Prevention of Perinatal HIV Transmission - PowerPoint PPT Presentation

1 / 54
About This Presentation
Title:

Prevention of Perinatal HIV Transmission

Description:

Is HIV Disease Reportable in New Jersey and Why? ... Convenience sample - 170 Pregnant Women ... Current Studies: Population-Based Approach Through Registry Matching ... – PowerPoint PPT presentation

Number of Views:45
Avg rating:3.0/5.0
Slides: 55
Provided by: ValuedGate69
Category:

less

Transcript and Presenter's Notes

Title: Prevention of Perinatal HIV Transmission


1
Prevention of Perinatal HIV Transmission
  • Sindy M. Paul, M.D., M.P.H.
  • March 5, 2008

2
Is HIV Disease Reportable in New Jersey and Why?
  • HIV, AIDS and perinatal exposure reportable to
    NJDHSS
  • Data used for
  • Resource allocation
  • Trend analysis
  • Targeting prevention programs
  • Identifying changes in organism

3
Epidemiology of HIV Disease in New Jersey
12/31/06
  • 5th in US Cumulative reported AIDS Cases
  • Highest proportion of women (32)
  • 3rd US Cumulative reported pediatric AIDS cases
  • 1,248/1,335 (94) pediatric HIV/AIDS perinatal
    transmission

4
  • Timing of Perinatal HIV Transmission
  • Cases documented intrauterine, intrapartum, and
    postpartum by breastfeeding
  • In utero 2540 of cases
  • Intrapartum 6075 of cases
  • Addition risk (14-29) with breastfeeding
  • Evidence suggests most transmission occurs during
    the intrapartum period

Fowler, MG, Ped. Clinics of N. America 2000.
5

Pediatric HIV/AIDS Cases Exposures1993-2006 By
CategoryAs of December 31, 2006
6
New Jersey Reported Perinatally HIV Exposed
Children Born in New Jersey 1993-2006 As of
December 31, 2006
12
307
83
7
45
1305
424
239
14
40
193
143
213
33
58
135
17
37
112
76
28
28 Born Out-of-state
7
New Jersey Perinatally Exposed HIV Infected
Children Born in New Jersey 1993-2006 As of
December 31, 2006
lt5
31
6
lt5
lt5
136
52
19
lt5
lt5
18
24
12
lt5
9
12
lt5
lt5
6
5
lt5
8
New JerseyTop 10 Hospitals of BirthPerinatally
HIV Exposed ChildrenBorn 1993-2006 - As of
December 31, 2006
9
New JerseyTop 10 Hospitals of BirthPerinatally
HIV Exposed ChildrenBorn 2001-2006 - As of
December 31, 2006
10
Perinatally Exposed HIV ChildrenPrevalence By
MunicipalityBorn 1993-2006As of December 31,
2006
11
Perinatally Exposed HIV ChildrenPrevalence By
MunicipalityBorn 2001-2006As of December 31,
2006
12
Prevention of Perinatal HIV Transmission
  • The Risk Of Transmission Can Be Reduced
  • Prenatal Care
  • Mandatory Counseling/Voluntary Testing
  • Know Serostatus As Early As Possible!
  • Antiretroviral Therapy OB Procedures
  • PACTG 076 AZT Decreases Transmission From 25 to
    8
  • Recommend Against Breast Feeding

13
Evaluation of Implementation
  • Access to Prenatal Care
  • Counseling and Testing Provider Patient
  • AZT and other Antiretroviral Agent Use
  • Impact on Transmission
  • Missed Opportunities
  • Potential Toxicities
  • Potential Adverse Outcomes

14
Access to Prenatal Care 1993, 1995, 1996
  • 25 of HIV Infected Pregnant Women Had No Known
    Prenatal Care
  • In 2000 14 No Known Prenatal Care 6 1-2
    Prenatal Visits
  • A Major Gap In Prevention Of Perinatal HIV
    Transmission In New Jersey
  • An Opportunity For Intervention

15
Implementation Of Counseling And Testing
Recommendations
  • 1995 NJ Law Mandatory Counseling, Voluntary
    Testing (Changing 6/08)
  • Surveillance Data 91 HIV Infected Pregnant
    Women Know Serostatus Prior to Delivery 4
    Tested at Delivery
  • Statewide Assessment Diffusion of Counseling And
    Testing OBGYN
  • Interview Study Of Pregnant Women

16
Provider Survey Results
  • 160/351 (51) Completed Survey
  • 94 Offer HIV Testing
  • 90 Discuss Benefits of HIV Testing
  • 77 Counsel
  • 59 Offer All 3 Components

17
Respondents More Likely To Offer Counseling
  • Fit Into Office Routine plt0.0001
  • Better Medical Outcome p0.0261
  • Easy p0.0016
  • Confident in Counseling plt0.0001
  • Patient Appreciation p0.0001
  • Standard of Care p0.0002
  • Actively Promoted p0.0012
  • Discuss with Colleague p0.0171

18
Conclusion
  • Doing Well, but Room for Improvement
  • Missed Opportunities
  • Improved Diffusion and Implementation of HIV
    Counseling and Testing among OBGN Could be
    Accomplished through Peer Education

19
Interview Study Pregnant Women
  • Convenience sample - 170 Pregnant Women
  • Objective To Ascertain How Pregnant Women
    Perceive AZT as a Possible Option to Prevent
    Perinatal HIV Transmission by Examining Their
    Knowledge, Attitudes, Beliefs, and Intentions
    Surrounding AZT Use.

20
Demographic Profile
  • African-American 53
  • Hispanic/Latina 29
  • Ages 18-34 84
  • Unemployed 63

21
HIV Counseling and Testing History
  • 74 Reported Being Told About Benefits of HIV
    Testing
  • 90 Tested for HIV
  • 10 Not Tested Yet
  • 13/17 (76) Intended to Be Tested
  • 4/17 (24) Did Not Intend to Be Tested

22
Intention to Use AZT
  • 57 Would Use AZT
  • 41 Unsure
  • 2 Would Not Take AZT

23
Factors Associated With Intention To Use AZT
  • Positive Beliefs About AZT plt0.0001
  • Recommended by Dr. or Nurse p0.0023
  • Access to AZT at Clinic or Dr. p0.0076
  • Enough Information plt0.0001
  • Conspiracy Theories NOT ASSOCIATED

24
Conclusion
  • Pregnant Women Are Willing to Consider AZT Use if
    They Are Given Adequate, Accurate Information.

25
Implementation of PHS Recommendations in New
Jersey
  • ART use increased from 8.3 in 1993 to 97.0
    known in 2006
  • Decrease in perinatal transmission from 21 in
    1993 to 2 in 2006
  • Room for improvement recent studies show vertical
    transmission can be as low as 1-2
  • What are the missed opportunities?

26
Missed Opportunities Children Who Became Infected
  • 7 children infected 1999, 1 infected 2000
    (preliminary data reports through 12/31/00)
  • 5 of the 8 (63) no known or inadequate prenatal
    care
  • 7/8 (88) HIV status unknown to the delivery team

27
Missed Opportunities Children Who Became
Infected Continued
  • 1 of the 8 (13) had prenatal care starting in
    3rd trimester with antiretroviral agents in
    pregnancy, labor/delivery, and neonatal period
    and a vaginal delivery
  • Major gap women presenting in labor with unknown
    HIV serostatus to the provider
  • Contributing factor lack of or inadequate
    prenatal care

28
Prevention of Perinatal HIV Transmission ?
Serostatus
  • Rapid Test for Unknown Serostatus
  • Short course therapy options
  • Intrapartum IV ZDV 6 weeks ZDV for newborn
  • ZDV3TC in labor 1 week ZDV3TC for newborn
  • 1 dose NVP labor onset 1 dose NVP for newborn
    at 48 hours of age
  • Single dose maternal/newborn NVP regimen
    intrapartum IV ZDV 6 weeks infant ZDV
  • If NVP used alone or incombination with ZDV,
    consider maternal ZDV/3TC intrapartum and
    continue 3 7 days postpartum to reduce NPV

29
Hospital SurveyManagement Labor Unknown
Serostatus
  • Questionnaire telephone survey of 12 hospitals
    Essex, Hudson, Union counties
  • IRB approval
  • 12 licensed acute care general hospitals
  • 9/12 (75) responded
  • 6/9 (67) provide obstetrical care
  • 1/9 (10) rapid test capability

30
Hospital Survey Management Labor Unknown
Serostatus
  • 1/6 (17) always offers CTS in labor
  • 2/6 (33) almost always offer CTS in labor
  • 2/6 (33) rarely or never offer CTS in labor
  • 0 policy for rapid test/short course therapy
  • 5/6 (83) use standard EIA Western Blot
  • 1/6 (17) use HIV DNA PCR
  • Problem obtaining results in 72 hrs to treat
    infant with ZDV

31
Intent of the Standard of Care
  • Provide HIV counseling and voluntary rapid or
    expedited testing of mothers or newborns if
    unknown HIV status or mother reports HIV
    infection with no documentation on the medical
    record
  • Offer maternal /or newborn ART if HIV , mother
    reports being HIV , or mother previously
    documented to be HIV

32
Intent of the Standard of Care
  • To decrease the risk of vertical transmission in
    every HIV exposed baby born in a New Jersey
    hospital to the best practice standards

33
Standard of CareWomen in Labor with ? HIV Status
  • Provide counseling (pre- and posttest)
  • Voluntary rapid or expedited HIV test
  • If HIV positive provide preliminary lab results
    (CDC ASTPHLD)
  • If HIV positive offer short course therapy
  • DO NOT DELAY RX pending confirmatory lab results
  • Refer mother child for follow-up care

34
CDC Recommendations Woman Presents in Labor with
? Status
  • CDC recommendations similar to NJ
  • Counseling
  • Template training based on NJ
  • Opt out option (Regs preclude in NJ)
  • POCT RT short course therapy
  • Retest in NJ 3rd Trimester
  • Referral for care and treatment

35
Prevalence of Diseases Screened for in Newborns
  • Tyrosemia 1 in gt
    300,000
  • Maple-syrup urine disease 1 in 175,000
  • Homocystinuria 1 in 100,000
  • Galactosemia 1 in 60,000
  • Phenylketonuria 1 in 14,000
  • Hypothyroidism 1 in 4,000
  • Perinatal HIV (US) 1 in 1,500

36
9/06 CDC Revised RecommendationsPregnant Women -
I
  • Universal opt-out HIV screening
  • Include HIV in routine panel of prenatal
    screening tests
  • Consent for prenatal care includes HIV testing
  • Notification and option to decline
  • Note NJ Law/Regulations signed consent or
    declination changing 6/08!

37
9/06 CDC Revised RecommendationsPregnant Women -
II
  • Second test in 3rd trimester for pregnant women
  • Known to be at risk for HIV
  • In jurisdictions with elevated HIV incidence
    including NJ
  • In high HIV prevalence health care facilities

38
9/06 CDC Revised RecommendationsPregnant Women -
III
  • Opt-out rapid testing with option to decline for
    women with undocumented HIV status in LD
  • Initiate ARV prophylaxis on basis of rapid test
    result
  • Note NJ Law Consent or Declination Required
    Changing 6/08
  • Rapid testing of newborn recommended if mothers
    status unknown at delivery
  • Initiate ARV prophylaxis within 12 hours of birth
    on basis of rapid test result

39
2008 Legislation Pregnant Women and Newborns
  • Effective 6/08
  • Follow current CDC recommendations
  • Give information
  • Opt-out HIV Testing 1st 3rd Trimesters
  • Opt-out Rapid HIV Testing LD
  • All newborns if mothers status unknown unless
    written parental religious objection

40
FDA Approved, Currently Available Rapid Tests
  • OraQuick Advance HIV1/HIV2
  • Reveal
  • Unigold Recombigen
  • Multispot HIV1/HIV2
  • Sure Chek(Complete), Stat Pak HIV1/HIV2
  • Confirmation with Western Blot or IFA
  • Rapid testing recommended by CDC

41
Requirements for Rapid HIV Testing
  • Have an adequate quality assurance program
  • Assurance that operators will receive and use
    instructional materials
  • Compliance with OSHA/PEOSH blood-borne pathogens
    regulations

42
The Need for Training
  • Blood body fluid precautions
  • Obtaining the specimen (finger stick or blood
    draw)
  • Performing the test
  • Providing test results and counseling
  • Quality assurance
  • OSHA/PEOSH requirements

43
Current Clinical Response to Rapid Testing
Preliminary Positive Results
  • Occupational Exposure
  • Women in labor with unknown HV status
  • Why? Because tested person benefits
  • - PEP reduces risk of occupational transmission
  • - Short course therapy reduces risk of
    mother-to-child HIV transmission

44
Summary of Recent Perinatal Infections 2003-2004
  • 7 cases
  • Only 1 received appropriate care and prevention
    medications
  • 2 Mom tested after birth
  • 2 No PNC, no meds
  • 1 neonate start ZDV day 3
  • 1 neonate no ZDV
  • 2 c/s (1 non-elective, 1 unknown)

45
Summary of Recent Perinatal Infections
2003-2004 Continued
  • 3 Mom diagnosed before pregnancy
  • - 3 No PNC, no meds
  • - 1 neonate no ZDV, 1 unknown, 1 ZDV
  • - 2 vaginal deliveries (1 home delivery)
  • - 1 c/s 34 weeks type unknown
  • 1 Mom diagnosed before pregnancy
  • - PNC starting 7 months, non-adherent meds
  • -elective c/s 38 weeks, ZDV LD, neonate day1

46
2005 Hospital Survey
  • Collaborative effort NJHA UMDNJ
  • Purpose evaluate implementation of standard of
    care
  • Goal RT Short course therapy for women in
    labor all hospitals
  • Self-administered survey
  • Data collection June September 2005

47
2005 Hospital Survey Preliminary Data
  • All 59 hospitals responded
  • 56 (94.9) have a policy for documenting HIV
    status in labor and delivery (LD)
  • 34 (57.6) have a policy for counseling women
    with unknown HIV status in LD
  • 39 (66.1) have a policy for HIV testing

48
2005 Hospital Survey Preliminary Data Continued
  • 56 (94.9) of responding hospitals have HIV
    testing available in LD
  • 45 (76.3) do point-of-care testing in LD
  • 40 (67.8) provide antiretroviral agents to the
    mother in labor and to the newborn

49
Major Missed Opportunities 2005
  • Potentially preventable cases persist
  • Lack of or inadequate prenatal care
  • Lack of availability of counseling, rapid testing
    and short course therapy at some New Jersey
    hospitals that provide OB care
  • For maximal reduction need RT Short course
    therapy at all OB hospitals

50
Efforts to Decrease Missed Opportunities
  • Target Population
  • - Women in labor with ? HIV status
  • - Women not in PNC
  • Approach
  • - Provider education
  • - Facility TA

51
Pregnant.
Are You HIV?
Find Out.
YOU CAN HELP Prevent HIV In Your Baby.
Call The NJ AIDS Hotline 1-800-624-2377.
Free HIV Test And Care During Pregnancy.
52
Potential Adverse Outcomes
  • Birth Defects
    - Match HARS To Birth Defects
    Registry - No Evidence Of Increased Incidence
  • Cancer
    -Match HARS To Cancer Registry
    -No Evidence Of Increased Incidence
  • Current Studies Population-Based Approach
    Through Registry Matching

53
Potential Toxicities Mitochondrial Disease
  • Primate Studies
  • French Cohort
    - 8/3,000 Children
  • US, Europe, Thailand, Africa
    - 0/27,000 Children
  • Current Studies in New Jersey
    - None Detected

54
Summary
  • Perinatal transmission decreased from 21 to 2
  • Major missed opportunity NJ present in labor
    HIV status unknown
  • Counseling, RT, short course Rx in labor
  • Continue to use epidemiology to evaluate the
    implementation and effectiveness of
    recommendations
  • Goal maximal decrease vertical HIV transmission
Write a Comment
User Comments (0)
About PowerShow.com