Increasing HIV testing among pregnant women: Results from the Ontario HIV seroprevalence study Robert S. Remis, Carol Swantee, Maraki Fikre Merid, Robert W.H. Palmer, Mark Fisher, Keyi Wu, Susan King, Peggy Millson, Liviana Calzavara, Elaine Whittingham and Carol Major Department of Public Health Sciences, University of Toronto Laboratories Branch, Ontario Ministry of Health and Long-Term Care Hospital for Sick Children 15th International Conference on AIDS Bangkok, Thailand, July 11-16, 2004

Background 1991: HIV prevalence 0.23/1,000 in childbearing women 1991: HIV prevalence 0.23/1,000 in childbearing women 1994: ZDV found to reduce HIV transmission 1994: ZDV found to reduce HIV transmission 1997: Modeled HIV prevalence 0.70/1,000 and % of pregnant women tested for HIV 1997: Modeled HIV prevalence 0.70/1,000 and % of pregnant women tested for HIV

Ontario HIV screening program 1995: Advisory to physicians to consider HIV test for pregnant women at increased risk 1995: Advisory to physicians to consider HIV test for pregnant women at increased risk December 1998: Program to offer HIV testing to all pregnant women December 1998: Program to offer HIV testing to all pregnant women Sep Jan 2002: Memo sent with test report to physicians when HIV test prescribed Sep Jan 2002: Memo sent with test report to physicians when HIV test prescribed Sep 2003: Memo reinstated with refinements Sep 2003: Memo reinstated with refinements

Study objectives Quantify and characterize HIV prevalence among women of childbearing age in Ontario Quantify and characterize HIV prevalence among women of childbearing age in Ontario Evaluate the Ontario HIV screening program Evaluate the Ontario HIV screening program

Data management Data extracted from LAByrinth Data extracted from LAByrinth Prenatal testing records linked to HIV diagnostic database Prenatal testing records linked to HIV diagnostic database Matching allowed for different spelling and structure of Matching allowed for different spelling and structure of name and reversal of month-day in birthdate Tests aggregated into episode equivalent to gestation period and HIV test uptake analysed for pregnancies Tests aggregated into episode equivalent to gestation period and HIV test uptake analysed for pregnancies

Unlinked seroprevalence study For 2002, specimens from women not HIV tested were tested after personal identifiers removed (anonymous, unlinked study) For 2002, specimens from women not HIV tested were tested after personal identifiers removed (anonymous, unlinked study) Data on age group and health region of test retained Data on age group and health region of test retained HIV prevalence examined and compared to that among women tested HIV prevalence examined and compared to that among women tested

Proportion of pregnancies tested for HIV by health region, 1st quarter %38,70843,881Total 87% 88% 90% 87% 92% 90% 89% 91% 10,186 9,191 4,625 6,129 3,220 2,970 2, ,741 10,427 5,162 7,055 3,504 3,310 2, Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP Proportion tested HIV tested Number of preg’s

HIV testing among pregnancies by timing of HIV test, Ontario, Jan 1999-Mar 2004 Proportion of pregnancies (%)

HIV testing among pregnancies for selected health regions, Jan 1999-Mar 2004

Number of PHU’s in each region by proportion tested for HIV, 1st quarter % % %70- 79%60- 69% Total 8 4 3Northern Eastern other 1 1 Ottawa 725Central West Southwest 6 5 Central East other 1 Toronto Total PHU’s Number of PHU’s by proportion of HIV testing uptake 1 1

Number of HIV-positive pregnancies Prior Current Total TOTAL

HIV-positive and number of pregnancies by test status, anonymous unlinked study 2002

Interpretation Based on recent analysis, actual uptake of HIV testing was slightly greater than our results suggest due to non-matches (for anonymous and coded HIV testing) Based on recent analysis, actual uptake of HIV testing was slightly greater than our results suggest due to non-matches (for anonymous and coded HIV testing) Estimated difference is 2% Estimated difference is 2% Study does not indicate why HIV test was not carried out Study does not indicate why HIV test was not carried out

Conclusions Critical to capture data from HIV diagnostic database in addition to prenatal database Critical to capture data from HIV diagnostic database in addition to prenatal database HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September 2001 HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September 2001 Impact of memo: from 60% to 75% Impact of memo: from 60% to 75% Uptake in latest quarter 90%, though slightly less (85%) for current pregnancy only Uptake in latest quarter 90%, though slightly less (85%) for current pregnancy only Less regional variation in HIV test uptake Less regional variation in HIV test uptake In five years, 201 women identified as HIV-positive, 51 previously diagnosed, 150 newly diagnosed In five years, 201 women identified as HIV-positive, 51 previously diagnosed, 150 newly diagnosed

Conclusions (continued) Based on results of 2002 unlinked seroprevalence study Based on results of 2002 unlinked seroprevalence study HIV prevalence higher (almost double) among women not tested HIV prevalence higher (almost double) among women not tested In 2002, though ~ 82% of pregnant women tested, only ~ 63% of HIV-infected pregnant women tested In 2002, though ~ 82% of pregnant women tested, only ~ 63% of HIV-infected pregnant women tested According to the preliminary results from a model (data not shown), about 6-8 mother-infant HIV transmissions occurred in 2003 According to the preliminary results from a model (data not shown), about 6-8 mother-infant HIV transmissions occurred in 2003

Acknowledgments Prenatal HIV Screening Evaluation Committee Prenatal HIV Screening Evaluation Committee Frank McGee, coordinator AIDS Bureau Frank McGee, coordinator AIDS Bureau Janis Tripp, consultant AIDS Bureau Janis Tripp, consultant AIDS Bureau Funding Funding AIDS Bureau, Ontario Ministry of Health and Long-Term Care AIDS Bureau, Ontario Ministry of Health and Long-Term Care Centre for Disease Prevention and Control, Health Protection, Health Canada Centre for Disease Prevention and Control, Health Protection, Health Canada