1. 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) Presenter Virginia L. Headley, PhD (Litaker Group) John R. Litaker, PhD (Litaker Group) Sandra A. Morris, MPH (DSHS) Ann S. Robbins, PhD. (DSHS)

2. 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. 3 Race/Ethnicity of HIV Positive Mothers and HIV Positive Mothers Delivering an Infected Infant in Texas, 2005-2009 HIV+ Women Delivering an Exposed Infant, 2005-2009 HIV+ Women Delivering an Infected Infant, 2005-2009 n=1918n=51

4. 4 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. 5 Perinatally Exposed and Infected Children in Texas, 1999-2009 n=9 n=22 n=20 n=14 n=7n=8 n=13 n=8

6. 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

7. Texas Congenital Syphilis Cases and Case Rates by Year of Report, 2003-2010 * 2009 and 2010 rates are based on 2008 birth data.

8. 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.

9. 9 Steps to Prevention Success  Woman receives prenatal care  Tested for HIV and syphilis at first prenatal visit  Tested again for HIV during 3 rd 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. 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)

11. 11 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 1 st prenatal visit and at delivery

12. 12 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

13. 13 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

14. 14 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

15. 15 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

16. 16 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

17. 17 Hospital Policy and Practices Survey Results PracticeWritten PolicyStanding OrderBoth 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%) Administer antiretrovirals to infected mothers 46 (38.7%)43 (36.1%)33 (27.7%) Administer antiretrovirals to exposed neonates 46 (38.7%)43 (36.1%)34 (28.6%) All of the above16 (13.4%) 9 (7.6%)

18. 18 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

19. 19 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

20. HIV Screening: Prenatally and On Admission

21. 21 Management of Neonates Born to “HIV Positive” Mothers NumberPrenatalL & DNeonate Treated 2NegativeEquiv or +EIA/ equiv WB No 1Negative+ EIA/WB sent no result in chart No 2NegativePositiveNo 1Positive No 1Positive AZT hospital 1Positive 6 week supply AZT 1Positive Rx 6 week supply AZT Total: 96/9 (66%) no treatment

22. Syphilis Screening: Prenatally and On Admission

23. 23 Rates of HIV Testing at L&D by Presence or Absence of Policies and Standing Orders ConditionWith %(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

24. 24 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

25. 25 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

26. 26 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.

27. 27 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)

28. 28 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

29. 29 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.

30. 30 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

31. 31 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.

32. 32 Questions? Contact Information Sharon K. Melville. M.D., M.P.H Manager, 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 Sharon.Melville@dshs.state.tx.us