Preventing Perinatal Transmission of HIV: An Expanded Look at the Cascade

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Preventing Perinatal Transmission of HIV An
Expanded Look at the Cascade

• Debora Barnes-Josiah, PHD
• CityMatCH
• University of Nebraska Medical Center
• and the
• Preventing Perinatal Transmission of HIV in U.S.
  Cities Urban Learning Cluster

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Estimated Number of Women Living with
AIDS,1993-1999, U.S.
SOURCE CDC, 2001
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Incidence of Perinatally-Acquired AIDS United
States, 1985-June 2000
PACTG 076
USPHS ZDV recs
USPHS prenatal CT recs
Reported through December 2000 SOURCE CDC, 2001
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What is the Preventing Perinatal HIV Transmission
in U.S. Cities - Urban Learning Cluster project?

• One of 6 CDC-sponsored cooperative agreements
  designed to reduce perinatal transmission of HIV
• Focuses on promoting the translation of research
  and data into effective practice in U.S. urban
  communities with the highest rates of perinatal
  HIV, through
• Multi-city Learning Clusters, and
• Targeted information dissemination.

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Goal 1 Inform and engage urban health
departments and leaders in the prevention of
perinatal transmission of HIV/AIDS.
Goal 2 Promote learning across urban communities
with the highest concentrations of perinatal HIV
transmission

• to identify and promote more effective,
  sustainable approaches to assessment and
  prevention
• to achieve measurable results in HIV prevention.

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What is a Learning Cluster?

• Strategically composed group of individuals and
  teams brought together for both giving and
  getting
• Focuses on a public health issue or methodology
  of shared interest
• Combines science, program and policy experts
  community-based teams

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City Team Membership

• HIV program/policy expertise
• MCH program/policy expertise
• Public Health Leadership
• Community Leadership
• State Representation
• Clinical Liaison

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2000/2001 Urban Learning Cluster Teams
Atlanta, GA Hartford, CT Jacksonville, FL Los
Angeles, CA Newark, NJ Norfolk, VA Philadelphia,
PA San Diego, CA Washington, DC
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Perinatal HIV Transmission Why an Urban Focus?

• Pediatric AIDS is overwhelmingly urban!
• 85 of cases are in the 100 largest metro areas
• 73 of cases are in 29 of the larger metro areas
• ULC cities have 19.4 of all reported cases lt13
  years old
• Centers for Disease Control and Prevention, 1998,
  2001
• Institute of Medicine, 1999

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THE CASCADE THE CHAIN OF EVENTS LEADING TO AN
HIV-INFECTED CHILD
THE PROPORTION OF WOMEN
WHO ARE HIV POSITIVE
WHO BECOME PREGNANT
WHO DO NOT SEEK PRENATAL CARE
WHO ARE NOT OFFERED HIV TESTING
WHO REFUSE HIV TESTING
WHO ARE NOT OFFERED TREATMENT
WHO REFUSE TREATMENT
WHO DO NOT COMPLETE THE TX REGIMEN
WHOSE CHILD IS INFECTED DESPITE TX
SOURCE IOM, 1999
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INTERVENTION POINTS FOR PREVENTING PERINATAL HIV
TRANSMISSION
1. PRE-CONCEPTION
WOMAN OF REPRODUCTIVE AGE
2. HIV INFECTION
3. PREGNANCY
4. PRENATAL CARE
5. HIV TESTING
6. HIV TREATMENT
7. DELIVERY
8. POSTPARTUM
HIV () INFANT
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4. PRENATAL CARE
1. PRE-CONCEPTION
WOMAN CHOOSES NOT TO ATTEND
2. HIV INFECTION
NO ACCESS
3. PREGNANCY
4. PRENATAL CARE
INAPPROPRIATE CARE MGT
NO MULTI- DISCIPLINARY REFERRAL
5. HIV TESTING
6. HIV TREATMENT
CULTURAL/ LANGUAGE BARRIERS
7. DELIVERY
8. POSTPARTUM
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4. PRENATAL CARE
1. PRE-CONCEPTION
PROVIDING SERVICES IN HOMELESS SHELTERS
NO ACCESS
2. HIV INFECTION
WOMAN CHOOSES NOT TO ATTEND
3. PREGNANCY
CROSS-TRAINING OF PROVIDERS
4. PRENATAL CARE
INAPPROPRIATE CARE MGT
COMPREHENSIVE SYSTEMS OF CARE
NO MULTI- DISCIPLINARY REFERRAL
5. HIV TESTING
6. HIV TREATMENT
CULTURAL/ LANGUAGE BARRIERS
INTENSIVE CASE MANAGEMENT
7. DELIVERY
8. POSTPARTUM
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5. HIV TESTING
1. PRE-CONCEPTION
TEST NOT OFFERED
SELECTIVE TESTING
2. HIV INFECTION
3. PREGNANCY
NOT ENOUGH PROVIDERS
CLIENT REFUSAL
4. PRENATAL CARE
5. HIV TESTING
TESTING POORLY EXPLAINED
NO 2ND SCREEN
6. HIV TREATMENT
INSTITUTIONAL CAPACITY
RESULTS LOST
7. DELIVERY
CLIENT NOT TOLD RESULTS OR LOST TO FOLLOW-UP
8. POSTPARTUM
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5. HIV TESTING
1. PRE-CONCEPTION
EXPANDED OUTREACH
TEST NOT OFFERED
2. HIV INFECTION
UNIVERSAL TESTING
3. PREGNANCY
CLIENT REFUSAL
PROVIDER EDUCATION MATERIALS
4. PRENATAL CARE
5. HIV TESTING
NO 2ND SCREEN
TREATMENT PROTOCOLS
RESULTS LOST
INSTITUTIONAL PROCEDURAL REVIEWS
6. HIV TREATMENT
EXPANDED FUNDING
LOST TO FOLLOW-UP
7. DELIVERY
INTER/INTRA-AGENCY COOPERATION / COLLABORATION
8. POSTPARTUM
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6. HIV TREATMENT
1. PRE-CONCEPTION
2. HIV INFECTION
APPROPRIATE THERAPY NOT AVAILABLE
3. PREGNANCY
4. PRENATAL CARE
TX NOT OFFERED BY PROVIDER
5. HIV TESTING
TX NOT OFFERED BY PROGRAM
6. HIV TREATMENT
CLIENT REFUSES
7. DELIVERY
8. POSTPARTUM
COMPLIANCE ISSUES
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7. DELIVERY
1. PRE-CONCEPTION
AVAILABILITY / ACCURACY OF PNC RECORDS
2. HIV INFECTION
TESTING POLICIES
3. PREGNANCY
4. PRENATAL CARE
TREATMENT AVAILABILITY
5. HIV TESTING
C-SECTION POLICIES
6. HIV TREATMENT
DURATION OF ROM
7. DELIVERY
DELIVERY PRACTICES
8. POSTPARTUM
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8. POSTPARTUM
1. PRE-CONCEPTION
2. HIV INFECTION
3. PREGNANCY
BREAST FEEDING
4. PRENATAL CARE
INTEGRATED TX OF MOTHER AND INFANT
5. HIV TESTING
6. HIV TREATMENT
INFANT / MOTHER FOLLOW UP
7. DELIVERY
8. POSTPARTUM
MATERNAL HEALTH
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COMMENTS AND CAVEATS

• Please note that some events may occur throughout
  the continuum
• Without action, an HIV negative infant can still
  result
• Infected infants may still result even under the
  best of circumstances

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Monitoring Missed Opportunities227 HIV-infected
Children Born 1995-977 States with Enhanced
Surveillance

• Prenatal Care
• 14 had none 26 unknown
• Of those who received care, 14 had lt2 visits

• Maternal HIV testing
• 20 tested after delivery
• 7 tested at delivery

• Antiretroviral therapy
• Of mothers tested before delivery and received
  prenatal care, 22 were not prescribed prenatal
  ZDV

• 29 had all 3 prevention interventions prenatal
  care, HIV test before birth, prescribed prenatal,
  intrapartum and/or newborn ZDV

SOURCE CDC, 2001
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Urban Learning Cluster City Teams

• Atlanta, GA Norfolk, VA
• Hartford, CT Philadelphia, PA
• Jacksonville, FL San Diego, CA
• Los Angeles, CA Washington, DC
• Newark, NJ

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CityMatCH Project Team

• Magda Peck, ScD - Principal Investigator
• Deanna Bartee, MSW - Project Coordinator
• Debora Barnes-Josiah, PhD - Faculty
  Epidemiologist
• Joan Rostermundt - Project Coordinator
• Patrick Simpson, MPH - Program Policy Manager
• Jennifer Skala, MEd- Project Coordinator
• Jeanette Leeper - Staff Secretary