Getting to Zero:

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Getting to Zero

• Eliminating Perinatal HIV Transmission in US
  Hospitals

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What is HRET?

• Independent, non-profit organization
• MISSION Transforming healthcare through research
  and education
• Engages in timely research and education on
  issues of critical interest to hospitals and
  health systems and the community they serve

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HRETs Focus Areas

• Enhancing and measuring community health
• ACHI
• Preparedness
• HIV
• Expanding coverage and access
• Employer Health Benefits Annual Survey
• End-of-Life studies
• ED Overcrowding

• Improving patient safety and quality of care
• Co-Management Learning Network
• Pathways for Medication Safety
• Simulations for Clinical Training
• Reducing Disparities in Health Care Treatment

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HRET and the AHA

• HRET as affiliated
• HRET as independent
• What does this mean for this perinatal HIV
  project?
• AHA Maternal and Child Health Section
• 3000 hospital members

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Materials Development

• Experience with hospital materials development
• Community Care Notebook
• Collaboration Primer
• Pathways to Medication Safety
• AHA Member Advisories
• Uniform Framework for Collection of Racial,
  Ethnic, and Primary Language Data and toolkit

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Dissemination / Publicity Avenues

• AHA News Outlets
• AHA News
• Biweekly to hospital CEOs
• Total distribution 21,757

• AHA News Now
• Daily news bulletin to senior mgmt.
• 85 of hospital CEOs read AHA News Now
• Total distribution 25,244

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Further Dissemination Tools

• Mass mailings or email correspondence to all
  hospital CEOs
• Annual survey data
• State Hospital Association communication
  contacts
• Access to state hospital assoc. websites
• Webpages
• HospitalConnect.com
• AHA MCH website
• HRET website

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HRET and the CDC

• Perinatal HIV Transmission Prevention in the
  United States National Organizations Working
  toward Elimination Cooperative Agreement
• Projected four year project 10/1/03-9/30/07
• Other current collaboration with the CDC
• HIV Prevention in the US The Role of Hospitals
• Hospital-Public Health Preparedness

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PARTNERSHIP GOAL
Completely eliminate mother-to-child HIV
transmission in the United States
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National Organizations Working Toward Elimination

• Centers for Disease Control and Prevention
• American College of Obstetricians and
  Gynecologists
• Association of Maternal and Child Health
  Programs state MCH directors
• CityMatCH urban MCH, HIV public health
  directors
• Francois-Xavier Bagnoud Center at UMDNJ AIDS
  education and training
• AHA Section on Maternal and Child Health

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HRET Project Activities/Role

• National survey of hospitals
• Develop tools and training materials for
  hospitals
• Establish a panel of experts in maternal and
  child health
• Expand MCH providers peer networking
  opportunities

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HRET Team

• Principal Investigators Mary Pittman, Francie
  Margolin
• Project Coordinators Kali Stanger, Jennifer
  Reiter
• Operations Jeanette Lyons
• Survey Methods Jeremy Pickreign, Heidi
  Whitmore, Samantha Hawkins
• Communications, liaison with other CDC projects

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National Advisory Committee

• Roles and expectations
• Input on specific materials based on expertise
• Review of additional materials
• Advice on dissemination strategies
• Meet in-person annually
• Quarterly conference calls

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Perinatal HIV in the US Overview

• Public Health successDramatic decrease in
  perinatally acquired AIDS cases
• Mother-to-child transmission can be prevented
  with intervention
• Rapid tests provide opportunity to identify
  undiagnosed HIV cases in LD and intervene

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Opportunities in the Hospital Setting

• Identify undiagnosed HIV cases
• Provide intervention in the LD and nursery
  settings
• Educate patients about HIV transmission and link
  HIV-positive patients to appropriate resources

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Challenges in the Hospital Setting

• Testing
• Legal restrictions
• Availability of prenatal care test results
• Counseling and consent
• Staff resources
• Reimbursement
• Cost
• Confirmatory testing and patient follow-up

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Challenges in the Hospital Setting, cont.

• Treatment
• Availability of medication
• Appropriate medication counseling
• Possibility of false positives, risk management
• Labeling and administering meds while maintaining
  patient privacy

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Implementation Considerations

• Counseling
• Confidentiality
• Informed consent
• Opt-out approach
• Testing
• Point of care vs. lab-based
• Preliminary
• Confirmatory
• Training

• Results
• Interpreting results
• Preliminary
• Confirmatory
• Treatment
• Guidelines
• Medication availability
• Follow-up care

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Lessons Learned from the Field

• 6,000-7,000 HIV infected women gave birth in 2000

Office of Inspector General, July 2003
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Lessons Learned from the Field

• LD the opportunity for engagement
• 48-hour window

N 557 deliveries to women without PNC 6 LD
units in Chicago (34 pts missing data)
Information courtesy of Dr. Pat Garcia
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• Objectives of MIRIADMother Infant Rapid
  Intervention
• At Delivery

• To determine the feasibility and performance of
  rapid HIV testing for women in labor with
  undocumented HIV status
• To provide timely antiretroviral drug prophylaxis
  to reduce perinatal transmission
• To facilitate follow-up care for HIV-infected
  women and their infants

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MIRIAD Findings

• Consent and counseling can be effectively
  provided in the LD setting

• Of the 5,374 eligible women on LD, 1,044 (19.4)
  could not be approached by the staff
• Of the remaining 4,330 women who were approached
  for rapid HIV testing, consent was obtained from
  3,660 (84.5)

Bulterys, et al. JAMA, July 14, 2004-Vol 292, No.
2
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MIRIAD Findings, cont.
Point-of-care testing returns results more
quickly than laboratory testing.

• Median turn-around times
• 9 hospitals using point-of-care testing - 45
  minutes
• 6 hospitals using 24-hour laboratory - 90
  minutes (plt0.0001)

Bulterys, et al. JAMA, July 14, 2004-Vol 292, No.
2
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MIRIAD Recommendations and Findings

• Voluntary HIV testing early in prenatal care is
  the optimum approach to perinatal HIV prevention
  and clinical care of HIV women.
• In laboring women with undocumented HIV status,
  rapid HIV testing using OraQuick delivered
  accurate and timely test results.
• Acceptance of HIV testing in labor was high but
  varied by time and day of the week.

Bulterys, et al. JAMA, July 14, 2004-Vol 292, No.
2
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MIRIAD Findings and Recommendations, cont.

• Point-of-care testing provided valid test results
  in a timely manner (MMWR 200352866-868).
• MIRIAD allowed HIV women immediate access to
  intrapartum/neonatal ARV prophylaxis.
• CDC recommends routine rapid HIV testing in labor
  for women with unknown HIV status using an
  opt-out approach.

Bulterys, et al. JAMA, July 14, 2004-Vol 292, No.
2 CDC Model Protocol
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HRET National Hospital Survey

• 2512 hospitals that do gt 300 births/year
• Sent to CEO to be completed by person most
  knowledgeable about HIV testing in LD
• E-mail plus follow-up hard copy
• Response increase strategy
• National partners, MCH calls, state hospital
  associations
• 51 response rate

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Survey Domains

• Testing policies and practices in
• Prenatal care
• Labor and delivery
• Neonatal care

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Some Preliminary Conclusions

• Need to increase universal testing of women
  without documented HIV results
• Treatment protocols, model policies, training
  materials considered effective
• Privacy issues and regulations/laws greatest
  perceived barriers to routine testing
• Cost less often perceived as important barrier

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More Preliminary Conclusions

• Need to educate about available tests
• Need to educate about feasibility of
  point-of-care testing
• Quality control, regulations, organization
  policies are barriers to point-of-care testing
• Timeliness facilitator of lab testing

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Proposed HRET Tools

• CEO buy-inpacket
• AHA statements / protocols
• National training video
• Slide presentation
• Hospital implementation manual (year 3)