1. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION POLICY CONSIDERATIONS ROBERT S. REMIS MD DEPARTMENT OF PUBLIC HEALTH SCIENCES, UNIVERSITY OF TORONTO Presentation to Mother-infant Working Group. Federal Provincial Territorial Committee Victoria, British Columbia, February 6, 2002

2. Chronology Feb 1994ACTG 076 Mother-infant transmission decreased from 25% to 8% with prophylactic zidovudine 1994-98Slow uptake of HIV testing among pregnant women in Canada 2001Increased HIV testing in prenatal period but substantial proportion women still not tested in many regions TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION BACKGROUND

3. Considerations §HIV testing necessary first step to prevention §Low HIV prevalence among women in Canada: About 0.3-1.0 per 1,000 (1 in 1,000 - 3,000) TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION BACKGROUND

4. Considerations §Positive testBenefits Therapeutic abortion Prophylaxis to reduce transmission to infant Reproductive decisions informed Access to ART Prevent secondary transmission to sex partners RisksPsychological (anxiety, depression) Relationships (rejection, abandonment, abuse) Discrimination (immigration, job, housing) TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION BACKGROUND

5. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OPT OUT Definition: HIV testing is carried out on all specimens unless the patient specifically refuses and this is recorded on the requisition by the treating physician. Physician provides counselling and, if women does not provide consent, HIV testing is not done. Advantages:High level of HIV testing achieved (95+%) Almost all HIV preventable HIV transmissions are prevented Testing is seen as routine and, therefore, less threatening Other benefits of HIV diagnosis (ART, secondary prevention) Disadvantages:Probability is greater that women will be tested without knowledge and consent

6. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OPT IN Definition: HIV testing is carried out only if specifically prescribed by the the treating physician. Testing is only carried out after counselling is provided and consent is obtained. Advantages:Greater assurance that women will be tested only with knowledge and consent. Disadvantages:Lower level of HIV testing (60-80%) Greater number of preventable HIV transmissions will occur Reduced access to other benefits of HIV diagnosis (ART, 2 o prevention)

7. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION SCENARIO ANALYSIS Province X Deliveries per year100,000 HIV prevalence in women CBA (per 1,000)1.0 Assumptions: Proportion of HIV-infected women know their serostatus50% Proportion of women screened before conception 20% Proportion of diagnosed accept ART and take adequately95% HIV transmission rate no therapy25% HIV transmission rate with combination ART2%

8. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION SCENARIO ANALYSIS Therefore Number of HIV-infected women100 Number of undiagnosed HIV-infected women 50 Opt inOpt out Proportion screened 70% 97% Number screened56,00077,600 Proportion with informed consent 90% 80% Number without informed consent5,60015,500

9. TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION SCENARIO ANALYSIS Opt inOpt out Number HIV infections among newly diagnosed0.91.2 Number HIV infections among undiagnosed3.80.4 Total4.61.6

10. §Most women want, above all, a baby who is healthy §Many if not most women assume that HIV testing is being done routinely as part of prenatal care §Question is not whether women will be diagnosed but when women will be diagnosed (much better earlier than later) §Almost all (>90%) of HIV transmissions from mothers to infants are potentially preventable TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OBSERVATIONS

11. §HIV transmission from mother to child is a tragedy for infant, mother, family and society §Undiagnosed HIV infection in pregnant women is relatively rare but slightly more frequent than for PKU and congenital hypothyroidism, which are well accepted §No system is perfect; opting out prevents more HIV transmissions at the cost of more women being tested without their full consent TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OBSERVATIONS

12. §To my knowledge, no HIV-infected woman diagnosed in pregnancy without her full consent has taken legal action against her caregiver §At least one HIV-infected woman not offered testing in pregnancy has initiated legal proceedings against her physician TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OBSERVATIONS

13. §The current situation in Canada is unsatisfactory §In Ontario, 42 HIV-infected infants born since July 1994 have been identified to date. An estimated 10 HIV- infected infants are born every year §Probably ~20 HIV-infected infants in Canada. Almost all are potentially preventable TESTING FOR HIV TO PREVENT MOTHER-INFANT TRANSMISSION OBSERVATIONS