perinatal hiv testing policies, practices and hiv/syphilis perinatal screening levels in texas...
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Perinatal HIV Testing Policies, Practices and HIV/Syphilis Perinatal Screening Levels in Texas Hospitals
Presentation to the 2011 CSTE Annual Conference Pittsburg, PA
June 14, 2011
Sharon K. Melville, MD, MPH (DSHS) PresenterVirginia L. Headley, PhD (Litaker Group)
John R. Litaker, PhD (Litaker Group)Sandra A. Morris, MPH (DSHS)Ann S. Robbins, PhD. (DSHS)
2
HIV Positive Women in Texas
2009 17,633 HIV+ women living in Texas
• 10,192 (58%) women of childbearing age (15-44 years)
• 389 (4%) of women gave birth to an infant
3
Race/Ethnicity of HIV Positive Mothers and HIV Positive Mothers Delivering an Infected Infant in Texas,
2005-200957%
22%
12% 10%
39%
27%
18% 16%
0%
10%
20%
30%
40%
50%
60%
1
Pe
rce
nt (
%)
by
Ra
ce/E
thin
icity
Black Hispanic White Other
HIV+ Women Delivering anExposed Infant, 2005-2009
HIV+ Women Delivering anInfected Infant, 2005-2009
n=1918 n=51
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Prenatal Care*, Texas
95% of all women delivering an infant in Texas received any prenatal care, 2009*
87% of HIV positive women delivering an infant received any prenatal care, 2009• 38% (3/8) of HIV positive women delivering an
infected infant received no prenatal care, 2009
*Based on provisional vital statistics birth data for year 2009
5
Perinatally Exposed and Infected Children in Texas, 1999-2009
0
50
100
150
200
250
300
350
400
450
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year of Birth
No
. o
f P
eri
nata
l E
xp
osu
res
0%
1%
2%
3%
4%
5%
6%
7%
8%
Perc
en
t In
fecte
d
Exposures Infected
n=9
n=22
n=22 n=22
n=20
n=14
n=7 n=8
n=13 n=13
n=8
6
No. Exposed=3,593 No. Infected=146
% of Total Births=
Numerator: No. of HIV Exposed Births by County
Denominator: No. of HIV Exposed Births for the State
Texas Congenital Syphilis Cases and Case Rates by Year of Report,
2003-2010
0
20
40
60
80
100
120
140
Year
Cas
es
0
5
10
15
20
25
30
35
Cas
es p
er 1
00,0
00 L
ive
Bir
ths
Cases 77 65 63 84 95 124 124 104
Case Rate 20.4 17 16.3 21 23.3 30.6 30.6 25.7
2003 2004 2005 2006 2007 2008 2009* 2010*
* 2009 and 2010 rates are based on 2008 birth data.
8
Congenital Syphilis Case Rates* by County: Texas, 2010
*CS cases per 100,000 live births. 2008 live birth numbers were used for the calculation as more recent data were unavailable.
Rates 0.0 Cases/100,000
1 to 49 Cases/100,000
50 to 99 Cases/100,000
100 or More Cases/100,000
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Steps to Prevention Success
Woman receives prenatal care Tested for HIV and syphilis at first prenatal visit Tested again for HIV during 3rd trimester (if high risk
jurisdiction) and syphilis at delivery (and third trimester if high risk mother or jurisdiction)
If HIV positive, receives ARV therapy for HIV at all three recommended timings
Pregnancy Labor and Delivery Neonatally
If syphilis reactive, receive adequate treatment (penicillin) as soon as diagnosed (30 days before delivery)
10
Texas Perinatal Testing Law
Until 1/1/2010
(at time of study in 2008) Opt-out HIV, syphilis and
hep B testing for all pregnant women at first prenatal visit and on admission to labor and delivery
AS OF 1/1/2010
• Test at first prenatal visit for syphilis, HIV, and hepatitis B (as before)
• Perform the second test for HIV in the third trimester (a change)
• Do expedited testing for HIV in Labor and Delivery (results available within 6 hours) IF no third trimester results available (a change)
• Expedited HIV test of baby within 2 hours after birth if mother did not get tested (a change)
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Study Objectives
Part of a larger study to determine hospital policies and practices for perinatal hepatitis B prevention
The purpose of this sub-study was to:
• Assess the policies and practices of Texas hospitals related to prevention of mother to child transmission of HIV
• Determine the level of HIV and syphilis screening of pregnant women prenatally and at delivery*
*At time of study Texas law required HIV and syphilis testing at 1st prenatal visit and at delivery
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Methods
The Texas Department of State Health Services (DSHS) contracted with the Litaker Group to conduct the study
• Self –Administered Cross-sectional Hospital Policy and Practices (HPP) Survey of 119 selected Texas hospitals
• Medical Chart Abstraction of hospital records of 12,670 mother-baby pairs from 2008 births at the 119 Texas hospitals
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Hospital Selection for Study• Statewide selection of hospitals (non-random):
• Hospitals of interest to Perinatal Hepatitis B Coordinators
• Hospitals with > 100 births per year
• Gap filling to ensure:• Statewide geographical distribution• Rural and metropolitan representation• Inclusive of all hospital types: public, nonprofit, for
profit
• Total selected for study: 119
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Representativeness of Selected Hospitals
• 119 study hospitals:
• 53% of 225 hospitals with “L&D” services• Total birth cohort = 291,767
• (≈70% of estimated 2008 births)
Compared to all hospitals with L&D services:• Higher proportion of metropolitan hospitals • Slightly lower proportion of public hospitals
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Hospital Policy and Practices Survey (HPP)
Determined existence of hospital policies and standing orders for:
1. Review of prenatal HIV results upon admission to labor and delivery
2. Provision of HIV testing to all women on admission for labor and delivery
3. Provision of HIV testing of neonates with mother of unknown HIV status
4. Administration of antiretrovirals (ARVs) to HIV positive mothers
5. and their exposed neonates
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Additional HPP Survey Information
Hospitals were also asked about their policies on:
• Sending neonatal antiretroviral medication (Zidovudine (AZT)) home with the mother (prescription or 6 week supply)
• Separate HIV testing consent for the
mother
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Hospital Policy and Practices Survey Results
Practice Written Policy Standing Order Both
Review prenatal HIV results
85 (71.4%) 77 (64.7%) 65 (54.6%)
Provide HIV testing on admission
89 (74.8%) 115 (96.6%) 87 (73.1%)
Test neonates with mothers with unknown status for HIV
30 (25.2%) 37 (31.1%) 21 (17.6%)
Administerantiretrovirals to infected mothers
46 (38.7%) 43 (36.1%) 33 (27.7%)
Administerantiretrovirals to exposed neonates
46 (38.7%) 43 (36.1%) 34 (28.6%)
All of the above 16 (13.4%) 16 (13.4%) 9 (7.6%)
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Additional Survey Information Results
• 10 (8.4%) hospitals have a policy to provide a 6-week supply of ARV medication (AZT) for exposed neonates
• 11 (9.2%) hospitals have a policy to provide a prescription for ARV medication for exposed neonates
• 67 (56.3%) hospitals have a policy requiring separate consent for mothers for HIV testing on admission to labor and delivery*
* Separate consent not required by Texas law
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Medical Chart Abstraction (MCA)• Mother-baby paired records
• Interval sampling for all 2008 live birth events• 75 – 116 per hospital based on birth cohort size
• Maternal charts abstracted:12,670
• Neonate charts abstracted: 13,036• Inclusive of multiple birth events
• Total: 25,706 charts from 119 hospitals
• Conducted April 2009 – February 2010
HIV Screening: Prenatally and On Admission
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Both
Prenatal
AdmissionEither
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Management of Neonates Born to “HIV Positive” Mothers
Number Prenatal L & D Neonate Treated
2 Negative Equiv or +EIA/ equiv WB
No
1 Negative + EIA/WB sent no result in chart
No
2 Negative Positive No
1 Positive Positive No
1 Positive Positive AZT hospital
1 Positive Positive 6 week supply AZT
1 Positive Positive Rx 6 week supply AZT
Total: 9 6/9 (66%) no treatment
Syphilis Screening: Prenatally and On Admission
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Both
Prenatal
AdmissionEither
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Rates of HIV Testing at L&D by Presence or Absence of Policies and Standing Orders
Condition With %(n) Without %(n)
P-value
Policy* 96.3 (88) 87.2 (31) 0.005
Standing Order*
96.2 (112) 58.7 (7) <0.000
Either Policy or Order
96.3 (114) 42.3 (5) <0.000
Both Policy and Order*adjusted for site visit review
96.3 (86) 87.9 (33) 0.0106
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Results Summary
• The majority of hospitals surveyed had policies and standing orders for reviewing HIV status of pregnant women and for HIV screening on admission to L&D
• The most common policy (75%) and standing order (97%) was for HIV testing at L& D admission.
• Only about 1/3 of hospitals had policies and procedures for ARV treatment of HIV + mothers and their neonates
• Over half of hospitals required a separate consent for HIV testing of pregnant women on admission to L&D
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Results Summary
• Hospitals having policy and standing orders in place had higher levels of HIV testing on admission to L&D.
• Having a standing order had the most impact on levels of HIV testing on admission to L&D
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Results Summary
• >99% of Texas pregnant women are getting screened for HIV and syphilis either prenatally or on admission to L&D.
• Statewide L&D admission screening is higher than prenatal screening for both HIV and syphilis.
• HIV and syphilis screening levels varied geographically, particularly prenatal testing .
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Study Limitations• Non-random hospital selection
• Slight bias toward metropolitan hospitals and non-profits
• Hospital-based deliveries only, exclusive of• Babies born outside “L&D” hospitals
• Medical charts not always complete, especially in record transition periods (e.g., from paper to electronic formats)
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Conclusions
• Overall, providers are doing well at screening pregnant women for HIV and syphilis at some point but improvement needed in testing at both time periods: prenatally and at delivery.
• Lower prenatal testing means missing an opportunity to start treatment earlier in pregnancy.
• Having policies and standing orders for L&D HIV screening improves rates of HIV testing on admission
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Conclusions
• Many Texas hospitals are requiring separate consent for HIV testing at L&D which is not required by law and is a barrier to testing.
• Improvement is needed in the number of hospitals that have policies and practices around provision of ARV for mothers in L&D and to their HIV exposed neonates.
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Conclusions
• Providers/hospitals in Texas are still missing opportunities to prevent mother to child transmission for HIV:
- inadequate mechanisms in place to assure exposed neonates get appropriate ARV therapy
- not initiating ARV treatment of mother and baby based on preliminary positive tests. Providers should not wait for confirmatory tests to initiate ARV treatment
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Acknowledgements
• Hospitals, especially their L&D, Nursery and Medical Records personnel
• Local health departments and Perinatal Hep B Coordinators
• The Litaker Group Team of reviewers and support staff
• Kacey Russell, M.P.H. and Ed Weckerly, M.P.H. At DSHS for HIV/STD surveillance data and slides.
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Questions?
Contact Information
Sharon K. Melville. M.D., M.P.HManager, HIV/STD Epidemiology & Surveillance Branch
HSES, Mail Code 1873, SKM
Texas Department of State Health Services
P.O. Box 149347
Austin, Texas 78714
Phone: (512) 533-3100