1. Uptake of HIV testing among pregnant women in Ontario: Results from the HIV seroprevalence study to December 2000 Robert S. Remis, Carol Major, Margaret Fearon, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Elisabeth Rea, Susan King, Marion Vermeulen and Elaine Whittingham Department of Public Health Sciences, University of Toronto Laboratories Branch, Public Health Branch, Ontario Ministry of Health and Long Term-Care Toronto Public Health Hospital for Sick Children, Toronto Canadian Association of HIV/AIDS Research Tenth Annual Scientific Conference Toronto, Ontario May 31-June 2, 2001

2. MOHLTC, Laboratories Branch, IMC – 2001 Acknowledgments Central Public Health Laboratory, Ontario Ministry of Health and Long-Term Care Central Public Health Laboratory, Ontario Ministry of Health and Long-Term Care Keyi Wu, programming Keyi Wu, programming Mark Fisher, systems consulting and custom download Mark Fisher, systems consulting and custom download Carol Swantee, program support Carol Swantee, program support Prenatal Screening Evaluation Committee Prenatal Screening Evaluation Committee Frank McGee, coordinator Frank McGee, coordinator Janis Tripp, consultant Janis Tripp, consultant Funding Funding AIDS Bureau, Ontario Ministry of Health AIDS Bureau, Ontario Ministry of Health Bureau of HIV/AIDS, STD & TB, Health Canada Bureau of HIV/AIDS, STD & TB, Health Canada

3. MOHLTC, Laboratories Branch, IMC – 2001 Background 1989-91: Ontario HIV seroprevalence study 1989-91: Ontario HIV seroprevalence study (Coates et al), 0.23 / 1,000 February 1994: ACTG 076 showed 67% decrease in mother-infant HIV transmission February 1994: ACTG 076 showed 67% decrease in mother-infant HIV transmission 1997: Modeled HIV prevalence, 0.70/1,000 and estimated uptake of prenatal HIV testing 1997: Modeled HIV prevalence, 0.70/1,000 and estimated uptake of prenatal HIV testing 1994-96, 20–25%

4. MOHLTC, Laboratories Branch, IMC – 2001 Ontario screening program Spring 1995: Advisory to physicians to consider HIV testing of pregnant womenSpring 1995: Advisory to physicians to consider HIV testing of pregnant women August 1997: Committee formed to plan programAugust 1997: Committee formed to plan program December 1998: Minister announced program to offer HIV testing to all pregnant womenDecember 1998: Minister announced program to offer HIV testing to all pregnant women January 1999: Promotional materials and requisitions sent to physiciansJanuary 1999: Promotional materials and requisitions sent to physicians

5. MOHLTC, Laboratories Branch, IMC – 2001 Study objectives Quantify and characterize HIV prevalence among women in Ontario, andQuantify and characterize HIV prevalence among women in Ontario, and Evaluate the Ontario universal HIV screening programEvaluate the Ontario universal HIV screening program

6. MOHLTC, Laboratories Branch, IMC – 2001 Data management Data extracted from Labyrinth (prenatal and HIV diagnostic) Data extracted from Labyrinth (prenatal and HIV diagnostic) Study period Jan 3, 1999 to Dec 30, 2000 Study period Jan 3, 1999 to Dec 30, 2000 Specimens from prenatal database included only if no previous specimen in the previous 6 months Specimens from prenatal database included only if no previous specimen in the previous 6 months Records for which HIV testing not prescribed on requisition matched to records in HIV diagnostic database Records for which HIV testing not prescribed on requisition matched to records in HIV diagnostic database Matching allowed for different spelling and structure of name (double-barrelled first and last names) and reversal of month/day in birth date Matching allowed for different spelling and structure of name (double-barrelled first and last names) and reversal of month/day in birth date

7. MOHLTC, Laboratories Branch, IMC – 2001 Data analysis Number of women tested at prenatal visit included:Number of women tested at prenatal visit included: Women for whom test ordered on prenatal requisition, andWomen for whom test ordered on prenatal requisition, and Women tested though diagnostic service on same day as prenatal specimenWomen tested though diagnostic service on same day as prenatal specimen Analysis in SAS of: Analysis in SAS of: Trends over time in proportion tested Trends over time in proportion tested Testing rates by health region and age group Testing rates by health region and age group HIV-positive women: number and rates by type of test, region and quarter HIV-positive women: number and rates by type of test, region and quarter

8. MOHLTC, Laboratories Branch, IMC – 2001 Number of prenatal specimens by health region, January 1999 to December 2000 Number specimens Proportion Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP 76,22361,40937,35540,03521,13323,31018,0831,33527%22%13%14%8%8%7% Total278,883100%

9. MOHLTC, Laboratories Branch, IMC – 2001 Number of prenatal specimens and number testing for HIV by quarter Prenatal specimens Prenatal visit Diagnostic service Proportion tested 1999 1999 Q133,66131%12%43% Q231,57838%10%49% Q334,32040%10%50% Q434,38340%10%50% Total 1999 133,94237%10%48% 2000 2000 Q135,87740%11%50% Q234,11540%10%50% Q337,58340%11%51% Q437,36540%12%52% Total 2000 144,94040%10%51%

10. MOHLTC, Laboratories Branch, IMC – 2001 HIV testing among women who submitted a prenatal specimen

11. MOHLTC, Laboratories Branch, IMC – 2001 HIV testing among women who submitted a prenatal specimen

12. MOHLTC, Laboratories Branch, IMC – 2001 HIV testing among women who submitted a prenatal specimen

13. MOHLTC, Laboratories Branch, IMC – 2001 Proportion of pregnant women testing for HIV by health region, last quarter 2000 Number of women HIV tested Proportion tested Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP 9,8668,1104,8606,2342,7902,9132,3951974,9174,2212,5432,6851,7271,6981,4269450%52%52%43%62%58%60%48% Total37,36519,31152%

14. MOHLTC, Laboratories Branch, IMC – 2001 Number of PHUs in each region by proportion of HIV testing, last quarter 2000 Number of PHUs by proportion of HIV testing uptake Total PHUs 20-29%30-39%40-49%50-59%60-69%70-79% Toronto 11 Central East, other 1416 Southwest 1231119 Central West 167 Ottawa 11 Eastern, other 235 Northern 13228 Total 1411108337

15. MOHLTC, Laboratories Branch, IMC – 2001 Number of HIV-positive women Prenatal screening Previously diagnosed Total 1999HIV+HIV+HIV+ Q1Q2Q3Q4233122224553 Total 1999 9817 2000 Q1Q2Q3Q435114211356127 Total 2000 23730 Both years 321547

16. MOHLTC, Laboratories Branch, IMC – 2001 HIV-positivity rates by time of diagnosis and quarter

17. MOHLTC, Laboratories Branch, IMC – 2001 HIV-positivity rates (per 1,000) by time of diagnosis and period Jan 1999 to Mar 2000 rate Apr to Dec 2000 rate Relative risk p-value HIV+ identified through: Prenatal screening 0.200.452.320.028 Previous diagnosis 0.470.400.87NS Total0.270.441.670.015

18. MOHLTC, Laboratories Branch, IMC – 2001 HIV-positivity rates (per 1,000) by health region and period for diagnoses at prenatal screening Region Jan 1999 to Mar 2000 Apr to Dec 2000 Relative risk p-value NorthernOttawa Eastern, Other Toronto Central East, Other Central West Southwest0.200.570.000.390.000.140.110.000.760.250.910.410.330.000.001.33Infinite2.30Infinite2.320.00NSNSNSNS0.029NSNS Total0.200.45

19. MOHLTC, Laboratories Branch, IMC – 2001 Interpretation Actual uptake of HIV testing may be higher due to false non-matches (e.g. anonymous HIV testing) Actual uptake of HIV testing may be higher due to false non-matches (e.g. anonymous HIV testing) Study does not indicate why uptake is less than ideal (qualitative research of pregnant women and physician survey are under way) Study does not indicate why uptake is less than ideal (qualitative research of pregnant women and physician survey are under way) Study does not indicate number of HIV-infected women undiagnosed Study does not indicate number of HIV-infected women undiagnosed Unlinked component of HIV seroprevalence study among women not HIV tested is critical Unlinked component of HIV seroprevalence study among women not HIV tested is critical This component has been delayed for almost two years by Ministry This component has been delayed for almost two years by Ministry

20. MOHLTC, Laboratories Branch, IMC – 2001 Conclusions Critical to capture data from HIV diagnostic database as well as from prenatal database Critical to capture data from HIV diagnostic database as well as from prenatal database HIV testing increased from 38% to 49% from January to May 1999, with modest increase since HIV testing increased from 38% to 49% from January to May 1999, with modest increase since Important regional differences in HIV test uptake Important regional differences in HIV test uptake Over 2 years, 47 women identified as HIV-positive, 13 previously diagnosed, 32 newly diagnosed Over 2 years, 47 women identified as HIV-positive, 13 previously diagnosed, 32 newly diagnosed Data suggests more high risk pregnant women are being offered and accepting HIV testing Data suggests more high risk pregnant women are being offered and accepting HIV testing

21. MOHLTC, Laboratories Branch, IMC – 2001 Conclusions According to model (not presented) According to model (not presented) Birth rate among diagnosed HIV-infected women is very low Birth rate among diagnosed HIV-infected women is very low ~50% of HIV-infected women undiagnosed at conception remain undiagnosed ~50% of HIV-infected women undiagnosed at conception remain undiagnosed Approximately 6–8 preventable mother-infant transmissions occur annually Approximately 6–8 preventable mother-infant transmissions occur annually