Transcript HIV Testing & Reproductive Health Mary Caffery RN MSN UCSD Mother Child Adolescent HIV Program 858-534-9202 [email protected] Treatment of TB, STDs, HIV, Hepatitis C, Family.

HIV Testing & Reproductive Health
Mary Caffery RN MSN
UCSD Mother Child Adolescent HIV Program
858-534-9202 [email protected]
Treatment of TB, STDs, HIV, Hepatitis C,
Family Planning and Substance Abuse:
Focus on TESTING
June 21, 2014 El Centro California
Financial Disclosure
I do not have any financial
arrangements or affiliations with
commercial sponsors which have
direct interest in the subject matter.
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Objectives
At the end of this session, participants will be
able to:
• Discuss current guidelines and
recommendations for HIV testing of pregnant
women and women of reproductive age.
• Review opportunities for routine HIV
screening of pregnant women, including at
labor and delivery
• Reflect on local HIV screening experiences
with pregnant women
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4
Have you ever had an HIV test?
86%
14%
0%
1. Yes, I have been tested for HIV
2. No, I have NEVER had an HIV test
3. I’m not sure
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Why should we integrate HIV
in reproductive health care settings?
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The AIDS epidemic is integrally linked to sexual
and reproductive health
• Most persons with HIV in the U.S./Mexico
acquired HIV through sexual exposure during
their reproductive years, and most continue
sexual activity after their diagnosis
• The majority of HIV infections are sexually
transmitted or associated with pregnancy,
childbirth and breastfeeding.
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Percentages of HIV Cases Diagnosed Among Female
Adults and Adolescents, by Transmission Category 46
States and 5 US-Dependent Areas 2010
<1%
High-risk
heterosexual
contact*
14%
Injection
drug use
86%
Other/not
identified†
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“The condom broke”
Offer
• Testing patient and partner
• PREP
• Plan B/ Emergency contraception
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Health Benefits of Stronger Linkages:
HIV & Reproductive Health Settings
• Public health benefits
• Economic efficiency
• Greater support for dual protection against
unintended pregnancy and sexually
transmitted infections, including HIV, for those
in need, especially young people
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Revised Recommendations for HIV Testing
of Adults, Adolescents, and Pregnant
Women in Health-Care Settings
September 22, 2006 / 55(RR14);1-17
• These revised CDC recommendations advocate
routine voluntary HIV screening as a normal
part of medical practice, similar to screening
for other treatable conditions
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Is HIV testing routinely offered to all sexually
active adults in your community?
21%
21%
45%
12%
1.
2.
3.
4.
Yes
Somewhat
No
Not sure
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Screening Guidelines are Clear
• In all health-care settings, screening for HIV infection
should be performed routinely for all patients, 13-64
• All patients initiating treatment for TB should be
screened routinely for HIV infection
• All patients seeking treatment for STDs should be
screened for HIV during each visit, regardless of whether
the patient is known or suspected to have specific
behavior risks
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Effective Screening Guidelines
• Voluntary
• Informed
• Consent in general consent for care
• Information/materials should be made
available
• If a patient declines, document in the record
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Routine testing results in more testing!
• Routine prenatal HIV testing with streamlined
counseling and consent procedures has
substantially increased the number of
pregnant women testing
• Opt-Out prenatal HIV testing led to more care
and fewer infected children
15
.
CDC.gov
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1 Test 2 Lives
CDC /ACOG Recommendations for
HIV Screening for Pregnant Women
• All pregnant women should be
tested for HIV infection
• All health care providers
should recommend HIV testing
to all of their pregnant
patients, as early as possible
• If a patient refuses an HIV test,
it should be re-offered at
regular intervals throughout
the pregnancy
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Screening => Protection
●
Without ARVs during pregnancy, risk of
transmission from mother to infant is 1 in 4
●
The risk of perinatal transmission <2%
●
Increased screening
●
Highly effective antiretroviral
●
Elective Cesarean section as appropriate
●
Formula feeding
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Estimated Numbers of Perinatally Acquired
AIDS Cases by Year of Diagnosis, 1985–2010 —
United States and Dependent Areas
1,000
No. of cases
800
600
400
200
0
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
Year of diagnosis
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CDC, 2013
Should pregnant women get a second
HIV test ?
90%
5%
5%
1. Yes
2. No
3. Only if women have high risk
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Timing of a Second Prenatal HIV Test
• A second HIV test during the third trimester, <36 weeks is costeffective even in areas of low prevalence and may be considered
for all pregnant women
• Women who are known to be at high risk (e.g., injection-drug
users and their sex partners, women who exchange sex for
money or drugs, women who are partners of HIV-infected
persons, and women who have had a new or more than one sex
partner during this pregnancy
• Women who have symptoms consistent with acute HIV infection.
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Addressing Reasons for Declining Testing
• Lack of perceived risk; fear of the disease; concerns:
partner violence or potential stigma or discrimination
• Women with previous - test should be informed of the
importance of retesting during each pregnancy
• Logistical reasons for not testing should be resolved
• Some who initially decline accept later date, if their
concerns are discussed
• Other women will continue to decline testing, their
decisions should be respected and documented in the
medical record
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Rapid Testing in Labor
Reactive
Control
Positive
Positive Negative
Read results in 20-40 minutes
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Who are the pregnant women who will
need rapid HIV testing on L&D?
0%
0%
0%
3%
0%
97%
1.
2.
3.
4.
5.
Women with no or limited prenatal care
Women who were not offered testing
Women whose results are unavailable
Women who declined testing previously
Women who report new risk behavior,
partner
6. All of the above
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Rapid Testing During Labor
• Any woman with undocumented HIV status at the
time of labor should be screened with a rapid HIV
test unless she declines (opt-out screening)
• Reasons for declining a rapid test should be explored
• Immediate initiation of appropriate antiretroviral
prophylaxis should be recommended to women on
the basis of a reactive rapid test result without
waiting for the result of a confirmatory test
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Timing of Perinatal HIV Transmission:
Non-Breastfeeding Women
●
Intrauterine (before 36 weeks) ~20% of cases
●
●
Virologic detection of HIV in newborn at 1–2 days of life
Peripartum ~80% of cases
Onset of placental separation
● Mother-to-fetus microtransfusions
● Labor and rupture of membranes
●
●
Most transmission occurs close to or during
labor and delivery (L&D)
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Postpartum Testing
• If a woman's HIV status is unknown at the time of
delivery, she should be screened immediately
postpartum with a rapid HIV test unless she declines
• When the mother's status is unknown postpartum,
rapid testing of the newborn as soon as possible after
birth is recommended so antiretroviral prophylaxis can
be offered to HIV-exposed infants. Women should be
informed that identifying HIV antibodies in the
newborn indicates that the mother is infected.
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Newborn testing / treatment
• For infants whose HIV exposure status is unknown
and who are in foster care, the person legally
authorized to provide consent should be informed
that rapid testing is recommended for infants
whose biologic mothers have not been tested
• The benefits of antiretroviral prophylaxis are best
realized when it is initiated <12 hours after birth
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Is Perinatal HIV Eliminated in your
Community?
6%
58%
36%
1. Yes
2. No
3. Not sure
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Why are some women not tested?
Provider
Patient
• Women’s reasons for not
being tested
– Do not think they are at
risk
– Have been tested
“recently”
– Test not offered or
recommended
•
•
•
•
Language barriers
Late entry or no prenatal care
Patient perceived as not at risk
Provider does not strongly
recommend testing to all
women
• Negative consequences
of testing rarely
mentioned
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Experts Agree on Routine Testing for Women:
The CDC and the ACOG recommend that females aged 13–64 years
be tested at least once in their lifetime and annually thereafter
based on factors related to risk
Ob–gyns should annually review patients’ risk factors for HIV and
assess the need for retesting. Repeat HIV testing should be
offered at least annually to women who are injection drug users
are sex partners of injection-drug users exchange sex for money or
drugs are sex partners of HIV-infected persons have had sex with
men who have sex with men since the most recent HIV test have
had more than one sex partner since their most recent HIV test
The opportunity for repeat testing should be made available to all
women even in the absence of identified risk factors
ACOG Number 596, May 2014
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Script for Providers
“I
test all my patients who are
between 19 and 64 years old for HIV as
a routine part of their care
More than one million people in the
U.S. have HIV and about one in five of
these people don’t know it
Because they don’t know, they can’t
get medicine that may help them live
longer”
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Script Continued
“This brochure (HIV and Women) tells
you about HIV and why you should be
tested. When you have finished
reading this information, I would be
glad to answer any questions that you
have. You will be tested for HIV today
unless you tell me not to”
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Advances in HIV Testing
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Is there anything new in HIV testing
going on in your community?
35
Will acute HIV infection be picked up
on the home HIV test kit?
59%
32%
8%
1. Yes
2. No
3. Not Sure
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Old & New Tests
in New Combinations
With More on the Way
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Recommended Testing Algorithm
DRAFT Recommendations: Diagnostic Laboratory Testing for HIV Infection in the United States 2012, CDC.gov
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How do these tests differ from
earlier HIV tests?
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How do these differ from earlier tests?
Tests for both virologic (p24 antigen) and serologic (antibody)
markers of HIV infection
Incorporates NAT to resolve discordant results, reduce
indeterminate test results, and identify acute HIV infection
All antibody-positive specimens tested for HIV-2; previously, only
those with negative or indeterminate HIV-1 Western blot received
specific HIV-2 testing
Emphasizes sensitivity during initial testing. Rare false-positive
antibody test results might occur; will be resolved during
subsequent laboratory testing recommended as part of initial clinical
evaluation
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Testing’s Role in Preventing HIV Infection
Nearly 1.2 million people in the United States are HIV-positive.
One in five of those don’t know they’re infected, a major
contributing factor to the 50,000 new HIV infections each year
Testing is the first step to engaging HIV-positive patients in care,
stopping individual disease progression, and stemming the spread
of HIV
Providers should test all patients between 13 and 64 years old,
regardless of risk profile, at least once in their lifetime, and
preferably on an annual basis as part of routine health screening
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There is an urgent need to increase the
proportion of persons who are aware of their
HIV-infection status
Expanded, routine, voluntary, opt-out
screening in reproductive health care settings
is needed
Such screening is cost-effective and feasible
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Getting the Word Out
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Pasa la Voz (Spread the Word): Using Women's
Social Networks for HIV Education and Testing
Rebeca L. Ramos MA, MPH, et. al
Public Health Rep. 2010 Jul-Aug; 125(4): 528–533
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Test Everyday!
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Perinatal HIV/AIDS
Rapid perinatal HIV consultation from
practicing providers
HIV testing in pregnancy
Treating HIV-infected pregnant women
Preventing transmission during labor and
delivery and the post-partum period
HIV-exposed infant care
Call for a Phone Consultation
(888) 448-8765
24 hours, Seven days a week
http://nccc.ucsf.edu/clinician-consultation/perinatal-hiv-aids/
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Call for a Phone Consultation
(888) 448-8765
24 hours, Seven days a week
Advice from national experts in perinatal HIV care
rovide consultation on all levels of perinatal HIV management, including on
complex and unique treatment dilemmas, to provide you the best possible
information on up-to-date, high-quality care
Consultation on complex perinatal HIV treatment issues
Addressing adherence issues
Managing HIV-positive pregnancies with late presentation to care
Safer conception options for HIV-affected couples
Referral to perinatal providers and reproductive health services
Connecting HIV-infected women and exposed infants to HIV-experienced clinicians
Connecting HIV-affected couples considering conception with supportive providers
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Resources for Clinicians
• Offering information on AIDS treatment,
prevention, and research
• Clinical guidelines for ARV treatment
– Perinatal/Mother-to-Child Transmission
– Pediatrics
– Adults and Adolescents
• http://www.aidsinfo.nih.gov
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References
A Guide to the Clinical Care of Women with HIV, 2013 Edited by Jean R Anderson, M.D.
Distributed by HRSA, available online at www.ask.hrsa.gov
Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in HealthCare Settings, MMWR September 22, 2006 / 55(RR14); 1-17.
Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1-Transmission in the
United States, 2014. Updated yearly.
http://aidsinfo.nih.gov/guidelines/perinatal
Rapid Human Immunodeficiency Virus Testing on Labor and Delivery
Lisa Rahangdale, MD, MPH, and Deborah Cohan, MD, MPH
OBSTETRICS & GYNECOLOGY VOL. 112, NO. 1, JULY 2008, 159-163
Women’s Opinions about Routine HIV Testing During Pregnancy:
Implications for the Opt-Out Approach Linda S. Podhurst, Ph.D.,
Deborah S. Storm, Ph.D., and Sarah Dolgonos, M.P.H.
AIDS PATIENT CARE and STDs Volume 23, Number 5, 2009
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Resources
 American College of Obstetricians and Gynecologists.(ACOG)
Committee Opinions www.acog.org
 WomenChildrenHIV.org A comprehensive, Internet-based library
of materials on mother and child HIV infection
• www.womenandhiv.org
 www.cdc.gov/hiv
 Pacific AIDS Education Center: Resources & References for HIV
Rapid Testing in Labor & Delivery
http://www.sfaetc.ucsf.edu/R TLD/RTLDManual/index.htm
 Treatment Guidelines: www.aidsinfo.nih.gov
 CDC Perinatal HIV:
http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets
 Perinatal Hotline Service 888-448-8765
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