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We have the Guidelines… what else do we need to do?

We have the Guidelines… what else do we need to do?. Getting to ZERO. Disseminate the current Guidelines

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We have the Guidelines… what else do we need to do?

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  1. We have the Guidelines…what else do we need to do?

  2. Getting to ZERO • Disseminate the current Guidelines • Focus education on anyone caring for pregnant women and infants < 2 years of age (Obstetrics, Family Practice, Internists, Pediatricians, case managers, statewide perinatal nurses, peer navigators) • Create Local / Community Perinatal Prevention Teams Representatives for all the stakeholders in the community • Intensify education for Labor & Delivery teams  Rapid Testing protocols and performance measures Management of HIV + deliveries - Optimize Options 10 Steps in L & D for a Healthy HIV Negative infant

  3. Getting to ZERO • Intensify education for pediatricians in newborn nurseries to optimize management of HIV exposed infants in the “highest risk” situations • Facilitate communication amongst the Perinatal Prevention Team including EMR, and data transfer • Create Statewide Performance Measures for Prevention – based on the guidelines • Earlier notification to the state DOH of a “high risk” perinatal exposure for assistance and tracking

  4. Getting to ZERO • Utilize the Perinatal Prevention Program at USF Center for HIV Education and Research www.usfcenter.org/perinatal • Work with the Florida/Caribbean AIDS Education Training Center (F/CAETC) www.fcaetc.org • National Perinatal HIV “Hotline” 888-448-8765

  5. Getting to ZERO • Distribute educational materials from Perinatal Prevention Program www.usfcenter.org/perinatal • Review systems practices and performance in any facility where an HIV infected infant is born – provide training and technical assistance

  6. Possible Interventions

  7. Possible Interventions

  8. Possible Interventions

  9. Possible Interventions

  10. Possible Interventions at Delivery

  11. Possible Interventions at Delivery

  12. 10 Action Steps for Mothers for a Healthy Baby • Know your HIV Status  CD4 counts, Viral Loads, etc. • Start Prenatal Care early  Take your ARVs as directed • Take care of yourself  eating, vitamins, exercise, rest • Avoid exposures  No alcohol or drugs, Stop smoking, Cut down on caffeine • Disclose your status & Create support for yourself + baby • Make the steps into your “Pregnancy Plan” • Ask for a Prenatal consultation – including no breastfeeding, no pre-mastication of baby’s foods, medications and testing for the baby • Plan the Delivery – medications, delivery location, option of a cesarean section, IV Zidovudine • Give the medications for your baby as directed • Follow-up care for you and your baby after the birth

  13. 10 Action Steps During Pregnancyfor a Healthy Baby • Review HIV status (viral loads, CD4 counts, STIs, etc.) • Review health of pregnancy status (previous pregnancies, deliveries, additional health concerns and healthy steps) • Provide Understanding and Support for Disclosure • Create a pregnancy plan with the mother (family) • Problem solve effective therapy • Initiate an ARV regimen per the guidelines • Confirm adequate response to ARVs in 2-4 weeks • Monitor adherence and response at least every 3 months and at least in each trimester (especially at 34-36 weeks) • Create a delivery plan based on all the data – review it serially • Implement the delivery plan and follow-up for mother and infant

  14. 10 Action Steps in Labor & Deliveryfor a Healthy Baby • Assess labor progression and delivery imminence • Confirm HIV status (1st and 3rd trimester testing) or Do Rapid Testing • Review[if HIV +] the ARV regimen, viral loads, CD4 counts, STIs, etc. • Clarify health of pregnancy (previous pregnancies, deliveries, additional health concerns in this pregnancy and healthy steps by the mother) • Create a plan for a safe delivery ( continue ARV regimen, arrest labor, IV zidovudine, cesarean section, other interventions) • Involve the pediatrician as indicated • Implement the safe delivery plan • Optimize maternal post-partum care (delivery completion, continuation of ARVs, indicated testing and vaccinations, follow-up) • Confirm interventions for the infant (testing, ARV regimen, Proscribe breastfeeding and pre-mastication of infant foods, follow-up) • Connect the mother and infant to local perinatal coordinator

  15. Pregnancy Plan • Set the dates for Prenatal Care • Review all your options • Ask about the perinatal coordinator and a pediatrician • Understand and document your medications lab results / dates – CD4, Viral Loads • Go over the decision-makingabout a Cesarean section • Understand the important signs for delivery Bleeding Rupture of membranes Labor pains Changes in temperature, blood pressure, edema, etc. • Communicating your health status with the Delivery Room staff • Plan for your Baby’s needs – medications, No breastfeeding, follow-up and testing for HIV, No pre-mastication of food • What to do after delivery for your health and your infant’s health

  16. Functional Cure for Infants • Recognize the “High Risk” for infection early • Discuss the risk and present a plan (before, during and after delivery as possible) • Initiate “Empiric Treatment” for HIV Infection within hours of delivery (2 hours – 36 hours) • Current approved medications  Lamivudine, Emtricitabine, Zidovudine, Nevirapine, Stavudine • Potential additional future ARVs  Darunavir (approved for > 3 years, + liquid) Raltegravir (approved for > 2 years, (-) liquid) Lopinavir/ritonavir (approved for > 4 weeks, + liquid) Tipranavir (approved for > 2 years, + liquid) Ritonavir (approved for > 4 weeks, + liquid)

  17. Perinatal HIV Transmission Prevention:Getting to ZERO 1. Take the GUIDELINES to the trenches 2. Create Community Perinatal Prevention Teams 3. Facilitate Communication – EMRs and data 4. Develop Performance Measures for PreventionTesting in 1st& 3rd trimester (HIV Ag/Ab tests, or viral loads / CD4 counts) Rapid testing at delivery (as needed) Implementation of appropriate delivery plans Initiate pediatric interventions per the guidelines

  18. Perinatal HIV Transmission Prevention:Getting to ZERO 4. Apply Performance Measures across the state 5. Empower and support women 6. Make Perinatal Prevention everyone’s priority 8. Review systems practices and performance in any facility where an HIV infected infant is born  Provide training and technical assistance

  19. Special Thanks Yvette Rivero, BS, MPH, Perinatal Prevention Director HIV/AIDS Surveillance and Prevention Florida Department of Health in Broward CountyScott Mickley, HIV/AIDS Surveillance Coordinator Florida Department of Health in Escambia County       for their assistance with scheduling the chart reviews

  20. Special Thanks Rashida Marshall, BS, Statewide Perinatal Coordinator Florida Department of HealthMarlene LaLota, MPH, Program AdministratorHIV/AIDS Prevention Program, Florida Department of Healthfor their data, organizational assistance, and the broad participation of the Florida Department of Health

  21. Special Thanks Sheryl Carney, BA, RN, Florida/Caribbean AETC South East Program Coordinator Perinatal Nurse Educator, University of Miami Miller School of MedicineClara Leach, RN, BSN, Program ManagerPerinatal HIV Prevention ProgramUniversity of South Florida, Center for HIV Education and ResearchFor their zeal for this topic and heroic organizational efforts

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