We have the Guidelines…what else do we need to do?
Getting to ZERO
• Disseminate the current Guidelines
• Focus education on anyone caring for pregnant women and infants < 2 years of age (Obstetrics, Family Practice, Internists, Pediatricians, case managers, statewide perinatal nurses, peer navigators)
• Create Local / Community Perinatal Prevention Teams Representatives for all the stakeholders in the community
• Intensify education for Labor & Delivery teams Rapid Testing protocols and performance measures Management of HIV + deliveries - Optimize Options 10 Steps in L & D for a Healthy HIV Negative infant
Getting to ZERO
• Intensify education for pediatricians in newborn nurseries to optimize management of HIV exposed infants in the “highest risk” situations
• Facilitate communication amongst the Perinatal Prevention Team including EMR, and data transfer
• Create Statewide Performance Measures for Prevention – based on the guidelines
• Earlier notification to the state DOH of a “high risk” perinatal exposure for assistance and tracking
Getting to ZERO
• Utilize the Perinatal Prevention Program at USF Center for HIV Education and Research www.usfcenter.org/perinatal
• Work with the
Florida/Caribbean AIDS Education Training Center (F/CAETC)
www.fcaetc.org • National Perinatal HIV “Hotline”
888-448-8765
Getting to ZERO
• Distribute educational materials from Perinatal Prevention Program
www.usfcenter.org/perinatal
• Review systems practices and performance in any facility where an HIV infected infant is born – provide training and technical assistance
Possible Interventions
Preconceptual Opportunities
Interventions
Discordant couple - Woman HIV negative - Man HIV positive
Recommend and Support DisclosureReproductive Options (Ask/invite partner into the discussion)Pre-conceptual consultation Serial testing for a negative partnerTreatment as PreventionPre-Exposure ProphylaxisProblem solve effective therapy 10 Actions for a Healthy Baby
HIV + couple – one or the other or both
Possible Interventions
Missed OpportunitiesIn Pregnancy
Interventions
Unplanned pregnancy Reproductive Options (going forward)Prenatal consultation Review / support disclosure Problem solve effective therapy 10 Actions for a Healthy Baby
Non-adherence to Rx
Non-disclosure
Lost to follow-up TOPWA Use of Peer Navigators and Case ManagersPlan for Follow-up and lost to follow-up DOH Intervention – financial incentives, DOT, hospitalization, incarceration
Substance use
Mental illness
High risk behaviors during pregnancy (HIV negative mothers)
Closer Follow-up with TOPWA, case managers, etc.Serial testing throughout pregnancy, 3rd Trimester, at delivery and at 6 weeks post-partum 10 Actions for a Healthy Baby
Possible Interventions
Missed Opportunities
Interventions
Newly Diagnosed during Pregnancy
Pregnancy Options Prenatal consultation (with a pediatrician) Review / support disclosure Problem solve effective therapy Expedient Initiation of ARVsCreate a “Pregnancy Plan” 10 Actions for a Healthy Baby
Non-adherence to ARVs during Pregnancy
Identify Reasons for Non-AdherenceReview / support disclosurePrenatal consultation (with a pediatrician) Problem solve effective therapyReview “Pregnancy Plan” and “10 Actions”Closer initial follow-up for support + success
Possible Interventions
Potential Missed Opportunities
Interventions
Primary HIV Infection during Pregnancy
Pregnancy Options Prenatal consultation Review / support disclosure Problem solve effective therapy Urgent Initiation of ARVsCreate a “Pregnancy Plan” Involve Local Perinatal Coordinator Utilize a Peer Navigator10 Actions for a Healthy Baby
Lack of Prenatal Care 3rd Trimester Diagnosis HIV
Perform Confirmation Testing Complete initial HIV EvaluationImmediate initiation of ARV Rx (without confirmation or genotype results)Alert the Perinatal Prevention Team
Possible Interventions at Delivery
Missed Opportunities Interventions
Lack of Prenatal Care Unknown HIV Status at delivery
Rapid Testing Act on + Results Perform Confirmation Testing – HIV EvaluationCreate management plan for delivery and infantImmediate Initiation of ARV Rx (without confirmation) (Consider 4 drug regimen – adding raltegravir)Begin IV Zidovudine for the motherConsider “High Risk” Empiric Treatment (ARVs for infant – Functional Cure)
No 3rd Trimester Testing Previously Negative Assessed as “High Risk” Situation for Mother
Possible Interventions at Delivery
Opportunity Interventions
Evidence of Inadequate or Ineffective Rx High Viral Load + / - other risks (Low CD4, STI, Drug abuse, etc.)
Initiate Therapy to Stop Labor & Delay DeliveryCreate management plan for delivery and infantRe-initiation of ARV Rx (Consider 4 drug regimen – adding raltegravir)Begin IV Zidovudine for the motherConsider “High Risk” Empiric Treatment for Infant (Functional Cure)
Premature Labor (<37 weeks GA) Inadequate Prenatal Care Known HIV + but No Recent VLs or CD4s
Initiate Therapy to Stop Labor & Delay DeliveryCreate management plan for delivery and infantImmediate Initiation/continuation of ARV Rx (Consider adding raltegravir)Begin IV Zidovudine for the motherConsider “High Risk” Empiric Treatment for Infant (Functional Cure)
10 Action Steps for Mothers for a Healthy Baby
1. Know your HIV Status CD4 counts, Viral Loads, etc.
2. Start Prenatal Care early Take your ARVs as directed
3. Take care of yourself eating, vitamins, exercise, rest
4. Avoid exposures No alcohol or drugs, Stop smoking, Cut down on caffeine
5. Disclose your status & Create support for yourself + baby
6. Make the steps into your “Pregnancy Plan”
7. Ask for a Prenatal consultation – including no breastfeeding, no pre-mastication of baby’s foods, medications and testing for the baby
8. Plan the Delivery – medications, delivery location, option of a cesarean section, IV Zidovudine
9. Give the medications for your baby as directed
10. Follow-up care for you and your baby after the birth
10 Action Steps During Pregnancyfor a Healthy Baby
1. Review HIV status (viral loads, CD4 counts, STIs, etc.)
2. Review health of pregnancy status (previous pregnancies, deliveries, additional health concerns and healthy steps)
3. Provide Understanding and Support for Disclosure
4. Create a pregnancy plan with the mother (family)
5. Problem solve effective therapy
6. Initiate an ARV regimen per the guidelines
7. Confirm adequate response to ARVs in 2-4 weeks
8. Monitor adherence and response at least every 3 months and at least in each trimester (especially at 34-36 weeks)
9. Create a delivery plan based on all the data – review it serially
10. Implement the delivery plan and follow-up for mother and infant
10 Action Steps in Labor & Deliveryfor a Healthy Baby
1. Assess labor progression and delivery imminence
2. Confirm HIV status (1st and 3rd trimester testing) or Do Rapid Testing
3. Review [if HIV +] the ARV regimen, viral loads, CD4 counts, STIs, etc.
4. Clarify health of pregnancy (previous pregnancies, deliveries, additional health concerns in this pregnancy and healthy steps by the mother)
5. Create a plan for a safe delivery ( continue ARV regimen, arrest labor, IV zidovudine, cesarean section, other interventions)
6. Involve the pediatrician as indicated
7. Implement the safe delivery plan
8. Optimize maternal post-partum care (delivery completion, continuation of ARVs, indicated testing and vaccinations, follow-up)
9. Confirm interventions for the infant (testing, ARV regimen, Proscribe breastfeeding and pre-mastication of infant foods, follow-up)
10. Connect the mother and infant to local perinatal coordinator
Pregnancy Plan
• Set the dates for Prenatal Care• Review all your options• Ask about the perinatal coordinator and a pediatrician• Understand and document your
medications lab results / dates – CD4, Viral Loads• Go over the decision-making about a Cesarean section• Understand the important signs for delivery
Bleeding Rupture of membranesLabor pains
Changes in temperature, blood pressure, edema, etc.• Communicating your health status with the Delivery Room staff• Plan for your Baby’s needs – medications, No breastfeeding,
follow-up and testing for HIV, No pre-mastication of food• What to do after delivery for your health and your infant’s health
Functional Cure for Infants
• Recognize the “High Risk” for infection early• Discuss the risk and present a plan (before, during and
after delivery as possible)• Initiate “Empiric Treatment” for HIV Infection within
hours of delivery (2 hours – 36 hours)• Current approved medications Lamivudine,
Emtricitabine, Zidovudine, Nevirapine, Stavudine• Potential additional future ARVs
Darunavir (approved for > 3 years, + liquid)Raltegravir (approved for > 2 years, (-) liquid) Lopinavir/ritonavir (approved for > 4 weeks, + liquid)Tipranavir (approved for > 2 years, + liquid)Ritonavir (approved for > 4 weeks, + liquid)
Perinatal HIV Transmission Prevention:Getting to ZERO
1. Take the GUIDELINES to the trenches
2. Create Community Perinatal Prevention Teams
3. Facilitate Communication – EMRs and data
4. Develop Performance Measures for PreventionTesting in 1st & 3rd trimester (HIV Ag/Ab tests, or viral loads / CD4 counts)Rapid testing at delivery (as needed)Implementation of appropriate delivery plans Initiate pediatric interventions per the guidelines
Perinatal HIV Transmission Prevention:Getting to ZERO
4. Apply Performance Measures across the state
5. Empower and support women
6. Make Perinatal Prevention everyone’s priority
8. Review systems practices and performance in any facility where an HIV infected infant is born Provide training and technical
assistance
Special Thanks
Yvette Rivero, BS, MPH, Perinatal Prevention Director HIV/AIDS Surveillance and Prevention
Florida Department of Health in Broward County
Scott Mickley, HIV/AIDS Surveillance Coordinator Florida Department of Health in Escambia County
for their assistance with scheduling the chart reviews
Special Thanks
Rashida Marshall, BS, Statewide Perinatal Coordinator Florida Department of Health
Marlene LaLota, MPH, Program AdministratorHIV/AIDS Prevention Program, Florida Department of Health
for their data, organizational assistance, and the broad participation of the Florida Department of Health
Special Thanks
Sheryl Carney, BA, RN, Florida/Caribbean AETC South East Program Coordinator
Perinatal Nurse Educator, University of Miami Miller School of Medicine
Clara Leach, RN, BSN, Program ManagerPerinatal HIV Prevention Program
University of South Florida, Center for HIV Education and Research
For their zeal for this topic and heroic organizational efforts
