Advancing HIV Prevention in the United States

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Advancing HIV Prevention inthe United States
Association of Maternal Child Health Programs
Annual Conference
March 1, 2004 Washington, DC
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Overview

• Advancing HIV Prevention a CDC Initiative
• Margaret Lampe, CDC
• Prenatal HIV Testing
• Stephanie Sansom, CDC
• Implementing HIV Counseling and Rapid Testing for
  Women in Labor The New Jersey Experience
  
• Carolyn Burr, François-Xavier Bagnoud Center,
  UMDNJ
  
• Perinatal HIV Prevention in New York
• Roberta Glaros, AIDS Institute, NYDOH

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Advancing HIV Prevention New Strategies for a
Changing Epidemic
Margaret A. Lampe Epidemiology Branch Division o
f HIV/AIDS Prevention Centers for Disease Control
Prevention

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Why a new initiative?
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OraQuick HIV-1 Rapid Antibody Test designed for
oral fluid, serum, whole blood
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FDA-approved November 7, 2002 for use with finger
stick whole blood specimens granted CLIA waiver
January 31, 2003
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Obtain finger stick blood specimen
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Loop collects 5 microliters of whole blood
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Insert loop into vial and stir
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Insert device test develops in 20 minutes
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Reactive Control
Positive
Positive
Negative
Read results in 20-40 minutes
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Confirmatory Testing Required

• For Western blot
• Venipuncture for whole blood
• Oral fluid specimen
• Immunofluorescence assay

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Rapid HIV-1 Antibody Testing at Labor Delivery
for Women of Unknown HIV Status

• A Practical Guide Model Protocol

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Rapid HIV Testing in LD

• MTCT rates of
• Early identification of HIV infection
• 3 part ART regimen including ZDV (AZT)
• Obstetric interventions
• Pre-conception is ideal time for HIV testing,
  prevention/treatment, next best is early in
  pregnancy
  
• 280-370 perinatally HIV-infected infants/yr

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Rapid HIV Testing in LD

• 40 of infected infants, maternal HIV status
  unknown to provider prior to LD
  
• ART can reduce MTCT up to 50 even when begun
  during LD.
  
• Good rapid tests are now available in the U.S.
  
  
• LD Rapid testing logistically feasible, with
  challenges (MIRIAD others)

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OIG Report

• Office of the Inspector General report Reducing
  Obstetrician Barriers to HIV testing
  
• CDC should facilitate the development and
  states implementation of protocols for HIV
  testing during labor and delivery in order to
  promote testing in this setting as the standard
  of care.

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Perinatal HIV Rapid Testing Working Group
10 individuals with expertise in

• Blood screening
• Laboratory science
• Epidemiology
• Rapid HIV testing technology
• Care and support of HIV- infected pregnant women

• Obstetrics
• Pediatrics
• Nursing
• Public health practice
• Health education and training

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Purpose of this Model Protocol

• Practical guidance to
• Clinicians
• Laboratorians
• Hospital Administrators
• Public Health Program Data Professionals
• Policy Makers
• Provide general structure of a rapid HIV testing
  protocol, can be adapted locally
  

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Contents Overview

• Planning considerations when getting started
• Choosing type of test
• Location (LD or Lab)
• Key elements of a local protocol
• Eligibility
• Opt-out approach
• Providing results, intrapartum clinical care
• Follow up care of woman and child
• Management Considerations

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Rapid HIV testing in LD

• Until all pregnant women with HIV access
  screening prenatally, the promise of ACTG 076 and
  other clinical trials cannot be realized.
  
• Rapid testing provides a last opportunity to
  reduce the impact of missed prevention
  opportunities

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Recommendation

• Hospitals should adopt a policy of routine,
  rapid HIV testing using an opt-out approach for
  women who have undocumented HIV test results when
  presenting to labor delivery.

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Acknowledgements

• Rapid Testing Working Group
• Margaret Lampe, CDC
• Bernard Branson, CDC
• Sindy Paul, NJ DOH
• Carolyn Burr, FXB (NPHRC)
• Elaine Gross, FXB (NPHRC)
• Robert Maupin, LSU (Obstetrics, MIRIAD)
• Cyndie Eicher, LSU (Laboratory)
• Brian Forsyth, Yale (Pediatrics)
• Dawn Averitt, The Well Project (peer support)
• Mary Glenn Fowler, CDC
• Women participating in
• focus groups, pilots, research studies rapid
  testing programs

Other support CDC Ida Onorato Marc Bulterys
Alan Greenberg Patrick Sullivan Perinatal Exec
utive Committee Pat Garcia (Northwestern Univ.)
Yolanda Olszewski (CORE Center, Chicago, IL) Yv
ette Rivero (Univ. Miami)
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Interested?

• www.cdc.gov/hiv/PROJECTS/perinatal/
• MLampe_at_cdc.gov
• Thank You

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Predictive Value-Single Screening Test Differing
HIV Prevalence
PPV may differ from these estimates
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MIRIAD Sites and Hospitals
Chicago
Cook County
New York
Bethany
St. Bernard
Bronx
-
Lebanon
Provident
Harlem
Mt. Sinai
Jacobi
University of
N. Central Bronx
Chicago
Lincoln
Atlanta
Grady
Louisiana
Miami
Jackson Memorial
Charity (New Orleans)
Jackson North
Earl K. Long (Baton
Jackson South
Rouge)
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Bethany Hospital

• Rapid test performed on Labor and Delivery unit.
• Eligible patients are determined here in the
  Labor and Delivery Triage area.

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Provident Hospital

• The rapid test is done on this counter, extra
  supplies are stored below.
  
• OB physicians and Midwives share MIRIAD testing
  at Provident.

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Cook County Hospital

• Clerks on each shift access HIV results from the
  computer system.
  
• Eligible patients are offered rapid testing and
  consented in the Triage area.

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