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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.

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rapid testing in labor and delivery
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
slide2

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Users are cautioned that due to the rapidly changing field of Perinatal HIV care, this information could become outdated quickly.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.

national hiv aids clinicians consultation center ucsf san francisco general hospital

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)

pacific aetc rapid testing in labor and delivery project
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
eliminating perinatal hiv transmission missed opportunities case 1
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
eliminating perinatal hiv transmission missed opportunities case 16
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
slide7
What were the missed opportunities?

HIV test during pregnancy

ARV prophylaxis

ARV for maternal health

eliminating perinatal hiv transmission missed opportunities case 2
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
eliminating perinatal hiv transmission missed opportunities case 29
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
slide10

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
eliminating perinatal hiv transmission missed opportunities case 3
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
eliminating perinatal hiv transmission missed opportunities case 312
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
slide13

What were the missed opportunities?

HIV test during pregnancy

Rapid test on L&D

ARV prophylaxis

Formula feeding for infant

eliminating perinatal hiv transmission missed opportunities case 4
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
eliminating perinatal hiv transmission missed opportunities case 415
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
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What were the missed opportunities?

HIV counseling and test during pregnancy

Rapid Test on L&D

ARV prophylaxis

eliminating perinatal hiv transmission missed opportunities case 5
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
slide18

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

eliminating perinatal hiv transmission missed opportunities case 6
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
slide20

What were the missed opportunities?

HIV test during pregnancy

Rapid test before delivery

ARV prophylaxis

ARV for maternal health

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