1. HIV Testing & Reproductive Health Treatment of TB, STDs, HIV, Hepatitis C, Family Planning and Substance Abuse: Focus on TESTING June 21, 2014 El Centro California Mary Caffery RN MSN UCSD Mother Child Adolescent HIV Program 858-534-9202 mcaffery@ucsd.edu

2. Financial Disclosure I do not have any financial arrangements or affiliations with commercial sponsors which have direct interest in the subject matter. 2

3. Objectives At the end of this session, participants will be able to: Discuss current guidelines and recommendations for HIV testing of pregnant women and women of reproductive age. Review opportunities for routine HIV screening of pregnant women, including at labor and delivery Reflect on local HIV screening experiences with pregnant women 3

4. 4

5. Have you ever had an HIV test? 5 1.Yes, I have been tested for HIV 2.No, I have NEVER had an HIV test 3.I’m not sure

6. Why should we integrate HIV in reproductive health care settings? 6

7. The AIDS epidemic is integrally linked to sexual and reproductive health Most persons with HIV in the U.S./Mexico acquired HIV through sexual exposure during their reproductive years, and most continue sexual activity after their diagnosis The majority of HIV infections are sexually transmitted or associated with pregnancy, childbirth and breastfeeding. 7

8. Percentages of HIV Cases Diagnosed Among Female Adults and Adolescents, by Transmission Category 46 States and 5 US-Dependent Areas 2010 8

9. “The condom broke” Offer Testing patient and partner PREP Plan B/ Emergency contraception 9

10. Health Benefits of Stronger Linkages: HIV & Reproductive Health Settings Public health benefits Economic efficiency Greater support for dual protection against unintended pregnancy and sexually transmitted infections, including HIV, for those in need, especially young people 10

11. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings September 22, 2006 / 55(RR14);1-17 These revised CDC recommendations advocate routine voluntary HIV screening as a normal part of medical practice, similar to screening for other treatable conditions 11

12. Is HIV testing routinely offered to all sexually active adults in your community? 12 1.Yes 2.Somewhat 3.No 4.Not sure

13. Screening Guidelines are Clear In all health-care settings, screening for HIV infection should be performed routinely for all patients, 13-64 All patients initiating treatment for TB should be screened routinely for HIV infection All patients seeking treatment for STDs should be screened for HIV during each visit, regardless of whether the patient is known or suspected to have specific behavior risks 13

14. Effective Screening Guidelines Voluntary Informed Consent in general consent for care Information/materials should be made available If a patient declines, document in the record 14

15. Routine testing results in more testing! Routine prenatal HIV testing with streamlined counseling and consent procedures has substantially increased the number of pregnant women testing Opt-Out prenatal HIV testing led to more care and fewer infected children 15

16. . CDC.gov 16

17. 1 Test 2 Lives CDC /ACOG Recommendations for HIV Screening for Pregnant Women All pregnant women should be tested for HIV infection All health care providers should recommend HIV testing to all of their pregnant patients, as early as possible If a patient refuses an HIV test, it should be re-offered at regular intervals throughout the pregnancy 17

18. Screening => Protection ● Without ARVs during pregnancy, risk of transmission from mother to infant is 1 in 4 ● The risk of perinatal transmission <2% ● Increased screening ● Highly effective antiretroviral ● Elective Cesarean section as appropriate ● Formula feeding 18

19. Estimated Numbers of Perinatally Acquired AIDS Cases by Year of Diagnosis, 1985–2010 — United States and Dependent Areas CDC, 2013 19

20. Should pregnant women get a second HIV test ? 20 1. Yes 2. No 3. Only if women have high risk

21. Timing of a Second Prenatal HIV Test A second HIV test during the third trimester, <36 weeks is cost- effective even in areas of low prevalence and may be considered for all pregnant women Women who are known to be at high risk (e.g., injection-drug users and their sex partners, women who exchange sex for money or drugs, women who are partners of HIV-infected persons, and women who have had a new or more than one sex partner during this pregnancy Women who have symptoms consistent with acute HIV infection. 21

22. Addressing Reasons for Declining Testing Lack of perceived risk; fear of the disease; concerns: partner violence or potential stigma or discrimination Women with previous - test should be informed of the importance of retesting during each pregnancy Logistical reasons for not testing should be resolved Some who initially decline accept later date, if their concerns are discussed Other women will continue to decline testing, their decisions should be respected and documented in the medical record 22

23. PositiveNegative Reactive Control Positive Read results in 20-40 minutes Rapid Testing in Labor 23

24. Who are the pregnant women who will need rapid HIV testing on L&D? 24 1.Women with no or limited prenatal care 2.Women who were not offered testing 3.Women whose results are unavailable 4.Women who declined testing previously 5.Women who report new risk behavior, partner 6.All of the above

25. Rapid Testing During Labor Any woman with undocumented HIV status at the time of labor should be screened with a rapid HIV test unless she declines (opt-out screening) Reasons for declining a rapid test should be explored Immediate initiation of appropriate antiretroviral prophylaxis should be recommended to women on the basis of a reactive rapid test result without waiting for the result of a confirmatory test 25

26. Timing of Perinatal HIV Transmission: Non-Breastfeeding Women ● Intrauterine (before 36 weeks) ~20% of cases ● Virologic detection of HIV in newborn at 1–2 days of life ● Peripartum ~80% of cases ● Onset of placental separation ● Mother-to-fetus microtransfusions ● Labor and rupture of membranes ● Most transmission occurs close to or during labor and delivery (L&D) 26

27. Postpartum Testing If a woman's HIV status is unknown at the time of delivery, she should be screened immediately postpartum with a rapid HIV test unless she declines When the mother's status is unknown postpartum, rapid testing of the newborn as soon as possible after birth is recommended so antiretroviral prophylaxis can be offered to HIV-exposed infants. Women should be informed that identifying HIV antibodies in the newborn indicates that the mother is infected. 27

28. Newborn testing / treatment For infants whose HIV exposure status is unknown and who are in foster care, the person legally authorized to provide consent should be informed that rapid testing is recommended for infants whose biologic mothers have not been tested The benefits of antiretroviral prophylaxis are best realized when it is initiated <12 hours after birth 28

29. Is Perinatal HIV Eliminated in your Community? 29 1. Yes 2. No 3. Not sure

30. Why are some women not tested? Patient Women’s reasons for not being tested – Do not think they are at risk – Have been tested “recently” – Test not offered or recommended Negative consequences of testing rarely mentioned Provider Language barriers Late entry or no prenatal care Patient perceived as not at risk Provider does not strongly recommend testing to all women 30

31. Experts Agree on Routine Testing for Women: The CDC and the ACOG recommend that females aged 13–64 years be tested at least once in their lifetime and annually thereafter based on factors related to risk Ob–gyns should annually review patients’ risk factors for HIV and assess the need for retesting. Repeat HIV testing should be offered at least annually to women who are injection drug users are sex partners of injection-drug users exchange sex for money or drugs are sex partners of HIV-infected persons have had sex with men who have sex with men since the most recent HIV test have had more than one sex partner since their most recent HIV test The opportunity for repeat testing should be made available to all women even in the absence of identified risk factors ACOG Number 596, May 2014 31

32. Script for Providers “ I test all my patients who are between 19 and 64 years old for HIV as a routine part of their care More than one million people in the U.S. have HIV and about one in five of these people don’t know it Because they don’t know, they can’t get medicine that may help them live longer” 32

33. Script Continued “This brochure (HIV and Women) tells you about HIV and why you should be tested. When you have finished reading this information, I would be glad to answer any questions that you have. You will be tested for HIV today unless you tell me not to ” 33

34. Advances in HIV Testing 34

35. Is there anything new in HIV testing going on in your community? 35

36. Will acute HIV infection be picked up on the home HIV test kit? 36 1.Yes 2. No 3. Not Sure

37. Old & New Tests in New Combinations With More on the Way 37

38. Recommended Testing Algorithm DRAFT Recommendations: Diagnostic Laboratory Testing for HIV Infection in the United States 2012, CDC.gov 38

39. How do these tests differ from earlier HIV tests? 39

40. Tests for both virologic (p24 antigen) and serologic (antibody) markers of HIV infection Incorporates NAT to resolve discordant results, reduce indeterminate test results, and identify acute HIV infection All antibody-positive specimens tested for HIV-2; previously, only those with negative or indeterminate HIV-1 Western blot received specific HIV-2 testing Emphasizes sensitivity during initial testing. Rare false-positive antibody test results might occur; will be resolved during subsequent laboratory testing recommended as part of initial clinical evaluation How do these differ from earlier tests? 40

41. Nearly 1.2 million people in the United States are HIV-positive. One in five of those don’t know they’re infected, a major contributing factor to the 50,000 new HIV infections each year Testing is the first step to engaging HIV-positive patients in care, stopping individual disease progression, and stemming the spread of HIV Providers should test all patients between 13 and 64 years old, regardless of risk profile, at least once in their lifetime, and preferably on an annual basis as part of routine health screening Testing’s Role in Preventing HIV Infection 41

42. There is an urgent need to increase the proportion of persons who are aware of their HIV-infection status Expanded, routine, voluntary, opt-out screening in reproductive health care settings is needed Such screening is cost-effective and feasible 42

43. Getting the Word Out 43

44. Pasa la Voz (Spread the Word): Using Women's Social Networks for HIV Education and Testing Rebeca L. Ramos MA, MPH, et. al Public Health Rep. 2010 Jul-Aug; 125(4): 528–533 44

45. Test Everyday! 45

46. Perinatal HIV/AIDS Rapid perinatal HIV consultation from practicing providers HIV testing in pregnancy Treating HIV-infected pregnant women Preventing transmission during labor and delivery and the post-partum period HIV-exposed infant care Call for a Phone Consultation (888) 448-8765 24 hours, Seven days a week http://nccc.ucsf.edu/clinician-consultation/perinatal-hiv-aids/ 46

47. Advice from national experts in perinatal HIV care rovide consultation on all levels of perinatal HIV management, including on complex and unique treatment dilemmas, to provide you the best possible information on up-to-date, high-quality care Consultation on complex perinatal HIV treatment issues Addressing adherence issues Managing HIV-positive pregnancies with late presentation to care Safer conception options for HIV-affected couples Referral to perinatal providers and reproductive health services Connecting HIV-infected women and exposed infants to HIV-experienced clinicians Connecting HIV-affected couples considering conception with supportive providers Call for a Phone Consultation (888) 448-8765 24 hours, Seven days a week 47

48. Resources for Clinicians Offering information on AIDS treatment, prevention, and research Clinical guidelines for ARV treatment – Perinatal/Mother-to-Child Transmission – Pediatrics – Adults and Adolescents http://www.aidsinfo.nih.gov 48

49. References A Guide to the Clinical Care of Women with HIV, 2013 Edited by Jean R Anderson, M.D. Distributed by HRSA, available online at www.ask.hrsa.govwww.ask.hrsa.gov Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health- Care Settings, MMWR September 22, 2006 / 55(RR14); 1-17. Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1- Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1-Transmission in the United States, 2014. Updated yearly. http://aidsinfo.nih.gov/guidelines/perinatal Rapid Human Immunodeficiency Virus Testing on Labor and Delivery Lisa Rahangdale, MD, MPH, and Deborah Cohan, MD, MPH OBSTETRICS & GYNECOLOGY VOL. 112, NO. 1, JULY 2008, 159-163 Women’s Opinions about Routine HIV Testing During Pregnancy: Implications for the Opt-Out Approach Linda S. Podhurst, Ph.D., Deborah S. Storm, Ph.D., and Sarah Dolgonos, M.P.H. AIDS PATIENT CARE and STDs Volume 23, Number 5, 2009 49

50. Resources  American College of Obstetricians and Gynecologists.(ACOG) Committee Opinions www.acog.org  WomenChildrenHIV.org A comprehensive, Internet-based library of materials on mother and child HIV infection www.womenandhiv.org  www.cdc.gov/hiv  Pacific AIDS Education Center: Resources & References for HIV Rapid Testing in Labor & Delivery http://www.sfaetc.ucsf.edu/R TLD/RTLDManual/index.htm  Treatment Guidelines: www.aidsinfo.nih.govwww.aidsinfo.nih.gov  CDC Perinatal HIV: http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets  Perinatal Hotline Service 888-448-8765 50