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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

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Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

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

  • 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)

  • 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

  • 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.)

  • 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

Breakfast Meetings

8:00 amRegistration and Breakfast

8:45 amWelcome and Overview

9:00 amWhat We Know About Perinatal HIV Transmission

9:30 amHIV Counseling and Rapid Testing in Labor

10:15 amBreak

10:30 amIssues and Experiences: Panel Discussion

11:30 amEducational Strategies

11:50 amEvaluations

12:00 noonAdjourn


Educational support materials

Educational Support Materials

  • 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

Overview

Scope of the Problem

What We Know about Reducing Perinatal HIV Transmission


Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

  • AIDS in women has risen from 7% early in the epidemic to 27% of adult cases

  • 163,396 AIDS cases in women reported through December 04

  • 118 new AIDS cases reported in children <14

  • 10,000–20,000 children living with HIV infection

  • 280–370 babies born each year with HIV infection

Epidemic in the US Among Women and Children, 2003


Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

  • 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


Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

Factors Influencing 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

  • Obstetrical Factors

    • Length of ruptured membranes and/or chorioamnionitis

    • Vaginal delivery (VL >1000)

    • Invasive procedures

  • Infant Factors

    • Prematurity

    • Breastfeeding


Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

  • Women with HIV infection in the US should not breastfeed

  • Women considering breastfeeding should know their HIV status

Breastfeeding and HIV Infection


Implementation of a statewide standard of care for rapid testing of women in labor with unknown hiv serostatus

  • A phase III randomized placebo-controlled trial of 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

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

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. 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.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.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

  • See: Provider Script

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


Results

Results

  • 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.)

Follow-up Survey of Change in Practice

Pre-Training (n-104)

Percent

4-Months Post Training (n – 38)

( p < . 01)


Results cont1

Results (cont.)

Change in practice (cont.)

Pre-Training

Percent

4-Months Post Training

( p < .01)


More results

More Results

  • 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

  • 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

  • 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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