1. Increasing HIV testing among pregnant women: Results from the Ontario HIV seroprevalence study Robert S. Remis, Carol Swantee, Maraki Fikre Merid, Robert W.H. Palmer, Mark Fisher, Keyi Wu, Susan King, Peggy Millson, Liviana Calzavara, Elaine Whittingham and Carol Major Department of Public Health Sciences, University of Toronto Laboratories Branch, Ontario Ministry of Health and Long-Term Care Hospital for Sick Children 15th International Conference on AIDS Bangkok, Thailand, July 11-16, 2004

2. Background 1991: HIV prevalence 0.23/1,000 in childbearing women 1991: HIV prevalence 0.23/1,000 in childbearing women 1994: ZDV found to reduce HIV transmission 1994: ZDV found to reduce HIV transmission 1997: Modeled HIV prevalence 0.70/1,000 and 20- 25% of pregnant women tested for HIV 1997: Modeled HIV prevalence 0.70/1,000 and 20- 25% of pregnant women tested for HIV

3. Ontario HIV screening program 1995: Advisory to physicians to consider HIV test for pregnant women at increased risk 1995: Advisory to physicians to consider HIV test for pregnant women at increased risk December 1998: Program to offer HIV testing to all pregnant women December 1998: Program to offer HIV testing to all pregnant women Sep 2001 - Jan 2002: Memo sent with test report to physicians when HIV test prescribed Sep 2001 - Jan 2002: Memo sent with test report to physicians when HIV test prescribed Sep 2003: Memo reinstated with refinements Sep 2003: Memo reinstated with refinements

4. Study objectives Quantify and characterize HIV prevalence among women of childbearing age in Ontario Quantify and characterize HIV prevalence among women of childbearing age in Ontario Evaluate the Ontario HIV screening program Evaluate the Ontario HIV screening program

5. Data management Data extracted from LAByrinth Data extracted from LAByrinth Prenatal testing records linked to HIV diagnostic database Prenatal testing records linked to HIV diagnostic database Matching allowed for different spelling and structure of Matching allowed for different spelling and structure of name and reversal of month-day in birthdate Tests aggregated into episode equivalent to gestation period and HIV test uptake analysed for pregnancies Tests aggregated into episode equivalent to gestation period and HIV test uptake analysed for pregnancies

6. Unlinked seroprevalence study For 2002, specimens from women not HIV tested were tested after personal identifiers removed (anonymous, unlinked study) For 2002, specimens from women not HIV tested were tested after personal identifiers removed (anonymous, unlinked study) Data on age group and health region of test retained Data on age group and health region of test retained HIV prevalence examined and compared to that among women tested HIV prevalence examined and compared to that among women tested

7. Proportion of pregnancies tested for HIV by health region, 1st quarter 2004 88%38,70843,881Total 87% 88% 90% 87% 92% 90% 89% 91% 10,186 9,191 4,625 6,129 3,220 2,970 2,216 171 11,741 10,427 5,162 7,055 3,504 3,310 2,494 188 Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP Proportion tested HIV tested Number of preg’s

8. HIV testing among pregnancies by timing of HIV test, Ontario, Jan 1999-Mar 2004 Proportion of pregnancies (%)

9. HIV testing among pregnancies for selected health regions, Jan 1999-Mar 2004

11. Number of PHU’s in each region by proportion tested for HIV, 1st quarter 2004 1 50- 59% 90- 100% 80- 89%70- 79%60- 69% 37 14 212Total 8 4 3Northern 5 2 3 Eastern other 1 1 Ottawa 725Central West 9 4 41Southwest 6 5 Central East other 1 Toronto Total PHU’s Number of PHU’s by proportion of HIV testing uptake 1 1

12. Number of HIV-positive pregnancies Prior 2 6 17 6 16 4 51 Current 10 20 32 29 48 11 150 Total 12 26 49 35 64 15 201 1999 2000 2001 2002 2003 2004 TOTAL

13. HIV-positive and number of pregnancies by test status, anonymous unlinked study 2002

16. Interpretation Based on recent analysis, actual uptake of HIV testing was slightly greater than our results suggest due to non-matches (for anonymous and coded HIV testing) Based on recent analysis, actual uptake of HIV testing was slightly greater than our results suggest due to non-matches (for anonymous and coded HIV testing) Estimated difference is 2% Estimated difference is 2% Study does not indicate why HIV test was not carried out Study does not indicate why HIV test was not carried out

17. Conclusions Critical to capture data from HIV diagnostic database in addition to prenatal database Critical to capture data from HIV diagnostic database in addition to prenatal database HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September 2001 HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September 2001 Impact of memo: from 60% to 75% Impact of memo: from 60% to 75% Uptake in latest quarter 90%, though slightly less (85%) for current pregnancy only Uptake in latest quarter 90%, though slightly less (85%) for current pregnancy only Less regional variation in HIV test uptake Less regional variation in HIV test uptake In five years, 201 women identified as HIV-positive, 51 previously diagnosed, 150 newly diagnosed In five years, 201 women identified as HIV-positive, 51 previously diagnosed, 150 newly diagnosed

18. Conclusions (continued) Based on results of 2002 unlinked seroprevalence study Based on results of 2002 unlinked seroprevalence study HIV prevalence higher (almost double) among women not tested HIV prevalence higher (almost double) among women not tested In 2002, though ~ 82% of pregnant women tested, only ~ 63% of HIV-infected pregnant women tested In 2002, though ~ 82% of pregnant women tested, only ~ 63% of HIV-infected pregnant women tested According to the preliminary results from a model (data not shown), about 6-8 mother-infant HIV transmissions occurred in 2003 According to the preliminary results from a model (data not shown), about 6-8 mother-infant HIV transmissions occurred in 2003

19. Acknowledgments Prenatal HIV Screening Evaluation Committee Prenatal HIV Screening Evaluation Committee Frank McGee, coordinator AIDS Bureau Frank McGee, coordinator AIDS Bureau Janis Tripp, consultant AIDS Bureau Janis Tripp, consultant AIDS Bureau Funding Funding AIDS Bureau, Ontario Ministry of Health and Long-Term Care AIDS Bureau, Ontario Ministry of Health and Long-Term Care Centre for Disease Prevention and Control, Health Protection, Health Canada Centre for Disease Prevention and Control, Health Protection, Health Canada