Rapid Testing in Labor and Delivery

1. Missed Opportunities For Prevention of Mother to Child Transmission of HIV through Routine Rapid Testing in Labor and Delivery National Perinatal HIV Consultation and Referral Service Shannon Weber, MSW sweber @nccc.ucsf.edu June 2007 Rapid Testing in Labor and Delivery

2. About this Presentation These slides were developed using current cases submitted by California clinicians involved in the RTLD project. The intended audience is clinicians and hospital staff involved with the development, implementation and evaluation of Rapid Testing in Labor and Delivery initiatives in California. Users are cautioned that due to the rapidly changing field of Perinatal HIV care, this information could become outdated quickly. Difficult clinical situations should be managed with local consultation or through the Perinatal Hotline. It is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent.

3. National HIV/AIDS Clinicians’ Consultation CenterUCSF – San Francisco General Hospital Perinatal Hotline(888) 448 - 8765 National Perinatal HIV Consultation & Referral Service Advice on testing and care of HIV-infected pregnant women and their infants Referral to HIV specialists and regional resources Warmline(800) 933 - 3413 National HIV Telephone Consultation Service Consultation on all aspects of HIV testing and clinical care PEPline(888) 448 - 4911 National Clinicians’ Post-Exposure Prophylaxis Hotline Recommendations on managing occupational exposures to HIV and hepatitis B & C HRSA AIDS ETC Program & Community Based Programs, HIV/AIDS Bureau & Centers for Disease Control and Prevention (CDC)

4. Pacific AETCRapid Testing in Labor and Delivery Project • Staff training and technical assistance related to all aspects of implementing HIV Rapid Testing in Labor & Delivery (RTLD) are available from the Pacific AIDS Education and Training Center (PAETC). • Resources & References for HIV Rapid Testing in Labor & Delivery:http://www.ucsf.edu/sfaetc/RTLD/RTLDManual/index.html

5. 29 year old immigrant from Central America Declined HIV test during prenatal care Presented at 32 weeks GA with fever and altered mental status Rapid HIV test positive Eliminating Perinatal HIV Transmission Missed Opportunities: Case #1

6. Confirmatory HIV test positive, CD4 count 103, Viral load 232,000,Head CT showed Toxoplasmosis, ARVs started immediately After 4 days of ARVs, patient’s viral load went from 232,000 to 19,000 Non-reassuring fetal heart tracing at 33+weeks, c/section Infant HIV negative Pt later reported that 1st husband died of AIDS 10 yrs ago and she was terrified to be tested Pt died 4 months postpartum of AIDS-related illness Eliminating Perinatal HIV Transmission Missed Opportunities: Case #1

7. What were the missed opportunities? HIV test during pregnancy ARV prophylaxis ARV for maternal health

8. 32 year old presented to care at 37+ weeks GA, positive HIV antibody test Admitted for DOT/HAART for 5 days before c-section at 38 weeks Infant is HIV negative. Review of her medical chart revealed a positive HIV antibody test 2 years prior during a previous pregnancy Eliminating Perinatal HIV Transmission Missed Opportunities: Case #2

9. During her previous pregnancy she presented for prenatal care at 37 weeks and was tested for HIV. The results came back two weeks later, on the day she delivered at another hospital. Neither the patient nor the hospital were aware of her results. Her first child tested positive for HIV after her HIV was rediscovered and disclosed in her second pregnancy. Eliminating Perinatal HIV TransmissionMissed Opportunities: Case #2

10. What were the missed opportunities? • First pregnancy: • HIV test results to patient, attending clinician, and L&D staff • Rapid test on L&D • ARV prophylaxis • ARV for positive infant • Second Pregnancy: • Adequate prenatal care • Timely HIV test

11. Couple want to conceive. Both get tested and are HIV Ab negative. 3-4 months later they conceive Mother was offered testing at a prenatal visit but declined because “I just got tested” and “Neither of us has had outside relations since we’ve been together.” Eliminating Perinatal HIV Transmission Missed Opportunities: Case #3

12. Baby delivered full term and breast-fed for one month Admitted at 3 months with respiratory distress, failure to thrive, severe thrush, axillary adenopathy, big liver Then confirmed to have PCP, CMV and HIV Eliminating Perinatal HIV Transmission Missed Opportunities: Case #3

13. What were the missed opportunities? HIV test during pregnancy Rapid test on L&D ARV prophylaxis Formula feeding for infant

14. Couple together for 5 years. Prenatal care through large HMO. Group counseling about ‘testing for lots of things;” no individual counseling. Patient says, “I signed to have everything done.” Patient never asked for or saw her test results and presumed all was fine. Eliminating Perinatal HIV Transmission Missed Opportunities: Case #4

15. Baby born at 32 weeks Diagnosed with failure to thrive, severe thrush, axillary adenopathy Then confirmed to have PCP, CMV and HIV A review of mom’s consent forms reveals “I decline HIV testing.” Eliminating Perinatal HIV Transmission Missed Opportunities: Case #4

16. What were the missed opportunities? HIV counseling and test during pregnancy Rapid Test on L&D ARV prophylaxis

17. A pregnant women, whose partner is known HIV positive, is tested for HIV in early pregnancy with a negative test result. One week prior to her delivery, she is retested using a standard HIV test. The positive test result was not communicated to the hospital or patient prior to the delivery. The patient delivered at term with a vacuum assisted vaginal delivery and breast-fed. The infant later tested positive for HIV. Eliminating Perinatal HIV Transmission Missed Opportunities: Case #5

18. What were the missed opportunities? 3rd trimester HIV test results delivered to patient and L&D staff ARV prophylaxis Non-instrumented delivery Formula feeding for infant

19. A 23-year old pregnant woman is incarcerated and presents to labor and delivery in active labor at term. Several hours after delivery, she consents to an HIV test which returned positive several days later. The infant was started on triple therapy. The woman had been a patient at the pediatric HIV clinic and was lost to care, never tested for HIV while incarcerated or during prenatal care. The infant tested positive for HIV. Eliminating Perinatal HIV Transmission Missed Opportunities: Case #6

20. What were the missed opportunities? HIV test during pregnancy Rapid test before delivery ARV prophylaxis ARV for maternal health