1. Rapid HIV Testing In L&D Maricopa Integrated Health System 2007 Community Strength Project We Believe in Families…. In care ….. In Miracles …… Funded 100% by the Health Resources and Services Administration and the Ryan White HIV/AIDS Treatment Modernization Act of 2006

2. 2 HIV/AIDS In The U.S. – 2004  Over 1,000,000 people in the U.S. are living with HIV  27% of new HIV infections are in women  79% of women with HIV were infected through heterosexual contact Source: Centers for Disease Control, www.cdc.gov, 2004. ADHS Epi Database, 2004.

3. 3 HIV/AIDS In Arizona & Maricopa County – 03/05  HIV/AIDS prevalence in Arizona is increasing at a faster rate than the state population  1 in 547 Arizonans has HIV/AIDS  889 women with HIV/AIDS live in Maricopa County- 51% are of childbearing age Source: ADHS Epi Database, 2004.

4. 4 Maternal to Child Transmission  Fewer than 100 new perinatal AIDS cases were reported in 2002.  However, there are an estimated 5,000-7,000 HIV-exposed infants being born each year.  An estimated 40% of women in the U.S. who delivered HIV-infected infants in 2000 had not been diagnosed prior to delivery. Source: Centers for Disease Control, www.cdc.gov 2002/2004.www.cdc.gov

5. 5 Testing Pregnant Women All pregnant women should be screened for HIV. If no test is documented in record:  CDC, ACOG, IOM & USPHS recommend Rapid HIV Testing in L & D for women without a documented HIV test during prenatal care (includes but is not limited to women with no prenatal care.)  Women with high-risk factors during their pregnancy should be retested.  AHCCCS requires Health Plans to follow ACOG recommendations (AMPM, Chapter 400) Source: Center for Disease Control, American College of Obstetrics/Gynecology, Institutes of Medicine, U.S. Public Health Service Task Force. 2004.

6. 6 State Laws Re: HIV Testing Brown = Voluntary HIV testing; no specific law Orange = Providers required to test for HIV unless mother refuses Gold = Providers required to offer HIV test White = Mandatory HIV testing of newborns

7. 7 Preventing MTCT To prevent mother-to- child transmission (MCTC):  Majority of MTCT occurs near or during L & D due to lack of prenatal care, no HIV testing or absence of perinatal ARV therapy.  Without any treatment, MTCT rate is 25%. Source: Centers for Disease Control, www.cdc.gov

8. 8 HIV Treatment During Prenatal Care  Pediatric Aids Clinical Trials Group (PACTG) Study published in the New England Journal of Medicine, 1994 shows:-Treating patient with AZT during pregnancy, labor & delivery, & the infant for 6 weeks: 8% transmission rate  AZT treatment & scheduled Cesarean section: 2% transmission rate Source: CDC. www.cdc.gov. 2004

9. 9 For More Information

10. 10 HIV Treatment During Labor & Delivery Even if treatment is not initiated until labor & delivery:  Antiretroviral medication given intrapartum & post- partum significantly reduces MTCT rates  (up to 42% reduction.) Source: Centers for Disease Control, www.cdc.gov. 2004www.cdc.gov

11. 11 HIV Treatment During Labor & Delivery Source: Centers for Disease Control, www.cdc.gov. 2004www.cdc.gov

12. 12 COST SAVINGS/ Return on Investment The Costs savings for an HIV Rapid Testing Program in Labor and Delivery is Enormous. Consider:  Total lifetime cost for all U.S. perinatally infected infants is $51.8-$68.5 million  $ 185,000 is the lifetime cost for a child born with HIV.  The cost per year is $12,333.33 based on this data.  THE COST OF THE HIV RAPID TEST? $18 Source: MRUS. 2004

13. 13 OraQuick Rapid HIV Testing  Identify & test patients in labor who may be HIV+  Based on CDC model protocol  Results for HIV-1 & HIV-2 in 20 minutes  Performed at point-of-care or in the lab  99.6% accurate  Positive results confirmed with a Western blot  GOAL: To link patients with HIV & their infants into care

14. 14 Rapid HIV Tests Comparison Chart

15. 15 Maricopa Cty Hospitals with HIV Rapid Testing Programs 1.Banner Good Samaritan Medical Center- 2005 2.Maricopa Medical Center- May 2005 3.St. Joseph’s Hospital-March 2006 4.Phoenix Indian Medical Center 5.John C. Lincoln- Pending 6.Desert Samaritan Hospital- Pending 7.Scottsdale Healthcare- Pending 8.Banner Estrella MC- Pending 9.Phoenix Baptist Hospital-Pending

16. 16 Evaluation Process- How are we doing?  Chart review  Determine if all qualifying patients were tested  Determine if protocols were followed  Laboratory log  Track turn-around times  Clinician Satisfaction Survey

17. 17 Improvement Projects Data HIV Test Results: One (1) False Positive Test -July 2005. (Western Blot was negative) No (0) True HIV Positive Tests

18. 18 HIV Rapid Testing in L & D- Process and Outcome Measurements for FY05-06 GoalResults- August 05 n=317 Results- 4th Quarter 05 n=99 Results- 1 st Quarter 06 n=130 Results 2 nd Quarter 06 n=131 Results 3rd Quarter 06 n=165 Number of Rapid tests performed/total number of women in imminent labor who have had no prenatal care (‘defined as 0- 1 prenatal care visits’) (% Compliance Rate)- Note: OraQuick is ordered. (L & D ONLY) >75% 45% 25% 56% 75% 91% Number of women who have had at least 1 HIV test during current prenatal care/total number of women who delivered at MMC & excludes those that declined (% Compliance Rate) (FHCs & physician offices) >90% 93% 90% 98% 91% 86%

19. 19 Challenges/Barriers and Strategies to address them 1.“Not My Patients”- “Not at this hospital”  Remind them it’s the standard of care  Risk management issue if Hospital doesn’t comply with the standard of care  Know your statistics! 2.“Don’t want to provide unnecessary treatment based on a false positive”  No evidence that providing one dose of ARV is harmful in any way to mom or baby  Know your statistics!

20. 20 Interpreting Rapid Test Results For a laboratory test: Sensitivity: Probability test=positive if patient=positive (99.6%) Specificity: Probability test=negative if patient=negative (99.9%) Predictive value: Probability patient=positive if test=positive Probability patient=negative if test=negative

21. 21 Example:Test 1,000 persons Test Specificity = 99.6% (4/1000) HIV prevalence = 10% True positive: 100False positive: 4 Positive predictive value: 100/104 = 96% HIV prevalence = 0.4% True positive:4 False positive : 4 Positive predictive value:4/8 = 50%

22. 22 Predictive Value-Single Screening Test: Differing HIV Prevalence HIV Prevalence Calculated Positive Predictive Value (PPV) OraQuickRevealSingle EIAUniGold 10%99%92%98%97% 5%98%85%96%95% 2%95%69%91%87% 1%91%53%83%77% 0.5%83%36%71%63% 0.3%75%25%60%50% 0.1% 50% 10%33%25% *PPV may differ from these estimates

23. 23 Call To Action!!!- MIHS Strategy  Ensure that Rapid HIV testing is available in every L & D department in all Maricopa County Hospitals  Ensure that Rapid HIV testing is offered to 100% of moms (in imminent labor) who do not already have a documented HIV test or who are at high-risk of contracting HIV during the pregnancy

24. 24 What We Can Offer Other Hospitals & Physicians  Training/In-services  Supplemental articles & materials  Research  Consultation  Experience

25. 25 Specific Training Opportunities  TA Manual available to other hospitals (created by MIHS’ Title IV Community Strength Project)  AETC Conference in April 2007 to discuss Rapid HIV Testing.  MIHS also presents to local medical groups/agencies.

26. 26 For More Information Debra Welborn – Title IV Program Coordinator MIHS 602-344-2628 debra.welborn@hcs.maricopa.gov Funding by the Department of Health and Human Services, Health Resources and Service Administration, the Ryan White CARE Act HIV/AIDS Treatment Modernization Act of 2006 and the Maricopa Integrated Health System See website at: www.mihs.org/ryanwhite

27. 27 AETC Conference Save The Date – April 24, 2007 HIV Rapid Testing Update UA College of Medicine Phoenix Campus Keynote Speaker: Bernard Branson, M.D. Associate Director for Laboratory Diagnostics Division of HIV/AIDS Prevention Centers for Disease Control and Prevention CME Provided Contact: Marcos Alcorn, BSHS, Program Coordinator Alcorn1@email.arizona.edu