1. Uptake of HIV testing among pregnant women in Ontario: Results from the HIV seroprevalence study to June 2002 Robert S. Remis, Carol Swantee, Carol Major, Margaret Fearon, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Elizabeth Rea, Susan King, Marion Vermeulen, Elaine Whittingham and Robert Palmer Department of Public Health Sciences, University of Toronto; Laboratories Branch and Public Health Branch, Ontario Ministry of Health and Long Term-Care; Toronto Public Health; Hospital for Sick Children Ontario HIV Treatment Network, 4th Annual Research Day, Toronto, Ontario, November 28, 2002

2. 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 Prenatal Screening Evaluation Committee Prenatal Screening Evaluation Committee Frank McGee, co-ordinator Frank McGee, co-ordinator Janis Tripp, consultant Janis Tripp, consultant Funding Funding AIDS Bureau, Ontario Ministry of Health and Long-Term Care AIDS Bureau, Ontario Ministry of Health and Long-Term Care Bureau of HIV/AIDS, STD and TB, Health Canada Bureau of HIV/AIDS, STD and TB, Health Canada

3. 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 ZDV reduced February 1994: ACTG 076 showed ZDV reduced mother-infant HIV transmission by 67% 1997: Modelled HIV prevalence, 0.70/1,000 and estimated uptake of prenatal HIV testing 1994-96, 20–25% 1997: Modelled HIV prevalence, 0.70/1,000 and estimated uptake of prenatal HIV testing 1994-96, 20–25%

4. Ontario HIV screening program Spring 1995: Advisory to physicians to consider HIV testing of pregnant women at increased HIV risk Spring 1995: Advisory to physicians to consider HIV testing of pregnant women at increased HIV risk August 1997: Committee formed to plan program August 1997: Committee formed to plan program December 1998: Minister announced program to offer HIV testing to all pregnant women December 1998: Minister announced program to offer HIV testing to all pregnant women January 1999: Promotional materials and requisitions sent to physicians January 1999: Promotional materials and requisitions sent to physicians September 2001: Memo included with prenatal test report to physicians who had not prescribed an HIV test September 2001: Memo included with prenatal test report to physicians who had not prescribed an HIV test

5. 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 universal HIV screening program Evaluate the Ontario universal HIV screening program

6. Data management Data extracted from LAByrinth (prenatal and HIV diagnostic databases) Data extracted from LAByrinth (prenatal and HIV diagnostic databases) Study period: January 3, 1999 to June 30, 2002 Study period: January 3, 1999 to June 30, 2002 Records from HIV prenatal database matched to records in Records from HIV prenatal database matched to records in HIV diagnostic database Matching allowed for different spelling and structure of Matching allowed for different spelling and structure of name (double-barrelled first and last names) and reversal of month/day in birth date Separate prenatal tests aggregated into episode equivalent to the gestation period; HIV uptake analysed for each pregnancy Separate prenatal tests aggregated into episode equivalent to the gestation period; HIV uptake analysed for each pregnancy

7. Data analysis Number of women tested at prenatal visit included: Number of women tested at prenatal visit included: Women for whom HIV test ordered on prenatal requisition, or tested though HIV diagnostic service Women for whom HIV test ordered on prenatal requisition, or tested though HIV diagnostic service Tests categorized as current or previous to pregnancy Tests categorized as current or previous to pregnancy 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. Number of pregnancies by health region January 1999 to June 2002 Number pregnancies Proportion Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP 130,604 108,237 64,171 76,455 37,696 40,215 31,649 2,045 27% 22% 13% 16% 8% 6% Total 491,072100%

9. HIV testing among pregnancies by timing of HIV test, Ontario Proportion of pregnancies (%)

10. HIV testing among pregnancies for selected health regions 0 10 20 30 40 50 60 70 80 90 100 Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2 Quarter (1999-2002) Proportion of pregnancies (%) Metro Toronto Central East, other Southwest Central West

11. HIV testing among pregnancies for selected health regions

12. Proportion of pregnancoes tested for HIV by health region, Quarter 2, 2002 76%29,29238,352Total 76% 78% 72% 81% 82% 79% 70% 8,128 6,553 3,529 4,350 2,531 2,297 1,802 102 10,762 8,611 4,536 6,081 3,108 2,816 2,293 145 Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP Proportion tested HIV tested Number of pregs

13. Number of PHUs in each region by proportion tested for HIV, Quarter 2, 2002 1 50-59% 90-100% 80-89%70-79%60-69% 37 1 111951Total 832Northern 55Eastern, other 1Ottawa 761Central West 9 1 1421Southwest 6 15 Central East, other 1Toronto Total PHUs Number of PHUs by proportion of HIV testing uptake 1 3

14. Number of HIV-positive pregnancies Previous HIV+ 4 7 19 5 35 Current HIV+ 11 21 31 15 78 Total HIV+ 15 28 50 20 113 1999 2000 2001 2002 TOTAL

15. HIV-positive pregnancies by time of diagnosis and quarter 1 3 5 7 9 11 13 15 Q1 1999 Q3 1999 Q1 2000 Q3 2000 Q1 2001 Q3 2001 Q1 2002 By Quarter Number of pregnancies Current Previous

16. Interpretation Actual uptake of HIV testing is somewhat higher due to false non-matches (especially in anonymous and coded HIV testing) Actual uptake of HIV testing is somewhat higher due to false non-matches (especially in anonymous and coded HIV testing) Study does not indicate why HIV test uptake is less than ideal (qualitative research of pregnant women and physician survey have been done) Study does not indicate why HIV test uptake is less than ideal (qualitative research of pregnant women and physician survey have been done) 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 (finally!) under way Unlinked component of HIV seroprevalence study among women not HIV tested is (finally!) under way

17. Conclusions 1 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 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 76%! Impact of memo: from 60 to 76%! Important regional differences in HIV test uptake Important regional differences in HIV test uptake Over 3.5 years, 113 women identified as HIV-positive, 35 previously diagnosed, 78 newly diagnosed Over 3.5 years, 113 women identified as HIV-positive, 35 previously diagnosed, 78 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

18. Conclusions 2 According to model (not presented) According to model (not presented) Birth rate among diagnosed HIV-infected women is low Birth rate among diagnosed HIV-infected women is low ~40% of HIV-infected women undiagnosed at conception remain undiagnosed ~40% of HIV-infected women undiagnosed at conception remain undiagnosed An estimated 8-10 preventable mother-infant HIV transmissions occurred in 2001 An estimated 8-10 preventable mother-infant HIV transmissions occurred in 2001