Transcript How to Work with Less. Leveraging Your Resources for

How to Work With Less
Leveraging Your Resources for
Perinatal Hepatitis B and HIV
Prevention
Hollie Malamud-Price, M.P.H.
Ryan White Treatment Modernization Act
Maternal and Child Coordinator
Division of Health, Wellness, and Disease Control
HIV/AIDS Prevention and Intervention Section
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What Are We Talking about Today
Basic Epidemiology of
Mother-to-Child Transmission
Preventing Mother-to-Child
Transmission (PMTCT)
Puzzle of Collaboration
What We Did in Michigan
Challenges
Lessons Learned
Resources
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Women and HIV
 Fastest-growing group of persons with new HIV
diagnosis (30% of U.S. infections in 2001)
 6,000 to 7,000 HIV-positive women deliver annually
 40% of HIV-infected infants born to mothers with
unknown status
 As of 2003: 5,000 cumulative deaths from
perinatally acquired AIDS in U.S.
Ann Intern Med. 2005;143:38-54.
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Women and HIV, cont…
 For women of all races and ethnicities, the largest
number of HIV/AIDS diagnoses during recent years
was for women aged 15–39
 High-risk heterosexual contact was the source of
80% of these newly diagnosed infections
 Women with AIDS made up an increasing part of the
epidemic.
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
In 1992, women accounted for an estimated 14% of adults and
adolescents living with AIDS in the 50 states and the District of
Columbia
By the end of 2005, this proportion had grown to 23%
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http://www.cdc.gov/hiv/topics/women/resources/factsheets/women.htm#3
Mother-to-Child Transmission
 Perinatal HIV transmission is the most
common route of HIV infection in children
 It is now the source of almost all AIDS cases in
children in the United States
 Most of the children with AIDS are members of
minority races/ethnicities
 Many of these infections involve women who
were not tested early enough in pregnancy or
who did not receive prevention services
CDC. HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev. ed. Atlanta: US Department of Health and Human
Services, CDC; 2007:1–54.
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Mother-to-Child Transmission
Rates of perinatal HIV Transmission of < 2%
are possible with:
1. Early identification of maternal HIV infection
2. 3 part (antenatal, peripartum and neonatal)
antiretroviral regimen
3. Pre-labor cesarean section if a maternal viral
load of <1000 copies/ml is not achieved
Approximately 144-236 infants per year
acquire HIV infection via MTCT in the U.S.
~40% of their mothers not tested until birth
or later
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Perinatal Prevention Cascade
Missed Opportunities
Prevention Opportunities
HIV positive woman or woman
who does not know hr status
Primary HIV prevention for women
Pre-conception counseling and care
Become Pregnant
Prevention of unintended pregnancy
No Prenatal Care
No HIV Test
Inadequate ARV Prophylaxis
Accessible, affordable, welcoming prenatal care
Universal prenatal HIV testing (routine, opt-out)
Re-offering testing to those who decline
Second test in third trimester
L&D rapid testing for women with unknown HIV
status
Providing ARV prophylaxis to all
eligible. Support for adherence to ARV
ARV prophylaxis of exposed newborns
Child Infected Despite Treatment
Comprehensive services for mother and infant
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Remaining Obstacles to Eradicating
Perinatal HIV in the U.S.
 Increase of HIV infection among women of child-bearing age
 Delayed or lack of prenatal care
 Women seen in antenatal care but not offered voluntary
counseling/testing due to perceived low risk
 Poor adherence to antiretroviral medications
 Lack of full implementation of routine, universal prenatal HIV
counseling and testing
Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and
Interventions to Reduce Perinatal HIV Transmission in the United States; November 2, 2007
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Prevalence of Diseases Screened
for in Newborns
Tyrosinemia:
Maple-syrup urine disease:
Homocystinuria:
Galactosemia:
Phenylketonuria:
Hypothyroidism:
Perinatal HIV exposure, US
Perinatal HIV infection, US
1 in >300,000
1 in 175,000
1 in 100,000
1 in 60,000
1 in 14,000
1 in 4,000
1 in 670
1 in 2,680 to 1
in 33,500
(according to interventions)
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Women and Hepatitis B

24, 000 births to hepatitis B surface antigen (HBsAg)
positive women annually

Without appropriate prophylaxis at birth 90% of
exposed infants will become infected
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CDC estimates 600 births to HBsAg positive women
in MI
• Approximately 300 are identified

<50% identified in Michigan and nationally
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Identified and Expected Births to
HBsAg-Positive Mothers, US, 1993-2003
23,827
19,043
60
20000
48% 15000
41%
40
10000
5000
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Source: National Immunization Program, CDC
03
20
02
20
01
00
20
Year
20
99
19
98
19
97
19
96
19
19
19
19
95
0
94
0
93
Percent Identified
80
Expected Number
100
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Hepatitis B Birth Dose

Infants born to HBsAg-positive
women and a completed vaccine
series
 With HBIG and hepB at birth
 80 - 95% protection
 With hepB only started at birth
 70 - 95% protection
Source: MMWR 2006; 55(RR-16)
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Advisory Committee on Immunization
Practices (ACIP) Hep B Recommendations

1991 – Universal program implemented
 First dose at birth or 1-2 mo for infants born to
HBsAg-negative moms
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2002 – Preference to give first hepB at birth
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2005 - First hepB vaccine should be given at birth
www.cdc.gov/ncidod/diseases/hepatitis/b/acip.htm
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Risk Factors for Acute Hepatitis B
U. S., 2006
Heterosexual (39%)*
Injecting
Drug Use
(16%)
Household Contacts; Health
Care, and Travel (5%)
MSM (24%)
Unknown (16%)
* Includes sexual contact with acute cases, carriers, and multiple partners.
Source: MMWR 2006; 55(RR-16):6-7
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Michigan’s Public Health Code
333.5123
 Requires pregnant women to be tested for HIV,
syphilis, and/or hepatitis B at initial prenatal care
visit, at the time of labor and delivery, and/or
immediate post partum if the mother’s status is
unknown or undocumented
 The Michigan Department of Community Health
(MDCH) also recommends retesting for HIV and
for HBsAg for hep B high risk negative women in
the third trimester
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Public Health Code, cont.

Informed consent is required for both HIV and
hep B testing

HIV testing requires a signed consent form

HIV providers can use the MDCH counseling and
testing booklet or a consent form of their choice

A general consent form for services is OK
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USPHS Guidelines for HIV
Screening
 1995: USPHS recommends that all
pregnant women be counseled for HIV and
encouraged to be tested
 2001: USPHS strengthens
recommendation for routine testing of all
pregnant women
 Simplification of testing process so that pretest
counseling is not a barrier
 More flexible consent process to allow for various type
of informed consent
 Routine retesting in 3rd trimester for facilities serving
high HIV prevalence (i.e., >.5%) communities
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HIV Infection
Ideal Disease for Screening
 HIV serious health disorder that can be
diagnosed in an asymptomatic state
 HIV can be detected by reliable,
inexpensive, and noninvasive screening
test
 Infected patients have YOLG if
treatment initiated early
 Cost of screening reasonably in relation
to anticipated benefit
MMWR 2006; 55 (NO RR-14) 1-17
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2006 CDC Releases Revised
Recommendations on HIV Testing
 All pregnant women in the United States
should be screened for HIV infection
 Transmission continues to occur among
women who lack pnc or who were not offered
voluntary HIV counseling and testing during
pregnancy
 Data confirm that testing rates are higher when
HIV tests are included in the standard panel of
screening tests for all pregnant women
MMWR 2006; 55 (NO RR-14) 1-17
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CDC Recommendations on
Maternal Hepatitis Screening
 Screen all pregnant women prenatally for HBsAg
 At time of delivery
Review maternal HBsAg status
Record results on both labor and delivery record
and on infant’s delivery summary sheet
Perform HBsAg testing STAT on women who:
Do not have a documented HBsAg test result
Tested HBsAg-negative prenatally and are at
risk for hepatitis B virus (HBV) infection
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Perinatal Cost Savings
 Universal prenatal screening is cost savings in the
U.S.
 Repeat testing in 3rd trimester is cost-effective in
areas of elevated HIV incidence among women of
child-bearing age
 The discounted lifetime treatment cost for perinatallyinfected children
 $113,476 for 9 years of survival
 $228,155 for 25 years of survival
 As years of survival increase for HIV-infected
children, the lifetime costs are also likely to increase
Sansom, et al. JAIDS 41: 4, April 2006
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Who is Responsible for
Perinatal Hepatitis B
and HIV Prevention?
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Puzzle of Collaboration
Reporting
L and D Knowing
the woman’s HIV
and Hep B status
Entering into
Prenatal Care
Obstetrical
Provider
Pregnant
Woman
Obstetrician
Providing Testing
Infection
Control/
Infectious
Disease
Provider
Treatment
Test Results
Being
Returned
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What Did Michigan Do?
Perinatal Hep B and HIV
Coordinators met one another!
Partnered and leveraged
resources!
Looked at what each program had
done
Made plans to move forward
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What Did Michigan Do?
Developed a survey that was sent
to all of Michigan’s 91 birthing
hospitals and 500nprenatal care
providers
Direct telephone follow-up with
each birthing hospital
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Example of Questions Asked
 HIV Policies
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Does your facility have written policies (WP) and
standing orders (SO) to:
1. Do HIV testing upon admission to L&D if results
are unknown or undocumented for HIV?
2. Repeat testing for (-) but high risk pregnant
women for HIV?
3. Do rapid (20 min–hrs) HIV testing?
How long does it take to get the results to the L&D
staff? ____
4. Do expedited (24-48 hrs) HIV testing? How long
does expedited testing take? _________
5. Do standard Elisa (3+ days) testing?
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Example of Questions Asked
 HBV Policies
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Does your facility have written policies (WP)
and standing orders (SO) to:
1. Test for HBsAg upon admission to L&D if
results are unknown or undocumented?
2. Repeat HBsAg testing for (-) but high risk
pregnant women?
3. Do STAT HBsAg testing?
4. Offer hepatitis B immune globulin (HBIG)
and hepatitis B vaccine to infants born to
HBsAg positive women?
5. Offer hepatitis B vaccine to all newborns?
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Survey Results-HIV

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40 (44%) has written policies and standing orders
(WP/SO) to offer HIV testing to women upon
admission to labor and delivery (L and D) with an
unknown or undocumented HIV status.
Of the 40 hospitals, 28 (70%) have WP/SO to offer
rapid testing (RT) in L and D.
Of the 40 hospitals, that have WP/SO to offer
HIV testing to women upon admission to L
and D with an unknown or undocumented
HIV status, 12 (30%) replied that is
unknown and/or do not offer RT in L and D.
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Survey Results-Hep B

Have written policies and standing orders to:
• 81 (89%) test women STAT upon admission to L
& D if no result is available for HBsAg
• 9 (10%) offer repeat testing for HBsAg negative
but high risk pregnant women
• 87 (96%) give HBIG and hepatitis B vaccine
within 12 hours to infants born to HBsAg
positive women
• 86 (95%) give hepatitis B vaccine to all
newborns
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Current Activities
Reviewing a sample of birth hospital
charts over the next five years.
All hospitals receive a report on
performance.
To date 18 hospitals have had record
reviews.
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Next Steps
Disseminate chart review data as it is
available to state working group
Determine what hospitals need
immediate technical assistance
Provide TA as much as possible based
on limited staff time and resources
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Challenges
Limited staff time and resources.
Not funded to do perinatal HIV
prevention by CDC or HRSA
Lack of state perinatal
regions/networks to assist in working
with birthing hospitals to promote
perinatal Hep B/HIV prevention.
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Over Coming Challenges
Recognize your limitations
Recognize what you can do
Leverage your resources-figure out
where you can collaborate!
Know one another and build
relationships
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Lessons Learned
Baby Steps are O.K.
Be patient with the process.
Beg, borrow, and steal-use materials from
national organizations to support your
work-CDC, ACOG, etc.
Partner with other public health programs
to spread the word-family planning, WIC,
etc.
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Resources
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National Resources-HIV
 CDC National Prevention Information Network (NPIN)
P.O. Box 6003,
Rockville, MD 20849-6003
Phone: 1-800-458-5231
TTY: 1-800-243-7012
FAX: 1-888-282-7681
In English, en Español
Monday through Friday, 9 a.m. to 8 p.m. Eastern Time
www.cdcnpin.org
[email protected]
Receive technical assistance and publication distribution
for organizations and professionals working in HIV/AIDS,
STD, and TB prevention
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National Resources-HIV
 National Perinatal HIV Consultation and Referral Service
(Perinatal Hotline)
1-888-448-8765
24 Hours/Day
www.ucsf.edu/hivcntr/Hotlines/Perinatal.html
The Perinatal Hotline provides around-the-clock advice
on indications and interpretations of standard and rapid
HIV testing in pregnancy as well as consultation on
antiretroviral use in pregnancy, labor and delivery, and
the postpartum period. The Perinatal HIV Consultation
and Referral Service also links HIV-infected pregnant
women with appropriate health care.
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National Resources-HIV
 http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf
 www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
 http://www.cdc.gov/hiv/topics/
perinatal/1test2lives/default.htm
 www.cdc.gov/hiv/projects/perinatal
 www.cdc.gov/hepatitis
 www.cdc.gov/hiv/rapid_testing
 AIDS Info
www.aidsinfo.nih.gov
1.800.448.0440
Resources on HIV/AIDS Treatment and Clinical Trials
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National Resources-Hep B
 www.cdc.gov/hepatitis
 www.hbvadvocate.org
 www.hivandhepatitis.com
 www.hblist.org
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Contact Information
Hollie Malamud-Price. M.P.H.
3056 W. Grand Blvd
Suite 3-150
Detroit, MI 48202
313.456.4362
[email protected]
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