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.

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

4. Female PLWHA of Child Bearing Age
(15-45), 2005-2012

5. Philadelphia Perinatal Exposures,
2005-2012

6. Proportion of HIV-Infected Women of Child
Bearing Age (15-45) who Delivered an Infant,
2005-2012

7. Philadelphia Perinatal Transmissions,
2005-2011

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

19. What is FIMR?
Community
Action
Changes in
Community
Systems
Cycle of
Improvement
Data
Gathering
Case
Review
Continuous
Quality
Improvement

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