HIV Counseling and Rapid/Expedited Testing in Labor

1. HIV Counseling and Rapid/Expedited Testing in Labor

2. Chain of events leading to an HIV-infected child • The proportion of women . . . •  Who are HIV-infected • Who become pregnant Who do not seek prenatal care Who are not offered HIV testing Who refuse testing Who are not offered ARV prophylaxis  Who refuse ARV prophylaxis  Who do not complete the ARV prophylaxis  Whose child is infected despite treatment IOM, 1998 François-Xavier Bagnoud Center, UMDNJ, 2003

3. Counseling During Labor • Not a great time but it is possible! • Other opportunities: ER visits for false labor, antenatal admissions, premature labor • Materials for patient education/informed consent • Policy and procedure in place with a counseling “script” for providers François-Xavier Bagnoud Center, UMDNJ, 2003

4. National Recommendations for HIV Testing of Pregnant Women USPHS Revised Recommendations for HIV Screening of Pregnant Women (11/01) • Universal testing for all pregnant womenas a routine part of prenatal care • Voluntary, informed consent • Documentation in writing preferably with patient’s signature • Expedited or rapid testing for women in labor with unknown status Regulations, laws, & policies about HIV screening of pregnant women vary state to state François-Xavier Bagnoud Center, UMDNJ, 2003

5. New Jersey Laws & Policies for HIV Testing of Pregnant Women Mandatory Counseling, Voluntary HIV Testing (Chapter 174, P.L. 1995) • Physician/primary health care provider must: • Provide information on HIV/AIDS: benefits of knowing status, treatment available to woman/fetus • Offer HIV testing to all pregnant women • Signed information sheet/consent form for HIV testing (or decision NOT to test) • Standard of Care: HIV counseling and voluntary rapid expedited testing in labor François-Xavier Bagnoud Center, UMDNJ, 2003

6. Barriers and Supports to Universal Prenatal HIV Testing • Provider’s recommendation about testing • 92.8% were tested if strongly recommended • 42% if clinician had not recommended • Private insurance associated with not being tested • Reasons for not being tested • Not perceiving herself at risk (55.3%) • Having been tested recently (39%) • Test not offered or recommended (11%) • Adverse consequences rarely mentioned François-Xavier Bagnoud Center, UMDNJ, 2003

7. Which pregnant women will need rapid HIV testing? • Women with no or limited prenatal care • Women who were not offered testing • Women whose results are unavailable • Women who declined testing previously François-Xavier Bagnoud Center, UMDNJ, 2003

8. Confidentiality Comfort Consent Reasons to test Results Rx to decrease risk FormulaforHIV Counseling and Testing in Labor C3 R3 François-Xavier Bagnoud Center, UMDNJ, 2003

9. Confidentiality • Who is in the room with the patient? • How can you assure confidentiality during • History taking • Giving test results • Giving medication for treatment? François-Xavier Bagnoud Center, UMDNJ, 2003

10. Comfort • What is her level of discomfort? • How is her pain being managed? • Is she anxious? François-Xavier Bagnoud Center, UMDNJ, 2003

11. HIV Counseling and Testing During LaborCase Studies • Lucy is admitted with contractions 7 minutes apart. She is 17, scared and asking to be given something to stop the pain. This is her first baby. Her parents are with her. She recently moved back home, and had only one visit with her present OB. You don’t have a prenatal chart for Lucy. François-Xavier Bagnoud Center, UMDNJ, 2003

12. HIV Counseling and Testing During LaborCase Studies • Ms. R is admitted from the ER fully dilated and pushing. This is her third baby and, according to her chart, she had two prenatal visits for care. Her history leads you to believe she is at risk for HIV. François-Xavier Bagnoud Center, UMDNJ, 2003

13. Informed Consent • What is the nurse’s role? • How much information is “informed?” • HIV is the virus that causes AIDS • A woman could be at risk for HIV and not know it • Effective interventions can protect the infant from HIV and improve mother’s health • HIV testing is recommended for all pregnant women • Services are available to help women reduce their HIV risk and provide medical care to women with HIV • Women who decline testing won’t be denied care • Centers for Disease Control & Prevention, Nov. 2001 François-Xavier Bagnoud Center, UMDNJ, 2003

14. HIV Counseling and Testing During LaborCase Studies • Ms. G. has just been admitted to L&D. No HIV test results are on her chart. A partner/husband and her mother are with her. The family only speaks a little English. • You need to take an admission history including asking about HIV testing in labor. François-Xavier Bagnoud Center, UMDNJ, 2003

15. HIV Counseling and Testing During LaborCase Studies • Ms. B. was just admitted in active labor. She has no record of prenatal care and no information about her HIV status. She “might have had an HIV test” in the past but isn’t sure if it was during this pregnancy. • This is the OB resident’s first week. François-Xavier Bagnoud Center, UMDNJ, 2003

16. Reasons for HIV Testing During Labor • HIV— the virus that causes AIDS — is spread by unprotected sexual intercourse • Therefore, all pregnant women may be at risk for HIV infection • A pregnant woman with HIV has a 1 in 4 chance of passing HIV to her baby if she is not treated • If a woman with HIV takes antiretroviral medicine during labor and delivery and her baby takes the medicine after birth, only 1 in 10 babies will get HIV François-Xavier Bagnoud Center, UMDNJ, 2003

17. HIV Counseling and Testing During LaborCase Studies • You begin to explain toMs. Q that her prenatal record does not indicate that she has had an HIV test during this pregnancy and that it is recommended for every pregnant woman. Ms. Q becomes angry and says “What kind of woman do you think I am?” François-Xavier Bagnoud Center, UMDNJ, 2003

18. Giving Results of Rapid Testing in Labor • When and how should results be given? • Post-test counseling for positive results • What does a preliminary positive test mean? • What do you say? • Post-test counseling for negative results • What treatment is available if the preliminary test is positive • Consent for prophylactic treatment based on preliminary test results François-Xavier Bagnoud Center, UMDNJ, 2003

19. Results of a Rapid TestDuring Labor • The results of Ms. L’s rapid HIV test are positive. Her labor is progressing and she is at 7 cm. Her family is in the room with her. The L & D nurse accompanies the Obstetrician to the room to tell Ms. L the results. When the doctor leaves, Ms. L asks for clarification of what she’s been told. • What are the issues? • What do you tell her? François-Xavier Bagnoud Center, UMDNJ, 2003

20. HIV Counseling and Testing During LaborCase Studies • Ms. M was not offered an HIV test during her prenatal care. She consented to have a rapid test during labor. The result of the test is negative. She asks the nurse if she can be certain that she doesn’t have HIV. François-Xavier Bagnoud Center, UMDNJ, 2003

21. The Postpartum Woman with a Negative HIV Test • Counseling regarding risk reduction • Assessment of on-going risk • Referral for intensive counseling if high risk François-Xavier Bagnoud Center, UMDNJ, 2003

22. Rx: Treatment to Reduce Perinatal HIV Transmission • Antiretroviral treatment to mother during labor and delivery and to the baby after birth decrease the risk of transmission to 1 in 10 • National guidelines offer 4 choices of treatment • Woman with a preliminary positive HIV test should delay breastfeeding until the results of the confirmatory test are known François-Xavier Bagnoud Center, UMDNJ, 2003

23. HIV Counseling and Testing During LaborCase Studies • Ms. P is in early labor. She refused testing during prenatal care. After consenting to the test, the preliminary result is positive. The physician and nurse explain to her the treatment options they recommend and the follow-up that will occur. • What are the treatment options for Ms P — for her baby? • What follow-up should be done? François-Xavier Bagnoud Center, UMDNJ, 2003

24. The Rapid Test: Single Use Diagnostic System (SUDS) • FDA licensed rapid test • Sensitivity/specificity comparable to EIA • Should be confirmed with WB or another rapid test • PPV low in low prevalence areas • Unconfirmed results CAN be given to women in labor or occupational exposure François-Xavier Bagnoud Center, UMDNJ, 2003

25. OraQuick Rapid HIV-1 Antibody test • FDA approved November 2002 • Uses whole blood from a fingerstick • Currently approved for laboratory use but designed for point-of-care • Very high sensitivity (99.6%) and specificity (100%) • Should be confirmed with WB François-Xavier Bagnoud Center, UMDNJ, 2003

26. Resources and Follow-up for the Family • The NJ Statewide Family Centered HIV Care Network • François-Xavier Bagnoud Center(FXB), UMDNJ, Newark • Jersey City Medical Center Regional Family HIV Treatment Center • Jersey Shore Medical Center Family HIV Program, Neptune • The Family Treatment Center at Newark Beth Israel Medical Center • Robert Wood Johnson AIDS Program (RWJAP), New Brunswick • Southern NJ Regional Family HIV Treatment Center, Cooper University Hospital, Camden • St. Joseph’s Hospital and Medical Center Comprehensive Care Center, Paterson François-Xavier Bagnoud Center, UMDNJ, 2003