1. Lessons Learned: Implementing HIV Rapid Testing in Labor and Delivery Hospitals in California Kama Brockmann Carol Dawson Rose Asilomar Faculty Development Conference October 3, 2007

2. Perinatal HIV Hotline 888-448-8765 National Perinatal HIV Consultation and Referral Service Advice on the HIV management in pregnant women and infants and HIV testing in pregnancy.

3. Women in CA Living with HIV/AIDS Number of Women in CA with HIV/AIDS % of CA Women with HIV/AIDS % of CA Pop Who are Women Hispanic405427.5%32.4% African American534236.2%6.6% White465031.5%46.6% Asian/Pacific Islander 4483.0%11% Total14756100.0% Based on AIDS Case Registry data cumulative through March 2006.

4. Comparison of Women with AIDS to Other States (2004) New York - 1 (19 m) Florida – 2 (16 m) California - 3 (35 m) Texas – 4 (22 m) Illinois - 6 (13 m) Women 20,867 (29.8%) 12,497 (27.6%) 6,346 (11.1%) 5,518 (18.5%) 3,077 (20%) Total Number of People Living with AIDS 70,133 (.37%) 45,140 (.28%) 56,988 (.16%) 29,891 (.14%) 15,418 (.12%) Men 49,265 (70.2%) 32,643 (72.3%) 50,642 (88.9%) 24,373 (81.5%) 12,342 (80%) Data from The Kaiser Family Foundation Stat Health Facts at statehealthfacts.org.

5. The California Rapid Testing in Labor and Delivery Project (RTLD) Goal: Eradicate perinatal (mom-to- baby) HIV transmission in California. Objective: In California, to have every pregnant woman, and her obstetric health care provider, know her HIV status as early as possible during her pregnancy and no later than when she begins delivery.

6. Timing of Mother-to-Child HIV Transmission (Formula) 0%20%40%60%80%100% Early Antenatal (<36 wks) Late Antenatal (36 wks to labor) Labor and Delivery Proportion of infections

7. Current HIV Testing Law for Pregnant Women in California AB 1676 (Dutra) became Health and Safety Code Sec 125085 and 125090 in Jan 2004. –This law requires that pregnant women be informed that: an HIV test will be preformed; the test is a routine part of prenatal testing; HIV can be transmitted during pregnancy, delivery, or breastfeeding; without treatment the risk of HIV transmission is about 25%, with treatment HIV transmission can be reduced to less than 2%, and they can accept or refuse the test and must sign a document stating their choice. –This law also requires that women in labor and delivery be tested by a method that will ensure the earliest possible results. –AB 682 (pending in legislature) retains all of this language except requiring a signature for testing. If AB 682 passes, California will become an Opt-Out state in Jan 2008. Link for DHS approved Perinatal HIV Testing Consent form: http://www.dhs.ca.gov/aids/resources/PDF/DHS8682_PerinatalInformationAndConsentForm.pdf

8. Rapid HIV Testing in Labor and Delivery (RTLD) Survey 18 page paper and electronic questionnaire to all 260 L&D hospitals with more than 50 births each year. –CA has 550,000 live births each year 12% of all births in the US Ultimately, 205 surveys were returned, for a 78.8% response rate. –It took about 6 months and as many as 5-8 contacts with some sites to secure responses.

9. Results: HIV HIV patients in population in 2005: –>60% reported that no HIV-infected women gave birth at their facility in 2005. –32% reported 1-10 births to HIV-infected women. –Three reported >30 births to HIV-infected women. 37% reported having a written protocol for managing women without a documented HIV test. 25% reported that they offer rapid HIV testing to every woman lacking such documentation.

10. Results: Prenatal Care Records 46% of the facilities reported >90% prenatal care record availability at the beginning of labor. (120/260 hospitals) HIV test results were documented about 45% of the time. (54/120 hospitals) So, as few as 21% of women may have an HIV test result available at the beginning of labor. (55 hospitals)

11. Collaboration Partners Pacific AIDS Education and Training Center (PAETC) Contracted with SOA to provide training and technical assistance to assist with implementation in 120 CA hospitals over 3 years.

12. Utilizing a regional model –Northern CA SF, East Bay, San Jose –Central CA San Joaquin –Southern CA Drew, USC, UC Irvine, UC San Diego

13. Needs Assessment Continuum –1 to 5 –1 hospital has implemented and offering HIV test to women who present without documented HIV test –5 rapid test is not currently available in hospital setting

14. Technical Assistance – Developing & adapting policy and procedures, assisting with cross-discipline integration (i.e. lab, pharmacy, nursing, obstetricians, administration) Training – All care providers at your facility, at your convenience.

15. Barriers to Implementation System –Lab –Record transfer Stigma –Not in my hospital Knowledge –What does it mean

16. Challenges for PAETC Need for expertise in perinatal care Resistance from hospitals Regional approach Essentially Prevention Project

17. Case Examples Southern Region Central Region Northern Region