Perinatal HIV Hotline Perinatal HIV Clinicians Network

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Perinatal HIV Hotline Perinatal HIV Clinicians
Network

• Jess Fogler, MD
• Shannon Weber, MSW
• All Titles Conference, Washington DC
• August 27th, 2006

jfogler_at_nccc.ucsf.edu sweber_at_nccc.ucsf.edu
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Incidence of Perinatally-Acquired AIDS United
States, 1985-2000
Reported through December 2000
Slide credit L. Mofenson
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Mother-to-Child TransmissionUnited States

• U.S. Public Health Success Story
• 6,000-7,000 HIV women give birth/yr
• Before 1994 25 transmission
• Today
• Number of infected infants born in U.S.
• Before 1994 2,000/yr
• Now

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Mother-to-Child TransmissionUnited States

• Factors leading to reduced transmission
• Enhanced prenatal HIV counseling and testing
• Use of highly active antiretroviral therapy
  (HAART) by pregnant women
• Increase in elective cesarean delivery for women
  with HIV viral loads 1000 c/mL

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Clinicians Needs

• Clinicians require information and expert
  consultation
• HIV testing for pregnant women/infants
• Rapid testing
• Antiretroviral (ARV) use
• pregnancy and labor delivery
• Care of HIV-exposed newborns
• Interpretation and application of information
  contained in the USPHS perinatal guidelines

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Clinicians Needs

• Some issues require urgent consultation
• Interpretation of rapid HIV tests in labor
• Management of ARVs during labor and delivery
• Mode of delivery
• Initial PEP choice for exposed infants

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Clinicians Needs

• Pregnant women and their infants also need
  referral to competent clinicians or consultants
  in their local areas.
• To Meet These Needs

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National Perinatal HIV Consultation and Referral
Service 888-448-8765

• Perinatal Hotline 24-hour telephone consultation
  to assist clinicians in caring for HIV-infected
  women and their exposed infants.
• Perinatal HIV Clinicians Network a service to
  help clinicians connect their patients with
  HIV-experienced providers.

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National Perinatal HIV Consultation and Referral
Service 888-448-8765

• Part of the National HIV/AIDS Clinicians
  Consultation Center
• A component of the AIDS Education and Training
  Centers (AETC) program funded by the Ryan White
  CARE Act
• Administered by the Health Resources and Services
  Administration (HRSA) HIV/AIDS Bureau, in
  partnership with the Centers for Disease Control
  and Prevention (CDC)

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National Clinicians Consultation Center

• Warmline 800-933-3413
• National HIV Telephone Consultation Service
• Consultation for clinicians with HIV management
  questions
• PEPline 888-448-4911
• National Clinicians Post-Exposure Prophylaxis
  Hotline Recommendations on managing occupational
  exposures to bloodborne
• pathogens
• Perinatal Hotline [phone]
• National Perinatal HIV Consultation and Referral
  Service
• Advice on managing HIV-infected pregnant women
  and
• HIV testing in pregnancy
• University of California San Francisco
• San Francisco General Hospital
• Supported by
• Health Resources and Services Administration
  (HRSA)
• AIDS Education and Training Centers (AETCs)
• and Centers for Disease Control and Prevention
  (CDC)

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Perinatal Hotline

• Staffed by physicians and clinical pharmacists
  with expertise in perinatal HIV care
• Available to all health care providers
• Free of charge and confidential
• 24-hour, live consultation
• 8am-8pm EST
• Full staff available
• After hours/weekends/holidays
• On-call clinician takes calls via answering
  service

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Perinatal Hotline

• Since inception 12/1/2004
• Average 30 calls per month

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(No Transcript)
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Perinatal Hotline Caller Profession
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Perinatal Hotline Caller HIV Patient Load
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Perinatal Hotline Caller Facility Type
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Perinatal Hotline Caller Location
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Calls 362 Average number topics per call 3.3
Data set 1/05-3/06
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Conclusions

• Clinicians questions about perinatal HIV care
  fall into four major categories
• 36 management of HIV in pregnancy
• About three quarters (73.3) addressing ARV
  therapy
• 20 HIV testing in pregnancy
• Few calls about rapid testing

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Conclusions

• 17 care of HIV-exposed infants
• Most calls about use of post-exposure prophylaxis
  and testing
• 14 labor delivery
• Some women in active labor when timely decisions
  needed to be made

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Sample Call 1

• Perinatal Hotline Call ID4377
• Question Which ARVs in this pregnant woman?
• Patient is 24 weeks pregnant and was diagnosed
  with HIV during this pregnancy.
• Initially started on AZT with viral load drop
  from 38k to 11k.
• 3TC was then added with viral load down to
  undetectable.
• Therapy stopped 2 weeks ago due to severe anemia
  from AZT requiring transfusion.
• The patient needs to restart ARVs. What is
  suggested?

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Sample Call 1

Answer Generally want pregnant patients on
fully suppressive triple combination therapy.
Rarely use mono or dual therapy these days.
Always best to have AZT as part of the regimen
unless serious maternal toxicity (as in this
case). Could use something like 3TC, tenofovir,
Kaletra.
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http//AIDSinfo.nih.gov
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Sample Call 2
Perinatal Hotline Call ID4199 Question Is
this patient HIV positive? 17 year old pregnant
woman with positive Elisa and indeterminate WB.
Tests repeated 6 weeks later and Elisa positive
with WB still indeterminate. Viral load was
undetectable. How to interpret? Should this
person be started on ARVs?

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Sample Call 2

Answer This patient is HIV-1 negative.
Pregnancy increases the number of false positive
Elisas. Some people have polymorphisms that
cause them to have an indeterminate WB. No need
to start ARVs.
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New CDC Testing Guidelines

• CDC recommendations will be updated in 2006
• At least one HIV test for everyone 13-64 years,
  Opt-out approach
• No pretest counseling, no consent forms required
• Annual testing for high-risk patients
• For pregnant women
• Routine 1st trimester opt-out testing
• Repeat testing in 3rd trimester for women in high
  prevalence areas ( 1)

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Opt InOpt Out

• Opt-in, in which each pregnant woman is provided
  with pre-HIV test counseling and must
  specifically consent to an HIV test, usually in
  writing.
• Opt-out, in which each pregnant woman is notified
  that an HIV test will be included in the standard
  battery of prenatal tests (e.g., tests performed
  on all pregnant women), and that she may refuse
  the HIV test.

Source CDC http//www.cdc.gov/hiv/projects/perin
atal/materials/OptOutNew3-2.htm
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Opt InOpt Out

• CDC data from medical records 1998 -1999
• Opt-in approach
• 25-69 consented to HIV testing
• Opt-out approach
• 71-98 consented to HIV testing

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Impact of New Testing Guidelines

• Increased testing of low-risk populations
• Decreased positive predictive of test

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Some Definitions.

• Characteristics of a test
• Sensitivity
• Probability test will be positive if patient is
  positive
• Specificity
• Probability test will be negative if patient is
  negative
• applied to a population
• Positive predictive value
• Probability patient is positive if test is
  positive

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Sensitivity and Specificity
Determining sensitivity and specificity of a test
used in 100 healthy individuals and 100
individuals with disease
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Sensitivity and Specificity
Sensitivity true positives / all
positives 95/100 95
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Sensitivity and Specificity
Specificity true negatives / all negatives
90/100 90 10 false positive rate
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Positive Predictive Value High Prevalence
Test 1000 persons with a test having specificity
99.8 HIV prevalence 10 True positives
100 (10/100 100/1000) False positives 2
(2/1000) Positive Predictive Value 100/102
98
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Positive Predictive Value Low Prevalence
Test 1000 persons with a test having specificity
99.8 HIV prevalence 0.2 True positives
2 (0.2/100 4/1000) False positives 2
(2/1000) Positive Predictive Value 2/4 50
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Positive Predictive Value Test Specificity 99.8
0.1 1 2 33
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Sample Call 3

• Perinatal Call ID10290
• Question Need help now!
• 31 year old G2P1 at 323 weeks gestational age
  with no prior prenatal care and reported crack
  use presented to LD today with confirmed PPROM
  for at least 2 days. Contracting painfully every
  2-3 minutes. Patient has had a dose of steroids
  and a rapid HIV test was sent on admission which
  has come back positive.
• What are your recommendations?

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Sample Call 3

• Answer
• Act as if this is a true positive but send
  confirmatory Western blot now
• Start IV AZT, oral 3TC and give a dose of
  nevirapine
• Begin aggressive pitocin augmentation for
  expedited vaginal delivery
• Avoid scalp electrodes, instrumented delivery
• Start PO AZT on the infant. Because of
  prematurity, cannot use nevirapine or 3TC (no
  dosing)

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Rapid Testing in Labor

• CDC recommends routine rapid HIV testing for
  women in labor without documented HIV test
• EIA screening test
• Results in
• 99-100 sensitive and specific
• Needs confirmatory Western blot
• Its not too late to intervene!

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Timing of Mother-to-Child HIV Transmission
(non-breastfeeding)
Early Antenatal (Labor and Delivery
Late Antenatal (36 wks to labor)
0
20
40
60
80
100
Proportion of infections
Slide credit L. Mofenson
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Importance of the Infant Pre- and Post-Exposure
Prophylaxis
30
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Transmission
15
10
9
6
0
APIPPP IPPP PP48 hr No AZT
Even When No Maternal AZT Received, Infant AZT
Started Within 24 Hours Reduces Transmission
Wade N et al. N Engl J Med 19993391409
Slide credit L. Mofenson
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Rapid Testing in Labor

• Positive Tests
• Positive predictive value 50 (depending on
  local prevalence)
• Act on all positive rapid tests as true positives
  (until confirmatory test)
• Initiate meds in mom ASAP
• Consider using expanded regimen for mom and
  infant
• Consult local perinatal HIV experts or call the
  Perinatal Hotline [phone]

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Rapid Testing in Labor

• A critical component of eliminating perinatal HIV
• implementation can be complex
• Requires coordination of health care providers,
  LD, laboratory, hospital administration, risk
  management etc.

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Rapid Testing Resources

• CDC Rapid HIV-1 Antibody Testing during Labor
  and Delivery for Women of Unknown HIV Status A
  Practical Guide and Model Protocol
• http//www.cdc.gov/hiv/rapid_testing/rtlabordeliv
  ery.htmintro2
• http//www.cdc.gov/hiv/projects/perinatal/labor_de
  livery.htm
• Local Trainings (CDC)
• http//www.cdc.gov/hiv/rapid_testing/training.htm
  CalSF

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Perinatal Hotline Consultant Group

• A group of national experts convenes on a
  quarterly basis to discuss difficult calls to the
  Perinatal Hotline
• Emerging issues
• Weighing risks and benefits of interventions for
  both mom and fetus
• Applying evidence to clinical practice

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Perinatal Hotline Consultant Group

• Recent topics
• High risk labor and delivery situations
• Mode of delivery
• Maternal resistance
• Prematurity

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Perinatal Clinicians Network

• A network of clinicians with perinatal HIV
  expertise
• Perinatal Hotline callers can be linked with
  local resources in the network
• For support, consultation, co-management or
  transfer of care for their patients
• Coordinator Shannon Weber, MSW
• sweber_at_nccc.ucsf.edu

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Perinatal Clinicians Network

• Building the network
• Database of HIV-experienced clinicians
• Obstetricians
• Infectious Diseases specialists
• Nurse Midwives
• Pediatricians
• Family Physicians

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Perinatal Clinicians Network

• Building the network
• Identifying existing local and regional networks
  of providers
• City
• State
• Ryan White Clinics

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Perinatal Clinicians NetworkCase 1

• The Perinatal Hotline received a call from an
  Obstetrician whose patients routine first
  trimester HIV screen was positive. The clinician
  had never cared for an HIV-positive patient
  before and wanted guidance about delivering test
  results and clinical care.
• After answering the callers clinical questions,
  the NCCC consultant referred the call to Shannon
  Weber.

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Perinatal Clinicians NetworkCase 1

• Shannon contacted a member of the Perinatal
  Hotline Consultant Group and an academic center
  in the callers area.
• Caller was linked with a clinician in the nearest
  suburban area who agreed to co-manage the case or
  accept the patient as a referral.

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Perinatal Clinicians NetworkCase 2

• An obstetrician in an urban area called the
  Perinatal Hotline seeking an HIV provider to help
  manage a pregnant HIV-positive patient.

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Perinatal Clinicians NetworkCase 2

• Shannon linked the obstetrician with local
  specialists who care for HIV-positive pregnant
  women, and the caller subsequently referred the
  patient to a local program.

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Perinatal Clinicians NetworkCase 3

• A social worker in a rural area with a recent
  increase in perinatal transmission cases called
  looking for Perinatal HIV resources. The areas
  HIV community is holding an upcoming training for
  local clinicians on Perinatal HIV to address ways
  to decrease the transmission rate.

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Perinatal Clinicians NetworkCase 3

• A clinician who assisted in a prior Perinatal
  Clinicians Network linkage offered to see clients
  from the area for the primary visit (four hours
  away) and to co-manage by telephone thereafter.
• Additionally, appropriate clinicians located one
  to two hours from the rural area were identified.
  
• The social worker incorporated Perinatal Hotline
  materials into the training and made contact with
  the local clinicians to further the collaboration.

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How Can the Perinatal Hotline and Clinicians
Network Help You?

• Consults on the phone
• One-time consultations
• Follow patients with you
• Offer second opinions about controversial issues
• Up to date evidence-based information
• Keep you informed of changes to the guidelines
• Send testing and treatment protocols
• Offer information about start up of rapid testing
  
• Materials, brochures, slides
• Help link patients with specialized local care
  through the Clinicians Network

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How Can You Help the Perinatal Hotline?

• Post NCCC phone numbers in vital areas
• Promote our program particularly at specialized,
  local conferences
• Participate in our Perinatal HIV Clinicians
  Network

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NCCC Faculty and Staff

• RONALD GOLDSCHMIDT, M.D., NCCC Director
• rgoldschmidt_at_nccc.ucsf.edu
• RICHARD ARANOW, M.D.
• raranow_at_nccc.ucsf.edu
• LARRY BOLY, M.D.
• lboly_at_nccc.ucsf.edu  
• HALLEY CORNELL, AETC Liaison
• hcornell_at_nccc.ucsf.edu
• GRACE M. DAMMANN , M.D.
• gdammann_at_nccc.ucsf.edu  
• BETTY J. DONG, Pharm.D.
• bjdong_at_itsa.ucsf.edu  
• JOSÉ EGUÍA, M.D.
• jeguia_at_itsa.ucsf.edu 
• JESS FOGLER, M.D.
• jfogler_at_nccc.ucsf.edu
• AMY GARLIN, M.D.
• agarlin_at_nccc.ucsf.edu 
• HAZEL GEORGETTI, B.A. ,

• CRISTINA I. GRUTA, Pharm.D.
• cgruta_at_nccc.ucsf.edu
• ANN HARVEY, M.D.
• aharvey_at_nccc.ucsf.edu
• AMY V. KINDRICK, M.D., M.P.H.
• akindrick_at_nccc.ucsf.edu
• GIFFORD LEOUNG, M.D.
• leoung_at_itsa.ucsf.edu
• MEGAN MAHONEY, M.D.
• mmahoney_at_itsa.ucsf.edu
• MEG NEWMAN, M.D.
• mnewman_at_php.ucsf.edu
• NANCY NGUYEN, PHARM.D.
• nnguyen_at_nccc.ucsf.edu
• PARYA SABERI, PHARM.D.
• parya.saberi_at_ucsf.edu  
• HELENA TANG, PHARM.D.
• htang_at_nccc.ucsf.edu  
• JASON TOKUMOTO, M.D.