Family-Centered Case Management An Essential Component in Reducing Mother-to-Child HIV Transmission

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Family-Centered Case ManagementAn Essential
Component in Reducing Mother-to-Child HIV
Transmission

• CitiMatCH Expedition 2004 Exploring the
  Boundaries of Urban MCH
• Portland, September 11-14, 2004
• Mary E. Caffery, RN, MSN University of
  California, San Diego
• Mother, Child Adolescent HIV Program

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• Scope of the HIV Epidemic in the U. S.
• Among Women and Children

• AIDS in women has risen from 7 early in the
  epidemic to 24 of adult cases today
• 141,000 AIDS cases in women reported through June
  2001
• 5-6,000 HIV positive women give birth annually
• 280370 babies continue to be born each year with
  HIV infection
• 
  CDC, 2003

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• Mother to Child HIV Transmission

• Without antiretroviral therapy during pregnancy,
  mother-to-child transmission has ranged from
  1625 in North America and Europe
• 21 transmission rate in the US in 1994
• Pediatric AIDS Clinical Trial Group 076 defined
  role of zidovudine (ZDV) in reducing transmission
  
• With use of ZDV, transmission was 11 in 1995
• Risk of perinatal transmission can be lt2
• highly active antiretroviral therapy (HAART)
• elective cesarean section (C/S) as appropriate
• formula feeding

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San Diego

• 2.9 million residents
• 35,000 births/yr
• 16 labor and delivery sites
• 12 of recent AIDS
• cases were women
• 40 HIV pregnant
• women/year

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California Legislation Perinatal HIV

• 2003 Dutra Bill AB 1676
• All prenatal providers required to include HIV
  testing as routine, with Hepatitis B screening
• Offer test at delivery
• Report results

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HIV infected women often face multiple challenges
accessing HIV services, prenatal care and
postpartum care

• Poverty, language barriers, illiteracy,
• Substance abuse, mental illness,
• domestic violence
• Inadequate transportation, unstable housing,
• Unemployed
• Inadequate or lack of insurance

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Barriers

• Urban health care systems are complex and often
  difficult to navigate, especially by clients who
  do not speak English, experience distrust with
  systems, are fearful, depressed or are
  stigmatized with HIV or other issues

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System Barriers

• Community prenatal care providers lack expertise
  in the delivery of services to HIV infected
  pregnant women.
• Traditional HIV case management programs lack
  capacity to provide prenatal guidance, or manage
  pregnancy related health and psychosocial issues.
  

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Goals

• To promote optimal maternal and infant health
  through improved access to prenatal and HIV
  services
• Comprehensive and integrated case management for
  HIV infected pregnant women will improve
  utilization of prenatal care, HIV care,
  interventions to reduce perinatal HIV
  transmission and infant diagnostic screening

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Accomplishments

• The Perinatal HIV Collaborative distributed
  10,000 HIV brochures in English and Spanish to
  perinatal providers promoting testing and
  referral of HIV infected clients for care and
  case management
• Prenatal providers received training in HIV
  testing for pregnant women and availability of
  services
• Utilizing Title I and Title IV funding, a
  University -based maternal child HIV program
  implemented a family-centered HIV case management
  program to integrate HIV care and prenatal care
  goals

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Perinatal HIV Case Management Services

• Highly skilled, bi-lingual clinical social
  workers with extensive experience in womens
  health provided comprehensive social services
  including outreach, case management, mental
  health assessments, psychosocial counseling,
  health education, partner testing and postpartum
  follow-up for the mother and her infant

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Goals of Case Management Services

• Assistance with basic needs
• housing, transportation, food, child care,
• Help obtaining health benefits, accessing
  prenatal care
• Coordination of health and social services
• Substance abuse, mental health dental,
  legal, peer-support, childbirth
  education, parenting classes employment/school
• Referrals to health professionals community
  agencies
• HIV education for clients, partners, families and
  the community

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Prenatal Case Management Services

• Initiated immediately at referral from test site,
  obstetric office and continued post-partum
• Case managers conduct extensive psychosocial
  assessment and developed family centered
  treatment plans
• Visits conducted at clinic and home
• Average contact Bi-weekly face-to-face Week
  ly phone calls

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• Case Management of
• HIV Exposed Infants

• Discharge planning with ZDV prophylaxis for 6
  weeks
• HIV diagnostic testing (PCR) to establish or rule
  out HIV infection as early as possible
• Linkages to an HIV specialist, primary care
• Long-term followup
• Provide anticapatory guidance and
• social services for the family

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Case Management of Postpartum Women

• Primary and HIV specialty care
• OB/GYN and family planning services
• Mental health and substance abuse treatment
• Coordination of care for the woman family
• Support services for the family

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With intensive case management

• Clients addressed behavioral goals to reduce risk
  for mother -to-child HIV transmission
• Reduced substance use and increased use of
  recovery programs
• More women and partners practiced safer sexual
  activity
• More women increased participation in general
  prenatal wellness measures
• improvements in nutrition
• less smoking
• more exercise

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Results

• 100 of women obtained
• prenatal care
• 92 of women were retained in care
• 90 of women obtained funding for
  prenatal services

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Results

• 92 of clients actively participated in
• health education
• 100 received substance abuse education,
  adherence counseling and safer sex
  education
• 100 of women received mental health assessments
  and referrals for supportive services

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Results

• 100 of clients obtained ante-partum
  antiretroviral medication to prevent perinatal
  HIV transmission
• 96 of women received intra-partum
  antiretroviral medication
• 100 of newborns received ZDV prophylaxis

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Results

• 100 of clients obtained at least three lab tests
  to confirm infant diagnosis
• No cases of Mother-to-Child HIV transmission

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Key Players

• County of San Diego Department of Health Human
  Agency (HHSA) Funded brochure, provided HIV
  education, provider education and public health
  nursing services, offered HIV testing, and
  provided outreach and case management through
  Ryan White Title I funds
• UCSD Mother, Child Adolescent HIV Program
• Sub-contractor with County HHSA for Case
  Management Services for Women and Children.
  Provided expertise in HIV and reproductive health
  care, infant screening and medical care.
  Provided Ryan White Title IV funding for
  wraparound HIV services for families. Retained
  social worker with MSW/MPH, extensive experience
  in womens health works with health care team to
  integrate HIV/Prenatal care. Collected data and
  conducted evaluation to monitor outcomes
• Community Based Agencies
• Southeast Abundant Resource Center Community
  agency provides strollers, car seats, and baby
  supplies to families.
• Christies Place Community agency provides
  counseling, childcare, support groups, and
  personal hygiene products to families

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Lessons Learned

• What works?
• Collaboration works!
• An integrated system of educating providers and
  consumers increased testing and referrals for
  care
• Focused efforts on the elimination of perinatal
  HIV transmission are necessary especially in
  communities that do not have high HIV
  seroprevalence.

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Lessons Learned

• Integration and creative use of funding
  stretched limited resources
• The group delegated the tasks to the most
  logical providers MCH Division) distributed the
  brochures and the Division of Community
  Epidemiology, as a subcontractor with the
  State/CDC perinatal HIV initiative conducted
  provider training
• The HHSA Office of AIDS Coordination funded case
  management, and the University HIV program
  provided case management and co-located HIV,
  reproductive health and pediatric follow-up

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Challenges

• What doesnt work?
• Inadequate funding. More funding is needed to
  fully implement this community wide approach
• What would we do differently
• This program would have been even more effective
  if we had obtained additional funding to permit
  smaller case management caseloads

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Overcoming Barriers

• Greatest barrier
• Lack of adequate attention on HIV and women
  results in limited resources for outreach, care,
  and case management
• How are barriers being overcome?
• Continuing efforts to educate community
• Collaboration with the AIDS Education and
  Training Center to train more providers and
  Regional Perinatal System to promote HIV testing
  and care during pregnancy
• Private funding has been secured for social
  marketing and distribution of brochures
• More funding is being sought to expand case
  management program

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What is the take home message from this promising
practice?

• When a community collaboration is committed to
  reducing mother to child HIV transmission, they
  can organize resources and activities to inform
  the community, educate the health care system,
  and provide the case management, which
  effectively links the pregnant woman, and her
  family to the specialized care that will promote
  maternal/child health and reduce the spread of
  HIV

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• References
• Public Health Service Task Force. Recommendations
  for Use of Antiretroviral Drugs in Pregnant
  HIV-1-Infected Women for Maternal Health and
  Interventions to Reduce Perinatal HIV-1
  Transmission in the United States, June 23, 2004,
  http//aidsinfo.nih.gov/guidelines/perinatal
• Revised Guidelines for HIV Counseling, Testing,
  and Referral and Revised Recommendations for HIV
  Screening of Pregnant Women, MMWR, November 9,
  2001/ Vol 50/ RR-19. http//aidsinfo.nih.gov/guide
  lines
• National Pediatric and Family HIV Resource
  Center. Follow-up care for infants born to
  mothers with HIV infection. Newark, NJ
  University of Medicine and Dentistry of New
  Jersey 2001
• New York State Department of Health AIDS
  Institute. Pediatric and Adolescent HIV
  Guidelines. In Criteria for the Medical Care of
  Children and Adolescents with HIV Infection.
  http//www.hivguidelines.org/public_html/center/cl
  inical-guidelines
• Internet-based library of materials on mother and
  child HIV infection can be found at
  http//WomenChildrenHIV.org

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Contact Information

• Mary E. Caffery, RN, MSN,
• UCSD Mother, Child Adolescent HIV Program
• 150 W. Washington St., 100
• San Diego, CA 92103
• 619-543-8080
• mcaffery_at_ucsd.edu