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 mcaffery_at_ucsd.edu

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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

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Perinatal HIV Testing in San Diego

• Actively promoted since early 1990s
• 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

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Outreach to Promote Rapid HIV Testing on LD

• 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

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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

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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

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Rapid HIV Test

• Acceptable Bulterys M, (MIRIAD) Study
• LD rapid testing logistically feasible
• CDC MIRIAD study others
  
• Reliable and reasonably priced rapid tests are
  licensed and available in the U.S.
• Lampe, 2004
• MTCT Interventions effective
• Wade, et al, 1999 NEJ M

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Lessons LearnedPlanning 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 certification for rapid test

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Reactive Control
Positive
Positive
Negative
Read results in 20-40 minutes
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Lessons LearnedImplementing 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

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Lessons LearnedPlanning 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

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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

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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

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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

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Lessons LearnedChange takes time

• Implement test
• Monitor process
• Evaluate and conduct CQI
• Acknowledge results

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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

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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

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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/rr5
  019References
• 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/pe
  rinatal
• 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-labordelivery.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 14833-54
• HIV Counseling and Rapid Testing in Labor PPT
  376KDate 11/2003 Source AETC National
  Resource Center, www.aidsetc.org

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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