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Implementing Rapid Testing on Labor and Delivery Units in San Diego County, Lessons Learned. Mary E. Caffery, RN, MSN, UCSD Mother, Child & Adolescent HIV Program 619-543-8080 [email protected] San Diego California. 3.1 million residents 35,000 + births annually

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Implementing Rapid Testing on Labor and Delivery Units in San Diego County, Lessons Learned

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Implementing Rapid Testing on Labor and Delivery Units in San Diego County, Lessons Learned

Mary E. Caffery, RN, MSN,

UCSD Mother, Child & Adolescent HIV Program

619-543-8080 [email protected]


San Diego California

3.1 million residents

35,000 + births annually

15 labor and delivery sites

11% of recent AIDS cases

were women

0.07% among women of

childbearing age are HIV +

Prenatal HIV testing rates 50 - 95%


Perinatal HIV Testing in San Diego

  • Actively promoted since early 1990’s

  • Increased after 1994 legislation and 076

  • 2004 Committee with UCSD, DHHS, PAETC developed and disseminated community standards for testing and care

  • Increased testing post Dutra Bill AB 1676

  • 2004 rapid testing introduced by DHHS


Outreach to Promote Rapid HIV Testing on L&D

  • Letter sent 2004

  • Follow up calls

  • 0 / 15 hospitals

  • Success of rapid testing program implemented by DHHS

  • Through Ryan White Title IV and AETC we began to offer information, consultation, training to hospitals

  • 50% of hospitals


UCSD Labor & Delivery Unit

  • Tertiary Care Center

  • 250 births monthly

  • 4% of women have no prenatal care

  • Estimates of patients with no HIV lab results available: 20%

  • Delivers 25 HIV positive women from Mother-Child HIV Program annually


Rapid Testing

  • Women who do not receive prenatal care

  • Pregnant women who seek prenatal care late or erratically

  • Women who receive prenatal care but are not offered testing

  • Women who test negative early in pregnancy, but have on-going risk

  • Women who do not have test results

  • Women at high risk:

    • women with an HIV positive partner,

    • new partner

    • sexually transmitted infection

    • substance abuse


Rapid HIV Test

  • Acceptable Bulterys M, (MIRIAD) Study

  • L&D rapid testing logistically feasible

    CDC MIRIAD study & others

  • Reliable and reasonably priced rapid tests are licensed and available in the U.S.

    Lampe, 2004

  • MTCTInterventions effective

    Wade, et al, 1999 NEJ M


Lessons Learned:Planning a Rapid HIV Testing Program Requires Collaboration

  • Involve key stakeholders: OB, Perinatal Practice Committee, Lab, HIV, Infection Control

  • Obtain extensive buy in

  • Identify Location of Testing:

    • Point of Care in Labor and Delivery or in the Laboratory

  • Choose the Type of Rapid HIV Testing to Use

  • Obtain State lab certificationfor rapid test


Reactive Control

Positive

Positive

Negative

Read results in 20-40 minutes


Lessons Learned:Implementing a Rapid HIV Testing Program Requires Significant Commitment and Resources

  • Develop protocols and consent for test and treatment

    • Consent to test/treat

  • Establish policy and procedures

  • Organize a multidisciplinary system to link testing with treatment, infant care and postpartum follow-up


Lessons Learned:Planning and Implementing a Rapid HIV Testing Program Poses Special Challenges

  • Overcoming stigma of HIV

  • Confidential counseling in labor

  • Informed consent

  • Obtaining and managing test

    results

  • Initiation of rapid treatment

  • Organization of follow-up care


Policy & Procedures for Rapid Testing during Labor and Delivery

  • Defines Eligibility for Rapid HIV Testing

  • Ensures Education, Counseling and Confidentiality of Pregnant Women

  • Defines Interpretation of Preliminary and Confirmatory Testing Results

  • Describes Provision of Results to Patients

  • Defines Clinical Management of Women with positive rapid HIV tests during labor, delivery, postpartum and treatment and testing for her newborn


Lessons Learned: Implementing a Successful Rapid HIV Testing Program Requires Multidisciplinary Staff Training (L & D, Pediatrics, pharmacy, postpartum, ancillary)

  • MTCT HIV Transmission,

  • Role of rapid test, confirmation of results

  • Patient confidentiality, education

  • Obtaining informed consent during labor


Lessons Learned: Implementing a Successful Rapid HIV Testing Program Requires Multidisciplinary Staff Training (L & D, Pediatrics, pharmacy, postpartum, ancillary)

  • Treatment options for positive rapid HIV tests

  • Methods to reduce risk of MTCT transmission

  • Care and diagnostic evaluations for infant,

  • Crisis Intervention, psychosocial aspects of HIV

  • Community resources


Lessons Learned:Change takes time

  • Implement test

  • Monitor process

  • Evaluate and conduct CQI

  • Acknowledge results


Lessons Learned

The keys to effective rapid HIV testing program:

  • Multidisciplinary Planning

  • Clear and concise procedures

  • Coordination of testing, treatment and newborn services

  • Training/ re-training of personnel

  • Recognition of when the testing/management does not comply with procedures and re-training


Current activities

  • Assist hospitals with the tools they need

    • Rapid tests

    • Policies and procedures

  • Educate providers about the need and their role

    • A script for pre and post-test counseling

    • Information on reduction of MTCT

    • On site educational programs & conferences


References

  • Centers for Disease Control and Prevention. Revised Guidelines for HIV Counseling, Testing, and Referral and Revised Recommendations for HIV Screening of Pregnant Women. MMWR 2001; 50(No. RR-19):59-81

    http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5019References

  • Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, 11/2005 Available at http://aidsinfo.nih.gov/guidelines/perinatal

  • Rapid HIV-1 Antibody Testing During Labor and Delivery for Women of Unknown HIV Status A Practical Guide and Model Protocol. Margaret Lampe

    Available at http://www.cdc.gov/hiv/rapid_testing/rt-labor&delivery.htm

  • American College of Obstetricians and Gynecologists.(ACOG) Committee Opinions304, November 2004

  • Prenatal Screening for HIV, A review of the Evidence for the US Preventive Services Task Force Ann of Intern Med 2005; 148:33-54

  • HIV Counseling and Rapid Testing in Labor [PPT 376K]Date: 11/2003 Source: AETC National Resource Center, www.aidsetc.org


Resources

  • Perinatal HIV Hotline Service 888-448-8765

    Provides 24-hour consultation from HIV experts on treating HIV-infected pregnant women and their children as well as advice on indications and interpretations of HIV testing in pregnancy

  • A comprehensive, Internet-based library of materials on mother and child HIV infection is found at http://WomenChildrenHIV.org

  • Carolyn K. Burr, EdD, RN François-Xavier Bagnoud Center

    UMDNJ

  • AETC http://www.aidsetc.orgResources on women and rapid testing

  • Perinatal HIV Preventions Toolkit California Perinatal Quality Care Collaborative www.cpqcc.org


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