Prenatal Testing Issues: Why is Rapid Testing Needed

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Prenatal Testing IssuesWhy is Rapid Testing
Needed?

• Cynthia Carmichael, MD
• Deputy Director, Contra Costa County, Faculty
• East Bay AETC
• North Richmond Center for Health

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Historical Perspective
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The Ideal

• Every pregnant woman enters into prenatal care
  early and has prenatal blood tests including HIV
  antibody test.
• Every HIV positive woman takes antiretroviral
  medication appropriately during pregnancy and
  labor to prevent her baby from contracting HIV
  infection.
• If a pregnant woman tests HIV negative early in
  pregnancy, the HIV test is repeated later in
  pregnancy.

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The Reality

• Some women get NO prenatal care.
• Some women get INADEQUATE prenatal care.

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For Example

• Alameda County
• 1.25 No PNC 6.15 Inadequate PNC
• Contra Costa County
• .72 No PNC 7.85 Inadequate PNC
• Solano County
• 5.49 No PNC 14.74 Inadequate PNC

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• Kern County
• 10.26 No PNC
• Merced County
• 30 Inadequate PNC

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• Risk of HIV Infection believed to be 2-4 fold
  higher among women presenting for delivery
  without prenatal care.
• 15 of women with HIV infection have no prenatal
  care compared to 2 of all pregnant women.

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Rapid HIV Testing in L D for

• Women in with no prenatal care.
• Women who have had erratic prenatal care.
• Non-legal residents who may not have opted for
  HIV test during prenatal care.
• Injection drug users.
• Women who did not have HIV test during prenatal
  care.
• Women who had negative HIV test(s) early in
  pregnancy.
• Others?

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Risks of Vertical Transmission

• Without medications for mother
• 50 risk if baby is born prematurely
• 16-25 if baby is full term in US/Europe
• 14 additional risk if breastfeeding mom has
  established HIV infection
• 29 additional risk if breastfeeding mom has
  primary HIV infection
• With medications for mom/baby before/during/after
  delivery.
• 7-8 if ACTG 076 protocol (ZDV alone) is followed
• lt 2 if mother gets effective antiretroviral
  therapy, elective c-section as appropriate, and
  baby is formula fed

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2006 Case 1 I just got tested

• Mom and dad want to have a baby
• Both get tested and are HIV Ab negative
• 3-4 months later they conceive a baby
• Mother was offered testing at a prenatal visit
  but declined because I just got tested and
  neither of us has outside relations

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2006 Case 1 I just got tested

• Baby born, full term, stable, AGA
• Thrush in first 2 months
• Admitted at 3 months with respiratory distress,
  failure to thrive, severe thrush, axillary
  adenopathy then confirmed to have HIV, PCP, and
  CMV.
• Labs CD4 342, HIV RNA PCR gt 750,000.
• Currently on ZDV, 3TC, Kaletra, EPO, Fe, GCSF,
  Ganciclovir, TMP-SMX, azithromycin, fluconazole,
  and amlodipine thru a Broviac !
• Also requires NG feeds, hyperal thru Broviac.

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2006 Case 2 But I got tested for everything

• Parents together for 4-5 years
• No prior children
• Prenatal care through large HMO
• Group counseling about testing for lots of
  things
• I signed to have everything done
• No individual counseling done
• Never asked for or saw test results
• Presumed all was fine

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2006 Case 2 But I got tested for everything

• Baby born, full term, stable, AGA
• Poor weight gain in first 2 months
• Admitted at 3 months with respiratory distress,
  failure to thrive, severe thrush, axillary
  adenopathy then confirmed to have HIV, PCP, and
  CMV (yes identical to 2006 Case 1!)
• Labs CD4 low, HIV RNA PCR gt 750,000.
• Currently on ZDV, 3TC, Kaletra, EPO, Fe, GCSF, IV
  ganciclovir (for CMV), TMP-SMX, azithromycin,
  fluconazole and has a Broviac for GCV and blood
  draws !
• Review of moms consent X by I decline

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The Bottom Line

• Because Antiretroviral medication can
• Prevent perinatal HIV infection.
• Be effective when administered before, during or
  after birth.

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• Prenatal Rapid Testing can prevent illness and
  death for those born to HIV positive mothers.
• Prenatal Rapid Testing can save lives

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2006 Case 1 I just got tested

• Mom and dad want to have a baby
• Both get tested and are HIV Ab negative
• 3-4 months later they conceive a baby
• Mother was offered testing at a prenatal visit
  but declined because I just got tested and
  Neither of us has had outside relations since
  weve been together

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2006 Case 1 I just got tested

• Baby born, full term, stable, AGA, breastfed x 1
  month
• Thrush in first 2 months, intermittent
  breastfeeding
• Admitted at 3 months with respiratory distress,
  failure to thrive, severe thrush, axillary
  adenopathy, big liver then confirmed to have
  PCP, CMV and HIV.
• Labs CD4 342, CD4 18, HIV RNA PCR gt 750,000.
• Currently on ZDV, 3TC, Kaletra, EPO, Fe, GCSF,
  Ganciclovir, TMP-SMX, azithromycin, fluconazole,
  and amlodipine thru a Broviac !
• Also requires NG feeds, and hyperal thru
  Broviac...

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2006 Case 2 But I got tested for everything

• Parents together for 4-5 years
• One 17 year old half-brother
• Father incarcerated previously
• Prenatal care through large HMO
• Group counseling about testing for lots of
  things no individual counseling
• I signed to have everything done
• Never asked for or saw her test results
• Presumed all was fine

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2006 Case 2 But I got tested for everything

• Baby born, 32 weeks, AGA
• Poor weight gain in first 2 months, big liver
• Admitted at 3 months with 3 weeks of respiratory
  distress, failure to thrive, severe thrush,
  axillary adenopathy then confirmed to have PCP,
  CMV and HIV (yes identical to 2006 Case 1!)
• CD4 226 (23), HIV RNA PCR gt 750,000.
• Current Rx ZDV, 3TC, Kaletra, EPO, Fe, GCSF, IV
  ganciclovir (for CMV), TMP-SMX, azithromycin, and
  has a Broviac for GCV and blood draws ! Anemia,
  PRBC tx Renal disease.
• Review of moms consent
• 
  I decline