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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 mcaffery@ucsd.edu. 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
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 mcaffery@ucsd.edu

san diego california
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
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
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
slide5

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
slide6

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
slide7

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

slide8

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
slide9

Reactive Control

Positive

Positive

Negative

Read results in 20-40 minutes

slide10
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
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
slide12

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
slide13

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
slide14

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
Lessons Learned:Change takes time
  • Implement test
  • Monitor process
  • Evaluate and conduct CQI
  • Acknowledge results
lessons learned
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
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
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
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.org Resources on women and rapid testing
  • Perinatal HIV Preventions Toolkit California Perinatal Quality Care Collaborative www.cpqcc.org