developing an annual community action plan based
on the recommendations of the case review team.
Once a plan has been developed, team member(s)
will accept responsibility for implementation, and the
team as a whole will monitor progress of the plan
during ongoing meetings.
26. Philadelphia FIMR Activities
• Case Review Team meets 10 times/year
Since September 2010:
Total CRT meetings = 43
Total Cases reviewed = 111
Total Maternal interviews = 43
• Community Action Team meets 2 or 3 times/year
Total CAT meetings since February 2011 = 8
27. CRT Themes/Issues Identified
• Lack of preconception counseling for HIV-
positive women
• Continuity of/Engagement in care for those
with MH/SA issues
• Lack of connection to prenatal care from ER
28. FIMR-HIV Community Action Team areas
of focus:
• Contraception Committee
• Emergency Department Protocol
Committee
• Engagement in Care Committee
• Behavioral Health Committee
29. Example of FIMR process
CRT issue identified in 2010 and 2011 case reviews:
•Need for dedicated Perinatal Medical Case Management PMCM for
HIV-positive pregnant women
CAT Recommendation, 2011:
•Dedicate funding and establish standards for PMCM
Action Steps:
•AACO prepared RFP for PMCM
•CAT Subcommittee developed standards for PMCM
Outcomes:
•2012 ActionAIDS awarded PMCM grant, currently employs 2.5 FTE
case managers who work with clients from pregnancy through baby’s
first year of life
30. The Good News: What Philly is Doing Well…
• Prenatal HIV testing at first visit and in third trimester are
standard practice at all OB/prenatal sites
• Clinical guidelines for appropriate use of ART in pregnancy
are being followed by local providers
• Rapid HV testing is available and appropriately offered at
Labor and Delivery to high risk patients of unknown HIV
status
• Connection to follow-up by pediatric HIV specialty practice
for prophylaxis and testing of exposed infants is occurring
consistently
• ActionAIDS Perinatal Medical Case Managers have
developed strong referral relationships with local HIV
providers
31. Ongoing Issues/Next Steps
Continue to analyze trends from chart reviews of
HIV-infected infants or high risk perinatal
exposures
Develop action steps informed by changing
healthcare landscape and needs
Engage policy and program leadership in
completion of action steps
Strengthen programs serving HIV-infected or
exposed women and children, pregnant women,
and pertinent health systems
32. Thank you!
Kathleen Brady, MD
Medical Director/Medical Epidemiologist
AIDS Activities Coordinating Office
Philadelphia Department of Public Health
Kathleen.A.Brady@phila.gov
(215) 685-4778
Tina J. Penrose, RN, MSN, MPH
Project Coordinator
PA/MidAtlantic AIDS Education & Training Center
Health Federation of Philadelphia
tpenrose@healthfederation.org
(215) 246-5299
Debra D'Alessandro, MPH
Public Health Program Manager
PA/MidAtlantic AIDS Education & Training
Center
Health Federation of Philadelphia
ddalessandro@healthfederation.org
(215) 246-5416
Editor's Notes
Number of exposures per year
Trending downward (2012=87 exposures)
Here we present the HIV Care continuum.
Slide 21: Here we present the HIV Care continuum by the year of delivery. In blue, is the percent of women who relinked to care within 3 months of their delivery. Between 2007 and 2011, linkage rates were stable at approximately 50%. Retention in the first year after delivery increased over time with 65% of women who delivered in 2011 being retained in care 1 year after delivery. In orange, is the viral suppression rates in the 1st year after delivery. Once again, viral suppression in the 1st year after delivery improved over a time with 55% of women who delivered in 2011 being suppressed in that first year. 2 year retention is in brown and 2 year viral suppression is in green. The trends for these 2 indicators is similar to year one with 38% women who delivered in 2011 being retained in the 2nd year after delivery and 49% being virally suppressed.
Why advocate for such a goal? There are several reasons here, summarized from earlier slides.
One, elimination of HIV MCT is feasible. We say that because we have preventive techniques which have already been demonstrably effective. By whatever count we use, the numbers of infection have declined remarkably. In other words, we have the tools--we know how to do this. The feasibility of elimination has also already been the conclusion of at least two of WHO’s regions.
Furthermore—number two—as seen above, available data support the idea that most of the ongoing cases of MCT are the result of so-called “missed opportunities” for preventing MCT (PMCT.
In addition—number three, something we have not discussed yet—considering the estimated lifetime care cost for a child infected with HIV now, a potential 25 million dollars could be saved annually if infection were prevented in 100 additional infants per year.
Overall, considering how much PMCT has already been accomplished, and that we know how to prevent a great deal of the remaining cases, and, considering the potential savings to the health-care system, elimination of HIV MCT is an obvious goal.
Finally—or maybe primarily—elimination of HIV MCT is the right thing to do.
CRT cases reviewed by year:
2010=5
2011=25
2012=31
2013=28
2014=22
KB: I think its important that we highlight what&apos;s going WELL as a city…would you agree? Would you add anything?