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Family-Centered Case Management An Essential Component in Reducing Mother-to-Child HIV Transmission


Family-Centered Case Management An Essential Component in Reducing Mother-to-Child HIV Transmission CitiMatCH Expedition 2004: Exploring the Boundaries of Urban MCH – PowerPoint PPT presentation

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Title: Family-Centered Case Management An Essential Component in Reducing Mother-to-Child HIV Transmission

Family-Centered Case Management An Essential
Component in Reducing Mother-to-Child HIV
  • CitiMatCH Expedition 2004 Exploring the
    Boundaries of Urban MCH
  • Portland, September 11-14, 2004
  • Mary E. Caffery, RN, MSN University of
    California, San Diego
  • Mother, Child Adolescent HIV Program

  • Scope of the HIV Epidemic in the U. S.
  • Among Women and Children
  • AIDS in women has risen from 7 early in the
    epidemic to 24 of adult cases today
  • 141,000 AIDS cases in women reported through June
  • 5-6,000 HIV positive women give birth annually
  • 280370 babies continue to be born each year with
    HIV infection

  • CDC, 2003

  • Mother to Child HIV Transmission
  • Without antiretroviral therapy during pregnancy,
    mother-to-child transmission has ranged from
    1625 in North America and Europe
  • 21 transmission rate in the US in 1994
  • Pediatric AIDS Clinical Trial Group 076 defined
    role of zidovudine (ZDV) in reducing transmission
  • With use of ZDV, transmission was 11 in 1995
  • Risk of perinatal transmission can be lt2
  • highly active antiretroviral therapy (HAART)
  • elective cesarean section (C/S) as appropriate
  • formula feeding

San Diego
  • 2.9 million residents
  • 35,000 births/yr
  • 16 labor and delivery sites
  • 12 of recent AIDS
  • cases were women
  • 40 HIV pregnant
  • women/year

California Legislation Perinatal HIV
  • 2003 Dutra Bill AB 1676
  • All prenatal providers required to include HIV
    testing as routine, with Hepatitis B screening
  • Offer test at delivery
  • Report results

HIV infected women often face multiple challenges
accessing HIV services, prenatal care and
postpartum care
  • Poverty, language barriers, illiteracy,
  • Substance abuse, mental illness,
  • domestic violence
  • Inadequate transportation, unstable housing,
  • Unemployed
  • Inadequate or lack of insurance

  • Urban health care systems are complex and often
    difficult to navigate, especially by clients who
    do not speak English, experience distrust with
    systems, are fearful, depressed or are
    stigmatized with HIV or other issues

System Barriers
  • Community prenatal care providers lack expertise
    in the delivery of services to HIV infected
    pregnant women.
  • Traditional HIV case management programs lack
    capacity to provide prenatal guidance, or manage
    pregnancy related health and psychosocial issues.

  • To promote optimal maternal and infant health
    through improved access to prenatal and HIV
  • Comprehensive and integrated case management for
    HIV infected pregnant women will improve
    utilization of prenatal care, HIV care,
    interventions to reduce perinatal HIV
    transmission and infant diagnostic screening

  • The Perinatal HIV Collaborative distributed
    10,000 HIV brochures in English and Spanish to
    perinatal providers promoting testing and
    referral of HIV infected clients for care and
    case management
  • Prenatal providers received training in HIV
    testing for pregnant women and availability of
  • Utilizing Title I and Title IV funding, a
    University -based maternal child HIV program
    implemented a family-centered HIV case management
    program to integrate HIV care and prenatal care

Perinatal HIV Case Management Services
  • Highly skilled, bi-lingual clinical social
    workers with extensive experience in womens
    health provided comprehensive social services
    including outreach, case management, mental
    health assessments, psychosocial counseling,
    health education, partner testing and postpartum
    follow-up for the mother and her infant

Goals of Case Management Services
  • Assistance with basic needs
  • housing, transportation, food, child care,
  • Help obtaining health benefits, accessing
    prenatal care
  • Coordination of health and social services
  • Substance abuse, mental health dental,
    legal, peer-support, childbirth
    education, parenting classes employment/school
  • Referrals to health professionals community
  • HIV education for clients, partners, families and
    the community

Prenatal Case Management Services
  • Initiated immediately at referral from test site,
    obstetric office and continued post-partum
  • Case managers conduct extensive psychosocial
    assessment and developed family centered
    treatment plans
  • Visits conducted at clinic and home
  • Average contact Bi-weekly face-to-face Week
    ly phone calls

  • Case Management of
  • HIV Exposed Infants
  • Discharge planning with ZDV prophylaxis for 6
  • HIV diagnostic testing (PCR) to establish or rule
    out HIV infection as early as possible
  • Linkages to an HIV specialist, primary care
  • Long-term followup
  • Provide anticapatory guidance and
  • social services for the family

Case Management of Postpartum Women
  • Primary and HIV specialty care
  • OB/GYN and family planning services
  • Mental health and substance abuse treatment
  • Coordination of care for the woman family
  • Support services for the family

With intensive case management
  • Clients addressed behavioral goals to reduce risk
    for mother -to-child HIV transmission
  • Reduced substance use and increased use of
    recovery programs
  • More women and partners practiced safer sexual
  • More women increased participation in general
    prenatal wellness measures
  • improvements in nutrition
  • less smoking
  • more exercise

  • 100 of women obtained
  • prenatal care
  • 92 of women were retained in care
  • 90 of women obtained funding for
    prenatal services

  • 92 of clients actively participated in
  • health education
  • 100 received substance abuse education,
    adherence counseling and safer sex
  • 100 of women received mental health assessments
    and referrals for supportive services

  • 100 of clients obtained ante-partum
    antiretroviral medication to prevent perinatal
    HIV transmission
  • 96 of women received intra-partum
    antiretroviral medication
  • 100 of newborns received ZDV prophylaxis

  • 100 of clients obtained at least three lab tests
    to confirm infant diagnosis
  • No cases of Mother-to-Child HIV transmission

Key Players
  • County of San Diego Department of Health Human
    Agency (HHSA) Funded brochure, provided HIV
    education, provider education and public health
    nursing services, offered HIV testing, and
    provided outreach and case management through
    Ryan White Title I funds
  • UCSD Mother, Child Adolescent HIV Program
  • Sub-contractor with County HHSA for Case
    Management Services for Women and Children.
    Provided expertise in HIV and reproductive health
    care, infant screening and medical care.
    Provided Ryan White Title IV funding for
    wraparound HIV services for families. Retained
    social worker with MSW/MPH, extensive experience
    in womens health works with health care team to
    integrate HIV/Prenatal care. Collected data and
    conducted evaluation to monitor outcomes
  • Community Based Agencies
  • Southeast Abundant Resource Center Community
    agency provides strollers, car seats, and baby
    supplies to families.
  • Christies Place Community agency provides
    counseling, childcare, support groups, and
    personal hygiene products to families

Lessons Learned
  • What works?
  • Collaboration works!
  • An integrated system of educating providers and
    consumers increased testing and referrals for
  • Focused efforts on the elimination of perinatal
    HIV transmission are necessary especially in
    communities that do not have high HIV

Lessons Learned
  • Integration and creative use of funding
    stretched limited resources
  • The group delegated the tasks to the most
    logical providers MCH Division) distributed the
    brochures and the Division of Community
    Epidemiology, as a subcontractor with the
    State/CDC perinatal HIV initiative conducted
    provider training
  • The HHSA Office of AIDS Coordination funded case
    management, and the University HIV program
    provided case management and co-located HIV,
    reproductive health and pediatric follow-up

  • What doesnt work?
  • Inadequate funding. More funding is needed to
    fully implement this community wide approach
  • What would we do differently
  • This program would have been even more effective
    if we had obtained additional funding to permit
    smaller case management caseloads

Overcoming Barriers
  • Greatest barrier
  • Lack of adequate attention on HIV and women
    results in limited resources for outreach, care,
    and case management
  • How are barriers being overcome?
  • Continuing efforts to educate community
  • Collaboration with the AIDS Education and
    Training Center to train more providers and
    Regional Perinatal System to promote HIV testing
    and care during pregnancy
  • Private funding has been secured for social
    marketing and distribution of brochures
  • More funding is being sought to expand case
    management program

What is the take home message from this promising
  • When a community collaboration is committed to
    reducing mother to child HIV transmission, they
    can organize resources and activities to inform
    the community, educate the health care system,
    and provide the case management, which
    effectively links the pregnant woman, and her
    family to the specialized care that will promote
    maternal/child health and reduce the spread of

  • References
  • 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, June 23, 2004,
  • Revised Guidelines for HIV Counseling, Testing,
    and Referral and Revised Recommendations for HIV
    Screening of Pregnant Women, MMWR, November 9,
    2001/ Vol 50/ RR-19. http//
  • National Pediatric and Family HIV Resource
    Center. Follow-up care for infants born to
    mothers with HIV infection. Newark, NJ
    University of Medicine and Dentistry of New
    Jersey 2001
  • New York State Department of Health AIDS
    Institute. Pediatric and Adolescent HIV
    Guidelines. In Criteria for the Medical Care of
    Children and Adolescents with HIV Infection.
  • Internet-based library of materials on mother and
    child HIV infection can be found at

Contact Information
  • Mary E. Caffery, RN, MSN,
  • UCSD Mother, Child Adolescent HIV Program
  • 150 W. Washington St., 100
  • San Diego, CA 92103
  • 619-543-8080