1. Texas HIV Perinatal Program Jenny R. McFarlane Texas Dept State Health Services HIV/STD Prevention Services Group Field Operations Team Leader jenny.mcfarlane@dshs.state.tx.us

2. Outline Background Texas Laws/CDC Guidance Texas program Future activities What programs can do

3. Background Perinatal HIV Transmission Accounts for nearly all pediatric AIDS cases. HIV transmission from mother to child during pregnancy, labor and delivery or by breast feeding accounted for approximately 91% of all AIDS cases reported among U.S. children between 1985 and 2004 (1).1 Can be prevented. Data indicate that when appropriate antiretroviral medications are given during pregnancy, labor and delivery and after birth, the risk of transmission can be reduced to less than 2% (2) compared with approximately 25% when no interventions are given (3).23 1. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004. Atlanta: US Department of Health and Human Services 2004.HIV/AIDS Surveillance Report, 2004 2. Cooper ER, Charurat M, Mofenson LM, Hanson IC, Pitt J, Diaz C, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr. 2002;29(5):484-94. 3. Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med. 1994;331(18):1173-80

4. HIV, Syphilis, and Hepatitis B Serologic Testing in Pregnant Women Health and Safety Code, § 81.090 Texas Administrative Code, RULE §97.135 OPT-OUT: verbally notify the woman that an HIV test will be performed if the patient does not object and note on the medical records that verbal notification was given and printed materials were distributed (required). Test is confidential, not anonymous. If woman objects, must be referred to anonymous test site.

5. 2006 CDC HIV Testing Recommendations for Pregnant Women Opt-Out Approach Test at first prenatal care visit 2 nd Test during third trimester <36 weeks Opt-Out rapid test at L&D if no history of test Immediate initiation of ART prophylaxis recommended to women on basis of reactive rapid test result without waiting for confirmatory

6. Formative Audience Research Sherry Mathews Advocacy Marketing -Formative Audience Research: 4/01/02 – 8/31/02 Location: Lufkin, Nacogdoches, Houston Audience: HIV positive women of CBA, women of CBA at risk of HIV infection, key informants working in health care and related fields Process and Outcomes: Thirty face to face interviews with HIV positive or at risk women of CBA, two focus groups with 13 residents of a facility for homeless HIV positive women and their children, 13 health care staff key informant interviews, recommended strategies based on findings and a literature review.

7. Formative audience research 4/1/02-8/31/02 indicates: Women underestimate their risk of HIV infection Most women do not know that perinatal transmission can be prevented through medication during pregnancy. Focus group respondent, The president needs to announce that!

8. In the beginning…. In 1999, through the HIV Prevention Cooperative Agreement the CDC earmarked $400,375 for HIV perinatal prevention activities. Funds may only be used for activities to prevent the perinatal transmission of HIV. Funds may not be used for medical care, including medications. DSHS initially allocated all of the funds to City of Houston Health and Human Services due to the large number of exposed infants in the Houston area.

9. In 2002, funds were redistributed to regions in East Texas that were identified as high HIV morbidity areas for women of childbearing age. 9% of HIV positive women giving birth in Texas come from PHRs 4/5N but only 5% of total Texas 2000 births (363,325) are from PHRs 4/5N Fewer resources available in the area. Three current HIV prevention and services CBOs were allocated funds in 2002. Special Health Resources, Longview Triangle AIDS Network, Beaumont Health Horizons, Nacogdoches The funds were added to CBOs existing federal HIV prevention grants. All of the programs perform specialized case management to women who are HIV positive and pregnant.

10. Specialized case management: Provide assistance with HIV medications adherence, attending HIV medical appointments, prenatal care appointments and postpartum care for the woman and the infant. Other targeted interventions: Include prevention case management to women of childbearing age at risk of HIV infection and HIV infected women of childbearing age, SISTA, HIV counseling and testing, pregnancy testing and education on HIV perinatal transmission and prevention, and reproductive choices education.

11. Programs developed social marketing campaigns that emphasize: the importance of HIV testing when pregnant, prenatal care, and treatment for women who are living with HIV. Billboards, radio, and television spots. Programs either perform provider education themselves, collaborate with AETC or contract with other clinicians. Education includes HIV perinatal transmission, the law for testing pregnant women, and treatment guidelines for HIV positive pregnant women.

12. Process Measures 2001-2005 189 HIV positive pregnant women receive specialized case management 55 provider trainings - 1880 attendants 194 tv/radio public information spots Multiple billboards for rotating cycles Outreach to 6,132 high risk child bearing age women

13. Next Steps Implement HIV rapid testing in labor and delivery sites. Improve EPS data Distribute Four Sisters Four Stories and Cuatro Mujeres Cuatro Historias Booklets Statewide social marketing campaign Collaborate with RW, Maternal Health and HBV nurse Case Managers

14. What to do? Assess your population Identify your HIV + women of cba Educate clients on HIV perinatal issues Transmission Medication Reproductive choices Partner Services Peer advocacy Staff need to know: Reporting requirements Testing law for pregnant women New CDC HIV testing recommendations for pregnant women Links for prenatal care Referral Networks – HIV/STD Prev, RW (Parts A, B, C, D)

15. What to do? Case Mangers role: Discuss pregnancy status with clients/partners Follow up on referrals (ob, pedi, HIV)– obtain consent Medications adherence Know delivery status Hospital pedi meds Follow infant status Follow moms post delivery care Report case, work with surveillance on EPS

16. What to do? HIV/STD Prevention Staff Assess pregnancy status of client and partners Educate on HIV perinatal issues Build referral resources Follow up on referrals Partner services Integrate perinatal issues into activities – SISTA, screenings Collaborate with HIV/DIS on no shows Report case, work with surveillance on EPS HIV c/t objective 90% HIV+ pregnant women successfully linked into prenatal care

17. Links Perinatal Hotline (888)448-8765 www.cdc.gov/hiv/topics/perinatal/index.htm www.hret.org/hret/programs/hivtransm.html www.cdc.gov/hiv/topics/testing/healthcare/ http://aidsinfo.nih.gov/ContentFiles/Perinatal_FS_en.pdf http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines& Search=Off&GuidelineID=9&ClassID=2 http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines& Search=Off&GuidelineID=9&ClassID=2

18. Contact Jenny R. McFarlane 512-533-3094 jenny.mcfarlane@dshs.state.tx.us 1100 W. 49 th Street Austin, Texas 78756