11

How to Work With LessHow to Work With LessLeveraging Your Resources for Leveraging Your Resources for

Perinatal Hepatitis B and HIV Perinatal Hepatitis B and HIV PreventionPrevention

Hollie Malamud-Price, M.P.H.Hollie Malamud-Price, M.P.H.Ryan White Treatment Modernization ActRyan White Treatment Modernization Act

Maternal and Child CoordinatorMaternal and Child CoordinatorDivision of Health, Wellness, and Disease ControlDivision of Health, Wellness, and Disease Control

HIV/AIDS Prevention and Intervention SectionHIV/AIDS Prevention and Intervention Section

22

What Are We Talking about TodayWhat Are We Talking about Today

Basic Epidemiology of Basic Epidemiology of Mother-to-Child TransmissionMother-to-Child TransmissionPreventing Mother-to-Child Preventing Mother-to-Child Transmission (PMTCT)Transmission (PMTCT)Puzzle of CollaborationPuzzle of CollaborationWhat We Did in MichiganWhat We Did in MichiganChallengesChallengesLessons LearnedLessons LearnedResourcesResources

33

Women and HIVWomen and HIV

Fastest-growing group of persons with new HIV Fastest-growing group of persons with new HIV diagnosis (30% of U.S. infections in 2001)diagnosis (30% of U.S. infections in 2001)

6,000 to 7,000 HIV-positive women deliver annually6,000 to 7,000 HIV-positive women deliver annually

40% of HIV-infected infants born to mothers with 40% of HIV-infected infants born to mothers with unknown statusunknown status

As of 2003: 5,000 cumulative deaths from As of 2003: 5,000 cumulative deaths from perinatally acquired AIDS in U.S.perinatally acquired AIDS in U.S.

Ann Intern Med. 2005;143:38-54.

44

Women and HIV, cont…Women and HIV, cont… For women of all races and ethnicities, the largest For women of all races and ethnicities, the largest

number of HIV/AIDS diagnoses during recent years number of HIV/AIDS diagnoses during recent years was for women aged 15–39was for women aged 15–39

High-risk heterosexual contact was the source of High-risk heterosexual contact was the source of 80% of these newly diagnosed infections80% of these newly diagnosed infections

Women with AIDS made up an increasing part of the Women with AIDS made up an increasing part of the epidemic.epidemic.

In 1992, women accounted for an estimated 14% of adults and In 1992, women accounted for an estimated 14% of adults and adolescents living with AIDS in the 50 states and the District of adolescents living with AIDS in the 50 states and the District of Columbia Columbia

By the end of 2005, this proportion had grown to 23% By the end of 2005, this proportion had grown to 23%

http://www.cdc.gov/hiv/topics/women/resources/factsheets/women.htm#3http://www.cdc.gov/hiv/topics/women/resources/factsheets/women.htm#3

55

Mother-to-Child TransmissionMother-to-Child Transmission

Perinatal HIV transmission is the most common Perinatal HIV transmission is the most common route of HIV infection in childrenroute of HIV infection in children

It is now the source of almost all AIDS cases in It is now the source of almost all AIDS cases in children in the United Stateschildren in the United States

Most of the children with AIDS are members of Most of the children with AIDS are members of minority races/ethnicities minority races/ethnicities

Many of these infections involve women who were Many of these infections involve women who were not tested early enough in pregnancy or who did not tested early enough in pregnancy or who did not receive prevention servicesnot receive prevention services

CDC. CDC. HIV/AIDS Surveillance Report, 2005. Vol. 17HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev. ed. Atlanta: US Department of Health and Human . Rev. ed. Atlanta: US Department of Health and Human Services, CDC; 2007:1–54.Services, CDC; 2007:1–54.

66

Mother-to-Child TransmissionMother-to-Child Transmission

Rates of perinatal HIV Transmission of Rates of perinatal HIV Transmission of << 2% 2% are possible with: are possible with:

1.1. EarlyEarly identification of maternal HIV infection identification of maternal HIV infection2.2. 3 part (antenatal, peripartum and neonatal) 3 part (antenatal, peripartum and neonatal)

antiretroviral regimen antiretroviral regimen 3.3. Pre-labor cesarean section if a maternal viral Pre-labor cesarean section if a maternal viral

load of <1000 copies/ml is not achievedload of <1000 copies/ml is not achieved

Approximately 144-236 infants per year Approximately 144-236 infants per year acquire HIV infection via MTCT in the U.S. acquire HIV infection via MTCT in the U.S. ~40% of their mothers not tested until birth ~40% of their mothers not tested until birth

or lateror later

77

HIV positive woman or woman who does not know hr status

Become Pregnant

No Prenatal Care

No HIV Test

Inadequate ARV Prophylaxis

Child Infected Despite Treatment

Perinatal Prevention CascadePerinatal Prevention Cascade

Primary HIV prevention for women Pre-conception counseling and care

Missed Opportunities Prevention Opportunities

Prevention of unintended pregnancy

Accessible, affordable, welcoming prenatal care

Comprehensive services for mother and infant

Universal prenatal HIV testing (routine, opt-out)Re-offering testing to those who declineSecond test in third trimesterL&D rapid testing for women with unknown HIV status

Providing ARV prophylaxis to all eligible. Support for adherence to ARVARV prophylaxis of exposed newborns

88

Remaining Obstacles to Eradicating Remaining Obstacles to Eradicating Perinatal HIV in the U.S.Perinatal HIV in the U.S.

Increase of HIV infection among women of child-bearing ageIncrease of HIV infection among women of child-bearing age

Delayed or lack of prenatal careDelayed or lack of prenatal care

Women seen in antenatal care but not offered voluntary Women seen in antenatal care but not offered voluntary counseling/testing due to perceived low riskcounseling/testing due to perceived low risk

Poor adherence to antiretroviral medicationsPoor adherence to antiretroviral medications

Lack of full implementation of routine, universal prenatal HIV Lack of full implementation of routine, universal prenatal HIV counseling and testingcounseling and testing

Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States; November 2, 2007Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States; November 2, 2007

99

1010

Prevalence of Diseases Screened Prevalence of Diseases Screened for in Newbornsfor in Newborns

Tyrosinemia: Tyrosinemia: 1 in >300,0001 in >300,000Maple-syrup urine disease: Maple-syrup urine disease: 1 in 175,0001 in 175,000Homocystinuria: Homocystinuria: 1 in 100,0001 in 100,000Galactosemia: Galactosemia: 1 in 60,0001 in 60,000Phenylketonuria: Phenylketonuria: 1 in 14,0001 in 14,000Hypothyroidism: Hypothyroidism: 1 in 4,0001 in 4,000Perinatal HIV exposure, USPerinatal HIV exposure, US 1 in 6701 in 670Perinatal HIV infection, USPerinatal HIV infection, US 1 in 2,680 to 11 in 2,680 to 1

in 33,500in 33,500(according to interventions)(according to interventions)

1111

Women and Hepatitis BWomen and Hepatitis B 24, 000 births to hepatitis B surface antigen (HBsAg) 24, 000 births to hepatitis B surface antigen (HBsAg)

positive women annuallypositive women annually

Without appropriate prophylaxis at birth 90% of Without appropriate prophylaxis at birth 90% of exposed infants will become infected exposed infants will become infected

CDC estimates 600 births to HBsAg positive women CDC estimates 600 births to HBsAg positive women in MIin MI• Approximately 300 are identifiedApproximately 300 are identified

<50% identified in Michigan and nationally<50% identified in Michigan and nationally

1212

Identified and Expected Births to Identified and Expected Births to HBsAg-Positive Mothers, US, 1993-2003HBsAg-Positive Mothers, US, 1993-2003

0

2 0

4 0

6 0

8 0

10 0

Y e a r

Perc

ent

Iden

tifi

ed

0

5 0 0 0

10 0 0 0

15 0 0 0

2 0 0 0 0

Expe

cted

Num

ber

Source: National Immunization Program, CDC

48%

23,827

19,043

41%

1313

Hepatitis B Birth DoseHepatitis B Birth Dose

Infants born to HBsAg-positive Infants born to HBsAg-positive women and a completed vaccine women and a completed vaccine seriesseries

With HBIG and hepB at birthWith HBIG and hepB at birth 80 - 95% protection80 - 95% protection

With hepB only started at birth With hepB only started at birth 70 - 95% protection 70 - 95% protection

Source: MMWR 2006; 55(RR-16)

1414

Advisory Committee on Immunization Advisory Committee on Immunization Practices (ACIP) Hep B RecommendationsPractices (ACIP) Hep B Recommendations

1991 – Universal program implemented1991 – Universal program implemented

First dose at birth or 1-2 mo for infants born to HBsAg-First dose at birth or 1-2 mo for infants born to HBsAg-negative momsnegative moms

2002 – Preference to give first hepB at birth2002 – Preference to give first hepB at birth

2005 - First hepB vaccine should be given at birth2005 - First hepB vaccine should be given at birth

www.cdc.gov/ncidod/diseases/hepatitis/b/acip.htmwww.cdc.gov/ncidod/diseases/hepatitis/b/acip.htm

1515* Includes sexual contact with acute cases, carriers, and multiple partners. Source: MMWR 2006; 55(RR-16):6-7

Heterosexual (39%)*

MSM (24%)Household Contacts; Health Care, and Travel (5%)

Unknown (16%)

InjectingDrug Use

(16%)

Risk Factors for Acute Hepatitis BU. S., 2006

1616

Michigan’s Public Health Code Michigan’s Public Health Code 333.5123333.5123

Requires pregnant women to be tested for HIV, Requires pregnant women to be tested for HIV, syphilis, and/or hepatitis B at initial prenatal care syphilis, and/or hepatitis B at initial prenatal care visit, at the time of labor and delivery, and/or visit, at the time of labor and delivery, and/or immediate post partum if the mother’s status is immediate post partum if the mother’s status is unknown or undocumentedunknown or undocumented

The Michigan Department of Community Health The Michigan Department of Community Health (MDCH) also recommends retesting for HIV and (MDCH) also recommends retesting for HIV and for HBsAg for hep B high risk negative women in for HBsAg for hep B high risk negative women in the third trimesterthe third trimester

1717

Public Health Code, cont.Public Health Code, cont.

Informed consent is required for both HIV and Informed consent is required for both HIV and hep B testinghep B testing

HIV testing requires a signed consent formHIV testing requires a signed consent form

HIV providersHIV providers can use the MDCH counseling and can use the MDCH counseling and testing booklet or a consent form of their choicetesting booklet or a consent form of their choice

A general consent form for services is OKA general consent form for services is OK

1818

USPHS Guidelines for HIV USPHS Guidelines for HIV ScreeningScreening

1995: USPHS recommends that all 1995: USPHS recommends that all pregnant women be counseled for HIV and pregnant women be counseled for HIV and encouraged to be testedencouraged to be tested

2001: USPHS strengthens 2001: USPHS strengthens recommendation for routine testing of all recommendation for routine testing of all pregnant womenpregnant women Simplification of testing process so that pretest Simplification of testing process so that pretest

counseling is not a barriercounseling is not a barrier More flexible consent process to allow for various type More flexible consent process to allow for various type

of informed consentof informed consent Routine retesting in 3Routine retesting in 3rdrd trimester for facilities serving trimester for facilities serving

high HIV prevalence (i.e., >.5%) communitieshigh HIV prevalence (i.e., >.5%) communities

1919

HIV Infection HIV Infection Ideal Disease for ScreeningIdeal Disease for Screening

HIV serious health disorder that can be HIV serious health disorder that can be diagnosed in an asymptomatic statediagnosed in an asymptomatic state

HIV can be detected by reliable, HIV can be detected by reliable, inexpensive, and noninvasive screening inexpensive, and noninvasive screening

testtest Infected patients have YOLG if Infected patients have YOLG if treatment initiated earlytreatment initiated early Cost of screening reasonably in relation Cost of screening reasonably in relation

to anticipated benefitto anticipated benefit MMWR 2006; 55 (NO RR-14) 1-17

2020

2006 CDC Releases Revised 2006 CDC Releases Revised Recommendations on HIV TestingRecommendations on HIV Testing

All pregnant women in the United States All pregnant women in the United States should be screened for HIV infectionshould be screened for HIV infection

Transmission continues to occur among Transmission continues to occur among women who lack pnc or who were not offered women who lack pnc or who were not offered voluntary HIV counseling and testing during voluntary HIV counseling and testing during pregnancy pregnancy

Data confirm that testing rates are higher when Data confirm that testing rates are higher when HIV tests are included in the standard panel of HIV tests are included in the standard panel of screening tests for all pregnant womenscreening tests for all pregnant women

MMWR 2006; 55 (NO RR-14) 1-17

2121

CDC Recommendations on CDC Recommendations on Maternal Hepatitis ScreeningMaternal Hepatitis Screening

Screen all pregnant women prenatally for HBsAgScreen all pregnant women prenatally for HBsAg

At time of deliveryAt time of delivery Review maternal HBsAg status Review maternal HBsAg status

Record results on both labor and delivery record Record results on both labor and delivery record and on infant’s delivery summary sheetand on infant’s delivery summary sheet

Perform HBsAg testing STAT on women who:Perform HBsAg testing STAT on women who:Do not have a documented HBsAg test resultDo not have a documented HBsAg test result

Tested HBsAg-negative prenatally and are at Tested HBsAg-negative prenatally and are at risk for hepatitis B virus (HBV) infection risk for hepatitis B virus (HBV) infection

2222

Perinatal Cost SavingsPerinatal Cost Savings Universal prenatal screening is cost savings in the Universal prenatal screening is cost savings in the

U.S.U.S. Repeat testing in 3Repeat testing in 3rdrd trimester is cost-effective in trimester is cost-effective in

areas of elevated HIV incidence among women of areas of elevated HIV incidence among women of child-bearing agechild-bearing age

The discounted lifetime treatment cost for perinatally-The discounted lifetime treatment cost for perinatally-infected childreninfected children $113,476 for 9 years of survival$113,476 for 9 years of survival $228,155 for 25 years of survival$228,155 for 25 years of survival

As years of survival increase for HIV-infected As years of survival increase for HIV-infected children, the lifetime costs are also likely to increase children, the lifetime costs are also likely to increase

Sansom, et al. JAIDS 41: 4, April 2006

2323

Who is Responsible for Who is Responsible for Perinatal Hepatitis B Perinatal Hepatitis B and HIV Prevention?and HIV Prevention?

2424

Puzzle of CollaborationPuzzle of Collaboration

Reporting

L and D Knowing the woman’s HIV and Hep B status

Entering into Prenatal Care

Test Results Being

Returned

Obstetrical Provider

Obstetrician

Providing Testing

Treatment

Pregnant Woman

Infection Control/

Infectious Disease Provider

2525

What Did Michigan Do?What Did Michigan Do?

Perinatal Hep B and HIV Perinatal Hep B and HIV Coordinators met one another!Coordinators met one another!

Partnered and leveraged Partnered and leveraged resources!resources!

Looked at what each program had Looked at what each program had donedone

Made plans to move forwardMade plans to move forward

2626

What Did Michigan Do?What Did Michigan Do?

Developed a survey that was sent Developed a survey that was sent to all of Michigan’s 91 birthing to all of Michigan’s 91 birthing hospitals and 500nprenatal care hospitals and 500nprenatal care providersproviders

Direct telephone follow-up with Direct telephone follow-up with each birthing hospitaleach birthing hospital

2727

Example of Questions AskedExample of Questions Asked HIV PoliciesHIV Policies Does your facility have written policies (WP) and Does your facility have written policies (WP) and

standing orders (SO) to:standing orders (SO) to: 1. Do HIV testing upon admission to L&D if results 1. Do HIV testing upon admission to L&D if results

are unknown or undocumented for HIV? are unknown or undocumented for HIV? 2. Repeat testing for (-) but high risk pregnant 2. Repeat testing for (-) but high risk pregnant

women for HIV? women for HIV? 3. Do rapid (20 min–hrs) HIV testing? 3. Do rapid (20 min–hrs) HIV testing? How long does it take to get the results to the L&D How long does it take to get the results to the L&D

staff? ____staff? ____ 4. Do expedited (24-48 hrs) HIV testing? How long 4. Do expedited (24-48 hrs) HIV testing? How long

does expedited testing take? _________does expedited testing take? _________ 5. Do standard Elisa (3+ days) testing?5. Do standard Elisa (3+ days) testing?

2828

Example of Questions AskedExample of Questions Asked

HBV PoliciesHBV Policies Does your facility have written policies (WP) Does your facility have written policies (WP)

and standing orders (SO) to: and standing orders (SO) to: 1. Test for HBsAg upon admission to L&D if 1. Test for HBsAg upon admission to L&D if

results are unknown or undocumented? results are unknown or undocumented? 2. Repeat HBsAg testing for (-) but high risk 2. Repeat HBsAg testing for (-) but high risk

pregnant women? pregnant women? 3. Do STAT HBsAg testing? 3. Do STAT HBsAg testing? 4. Offer hepatitis B immune globulin (HBIG) 4. Offer hepatitis B immune globulin (HBIG)

and hepatitis B vaccine to infants born to and hepatitis B vaccine to infants born to HBsAg positive women?HBsAg positive women?

5. Offer hepatitis B vaccine to all newborns?5. Offer hepatitis B vaccine to all newborns?

2929

Survey Results-HIVSurvey Results-HIV 40 (44%) has written policies and standing orders 40 (44%) has written policies and standing orders

(WP/SO) to offer HIV testing to women upon (WP/SO) to offer HIV testing to women upon admission to labor and delivery (L and D) with an admission to labor and delivery (L and D) with an unknown or undocumented HIV status. unknown or undocumented HIV status.

Of the 40 hospitals, 28 (70%) have WP/SO to offer Of the 40 hospitals, 28 (70%) have WP/SO to offer rapid testing (RT) in L and D.rapid testing (RT) in L and D.

Of the 40 hospitals, that have WP/SO to offer Of the 40 hospitals, that have WP/SO to offer HIV testing to women upon admission to L HIV testing to women upon admission to L and D with an unknown or undocumented and D with an unknown or undocumented HIV status, 12 (30%) replied that is unknown HIV status, 12 (30%) replied that is unknown and/or do not offer RT in L and D.and/or do not offer RT in L and D.

3030

Survey Results-Hep BSurvey Results-Hep B Have written policies and standing orders to:Have written policies and standing orders to:

• 81 (89%) test women STAT upon admission to 81 (89%) test women STAT upon admission to L & D if no result is available for HBsAgL & D if no result is available for HBsAg

• 9 (10%) offer repeat testing for HBsAg negative 9 (10%) offer repeat testing for HBsAg negative but high risk pregnant women but high risk pregnant women

• 87 (96%) give HBIG and hepatitis B vaccine 87 (96%) give HBIG and hepatitis B vaccine within 12 hours to infants born to HBsAg within 12 hours to infants born to HBsAg positive women positive women

• 86 (95%) give hepatitis B vaccine to all 86 (95%) give hepatitis B vaccine to all newborns newborns

3131

Current ActivitiesCurrent Activities

Reviewing a sample of birth hospital Reviewing a sample of birth hospital charts over the next five years.charts over the next five years.

All hospitals receive a report on All hospitals receive a report on performance.performance.

To date 18 hospitals have had record To date 18 hospitals have had record reviews.reviews.

3232

Next StepsNext Steps

Disseminate chart review data as it is Disseminate chart review data as it is available to state working groupavailable to state working group

Determine what hospitals need Determine what hospitals need immediate technical assistanceimmediate technical assistance

Provide TA as much as possible Provide TA as much as possible based on limited staff time and based on limited staff time and resourcesresources

3333

ChallengesChallengesLimited staff time and resources.Limited staff time and resources.

Not funded to do perinatal HIV Not funded to do perinatal HIV prevention by CDC or HRSAprevention by CDC or HRSA

Lack of state perinatal Lack of state perinatal regions/networks to assist in working regions/networks to assist in working with birthing hospitals to promote with birthing hospitals to promote perinatal Hep B/HIV prevention.perinatal Hep B/HIV prevention.

3434

Over Coming ChallengesOver Coming Challenges

Recognize your limitationsRecognize your limitations

Recognize what you can doRecognize what you can do

Leverage your resources-figure out Leverage your resources-figure out where you can collaborate!where you can collaborate!

Know one another and build Know one another and build relationshipsrelationships

3535

Lessons LearnedLessons Learned

Baby Steps are O.K.Baby Steps are O.K.

Be patient with the process.Be patient with the process.

Beg, borrow, and steal-use materials from Beg, borrow, and steal-use materials from national organizations to support your national organizations to support your work-CDC, ACOG, etc.work-CDC, ACOG, etc.

Partner with other public health programs Partner with other public health programs to spread the word-family planning, WIC, to spread the word-family planning, WIC, etc.etc.

3636

ResourcesResources

3737

National Resources-HIVNational Resources-HIV CDC National Prevention Information Network (NPIN)CDC National Prevention Information Network (NPIN)

P.O. Box 6003,P.O. Box 6003,Rockville, MD 20849-6003Rockville, MD 20849-6003Phone: 1-800-458-5231Phone: 1-800-458-5231TTY: 1-800-243-7012TTY: 1-800-243-7012FAX: 1-888-282-7681FAX: 1-888-282-7681In English, en EspañolIn English, en EspañolMonday through Friday, 9 a.m. to 8 p.m. Eastern TimeMonday through Friday, 9 a.m. to 8 p.m. Eastern Time

www.cdcnpin.orgwww.cdcnpin.orginfo@cdcnpin.orginfo@cdcnpin.org

Receive technical assistance and publication distribution Receive technical assistance and publication distribution for organizations and professionals working in HIV/AIDS, for organizations and professionals working in HIV/AIDS,

STD, and TB preventionSTD, and TB prevention

3838

National Resources-HIVNational Resources-HIV

National Perinatal HIV Consultation and Referral Service National Perinatal HIV Consultation and Referral Service (Perinatal Hotline)(Perinatal Hotline)1-888-448-87651-888-448-876524 Hours/Day24 Hours/Daywww.ucsf.edu/hivcntr/Hotlines/Perinatal.html www.ucsf.edu/hivcntr/Hotlines/Perinatal.html

The Perinatal Hotline provides around-the-clock advice The Perinatal Hotline provides around-the-clock advice on indications and interpretations of standard and rapid on indications and interpretations of standard and rapid HIV testing in pregnancy as well as consultation on HIV testing in pregnancy as well as consultation on antiretroviral use in pregnancy, labor and delivery, and antiretroviral use in pregnancy, labor and delivery, and the postpartum period. The Perinatal HIV Consultation the postpartum period. The Perinatal HIV Consultation and Referral Service also links HIV-infected pregnant and Referral Service also links HIV-infected pregnant women with appropriate health care.women with appropriate health care.

3939

National Resources-HIVNational Resources-HIV

http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdfhttp://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf

www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htmwww.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

http://www.cdc.gov/hiv/topics/ http://www.cdc.gov/hiv/topics/ perinatal/1test2lives/default.htmperinatal/1test2lives/default.htm

www.cdc.gov/hiv/projects/perinatalwww.cdc.gov/hiv/projects/perinatal

www.cdc.gov/hepatitiswww.cdc.gov/hepatitis

www.cdc.gov/hiv/rapid_testingwww.cdc.gov/hiv/rapid_testing

AIDS InfoAIDS Infowww.aidsinfo.nih.govwww.aidsinfo.nih.gov 1.800.448.04401.800.448.0440Resources on HIV/AIDS Treatment and Clinical TrialsResources on HIV/AIDS Treatment and Clinical Trials

4040

National Resources-Hep BNational Resources-Hep B

www.cdc.gov/hepatitiswww.cdc.gov/hepatitis

www.hbvadvocate.orgwww.hbvadvocate.org

www.hivandhepatitis.com www.hivandhepatitis.com

www.hblist.org www.hblist.org

4141

Contact InformationContact Information

Hollie Malamud-Price. M.P.H.Hollie Malamud-Price. M.P.H.3056 W. Grand Blvd3056 W. Grand Blvd

Suite 3-150Suite 3-150

Detroit, MI 48202Detroit, MI 48202

313.456.4362313.456.4362

malamudh@michigan.gomalamudh@michigan.govv