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Implementation of a Statewide Standard of Care for Rapid Testing of Women in Labor with Unknown HIV Serostatus. The Role of Provider Education Elaine Gross, RN, MS, CNSC and Carolyn Burr, EdD, RN National Pediatric & Family HIV Resource Center/FXB, UMDNJ

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Implementation of a Statewide Standard of Care for Rapid Testing of Women in Labor with Unknown HIV Serostatus

The Role of Provider Education

Elaine Gross, RN, MS, CNSC and Carolyn Burr, EdD, RNNational Pediatric & Family HIV Resource Center/FXB, UMDNJ

Sindy Paul, MD, MPHNew Jersey Department of Health and Senior Services


Background
Background Testing of Women in Labor with Unknown HIV Serostatus

  • Number of infants born with HIV in NJ continues to decrease

  • In 1999 & 2000, 7 of 8 HIV-infected infants were born to women whose status was not known to L & D staff

  • In response, NJ Department of Health and Senior Services (NJDOHSS), after consulting with key stakeholders, developed a Standard of Care for HIV counseling and rapid testing (C & RT) for women in labor with unknown/undocumented HIV serostatus


Background continued
Background (continued) Testing of Women in Labor with Unknown HIV Serostatus

  • NPHRC was funded to help implement the Standard of Care through educational programs, supportive materials and technical assistance

  • The project was a collaboration of NPHRC/FXB, NJDHSS, MCH Consortia and the Academy of Medicine of New Jersey


Methods
Methods Testing of Women in Labor with Unknown HIV Serostatus

  • Model curriculum for C & RT in labor

    • Needs assessment: key informant interviews

    • PowerPoint slides/overheads

    • A “script” for HIV C & RT in labor

    • Model hospital policy/procedure

  • Half day train-the-trainer (TOT) program for OB nurse educators and managers with a focus on skill-building; co-sponsored by NJ MCH Consortia     


Methods cont
Methods (cont.) Testing of Women in Labor with Unknown HIV Serostatus

  • 3-hour CME meeting for OBs, CNM and Advance Practice Nurses (APNs), co-sponsored by the Academy of Medicine of NJ

  • Pre-training survey of all participants about hospital practices regarding HIV C & T for pregnant women

  • Follow-up survey 4 months post training


Nurse t o t agenda
Nurse T.O.T. Agenda Testing of Women in Labor with Unknown HIV Serostatus

Breakfast Meetings

8:00 am Registration and Breakfast

8:45 am Welcome and Overview

9:00 am What We Know About Perinatal HIV Transmission

9:30 am HIV Counseling and Rapid Testing in Labor

10:15 am Break

10:30 am Issues and Experiences: Panel Discussion

11:30 am Educational Strategies

11:50 am Evaluations

12:00 noon Adjourn


Educational support materials
Educational Support Materials Testing of Women in Labor with Unknown HIV Serostatus

  • Script for counseling in labor

  • Generic hospital policy/procedure

  • Slide set and case studies for educating staff

  • Patient education materials


Overview

some slides from the program Testing of Women in Labor with Unknown HIV Serostatus

Overview

Scope of the Problem

What We Know about Reducing Perinatal HIV Transmission


Epidemic in the US Among Women and Children, 2003


  • Without antiretroviral (ARV) drugs during pregnancy, perinatal transmission ranged from 16%–25% in North America and Europe

  • US transmission before zidovudine (ZDV) prophylaxis was 21%

  • Today, risk of perinatal transmission can be <2% with:

    • highly effective ARV therapy

    • elective cesarean section (C/S) as appropriate

    • formula feeding

Perinatal HIV Transmission


Factors Influencing perinatal transmission ranged from Perinatal Transmission

  • Maternal Factors

    • HIV-1 RNA levels (viral load [VL])

    • Low CD4+ lymphocyte count

    • Co-infections: Hepatitis C, CMV, BV

    • Maternal injection drug use


Factors influencing perinatal transmission
Factors Influencing perinatal transmission ranged from Perinatal Transmission

  • Obstetrical Factors

    • Length of ruptured membranes and/or chorioamnionitis

    • Vaginal delivery (VL >1000)

    • Invasive procedures

  • Infant Factors

    • Prematurity

    • Breastfeeding


Breastfeeding and HIV Infection


  • A phase III randomized placebo-controlled trial of perinatal transmission ranged from ZDV for preventing maternal-fetal HIV transmission

    Treatment Regimen

    • Antepartum 100 mg ZDV po 5x day, started at 14–34 weeks gestation

    • IntrapartumDuring labor, 1-hour initial dose 2 mg/kg IV followed by continuous infusion of 1 mg/kg until delivery

    • Postpartum/Infant Regimen2 mg/kg po q 6 hr for 6 weeks, start 8–12 hours after birth

ACTG 076


Maria
Maria perinatal transmission ranged from

Case studies

Maria J. (former IVDU) is 32 weeks gestation, tested HIV negative at her 1st prenatal visit during the second trimester. This is her 3rd pregnancy, she has a history of STDs and genital herpes. She reports that her partner sometimes refuses to wear a condom and he “gets very angry about it, especially when he’s had a few drinks.” This visit she complains about a yellowish vaginal discharge that itches.

  • What are the issues in this case?

  • Should Maria be retested for HIV infection?


Late presentation
Late presentation perinatal transmission ranged from

Ms. R is admitted from the ER fully dilated and pushing. According to her chart, she had 2 prenatal visits for care and this is her 4th baby. Her history leads you to believe she is at risk for HIV.

  • What are the issues?


Ms m a negative test during labor
Ms M. perinatal transmission ranged from A negative test during labor

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.

Ms M: asks for reassurance that the negative test is truly negative


Mrs q no record of hiv test private patient
Mrs. Q. perinatal transmission ranged from No record of HIV test, private patient

Mrs. Q’s prenatal record does not indicate an HIV test during this pregnancy. She’s a private patient of the acting Chief of OB.

When the nurse offers Mrs Q. rapid HIV testing she says: “What kind of woman do you think I am?”


Ms g language as a barrier
Ms. G. perinatal transmission ranged from Language as a barrier

Ms. G. has just been admitted to L&D. No HIV test results are on her chart. Her husband and her mother are with her. The family speaks little English.

Husband: concerned about wife; keeps asking for “DOCTOR”

Mother: refuses to leave her daughter


Provider guide to counseling
Provider Guide to Counseling perinatal transmission ranged from

  • See: Provider Script

  • Script was developed by key informant interviews and focus groups of postpartum women


Results
Results perinatal transmission ranged from

  • 5 Nurse TOT reached 138 nurses representing 72 hospitals

  • 3 CME meetings (n – 91)

    • 26 MDs

    • 21 Nurse Midwives/APNs

    • 26 OB nurses

    • 18 others

  • Post training follow-up survey 38/57 (67%)


Results cont
Results (cont.) perinatal transmission ranged from

Follow-up Survey of Change in Practice

Pre-Training (n-104)

Percent

4-Months Post Training (n – 38)

( p < . 01)


Results cont1
Results (cont.) perinatal transmission ranged from

Change in practice (cont.)

Pre-Training

Percent

4-Months Post Training

( p < .01)


More results
More Results perinatal transmission ranged from

  • 75% of the nurses in the follow-up survey said the workshop had a positive/very positive impact on how they provided services to women at risk for HIV

  • 38% of the nurses used the curriculum to train colleagues


Conclusions
Conclusions perinatal transmission ranged from

  • HIV C & T for women in labor is a sensitive and uncomfortable practice for OB providers and for women

  • Targeted provider education using multiple strategies can increase a hospital’s response to recommendations for HIV C & RT in labor

  • Change in hospital practices. More women were being asked their HIV status in labor, offered rapid testing and treatment


Conclusions1
Conclusions perinatal transmission ranged from

  • Partnering with MCH and HIV professional organizations helped to reach the target audiences

  • This project was an important part of a state’s efforts to reduce perinatal transmission through the implementation of a standard of care for HIV C & RT of women in labor with unknown or undocumented HIV status


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