1. HIV/AIDS Perinatal Surveillance 2002 Minnesota Department of Health HIV/AIDS Surveillance System Minnesota Department of Health HIV/AIDS Surveillance System

2. Background This slide set describes births to HIV-infected women in Minnesota by person, place, and time. The slides rely on data from HIV/AIDS cases diagnosed and infants exposed through 2002 and reported to the Minnesota Department of Health (MDH) HIV/AIDS Surveillance System. Some limitations of surveillance data:  Data do not include HIV-infected persons who have not been tested for HIV  Data do not include persons whose positive test results have not been reported to the MDH  Data do not include children whose perinatal HIV exposure has not been reported to MDH  Case numbers for the most recent years may be undercounted due to delays in reporting

3. Introduction Since 1982, there have been 280 births to women living with HIV/AIDS in Minnesota. Of these, 35 (12.5%) children have been diagnosed with HIV/AIDS, 172 (61.4%) are seroreverters*, and 73 (26.1%) have an indeterminate HIV status †. In 1994 and 1995, the U.S. Public Health Service (PHS) made recommendations for universal HIV testing of all pregnant women, and the use of zidovudine (ZDV ‡ ) to prevent mother-to-child (MTC) transmission of HIV. Rates of MTC HIV transmission in Minnesota have decreased since the publication of these PHS recommendations. During the years 1982-1994 the rate of MTC transmission was 25%, decreased to 10% during 1995-1999, and was 2% in 2000-2002. A total of 10 children acquired HIV perinatally in Minnesota since 1996. * At the time of birth an infant may test positive for HIV due to the presence of antibodies from the HIV-infected mother. If the infant does not go on to develop infection, s/he will eventually test negative for HIV antibodies and is said to be a “seroreverter.” † An indeterminate status means the Minnesota Department of Health (MDH) is unaware of the child’s status (either due to no follow-up HIV test or more likely the result of the negative follow-up test was not reported to MDH). ‡ Zidovudine (ZDV) is an anti-HIV drug.

4. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Births to HIV-Infected Women and Number of Perinatal HIV Infections* by Year of Birth, Minnesota 1990-2002 * HIV or AIDS at first diagnosis for a child exposed to HIV during mother’s pregnancy, at birth, and/or during breastfeeding. NOTE: Reporting of births is known to be incomplete. During 2001 an Enhanced Perinatal Surveillance Project (EPS) Project was undertaken and identified 19 of the 37 births reported in 2001. Rate of Perinatal Transmission for years 2000-2002 = 2%

5. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Time of Mother’s Diagnosis for Perinatal HIV Infections, Minnesota 1996 -2002 Time of HIV DiagnosisNumber (%) Before pregnancy*2 (20) During pregnancy, before delivery † 1 (10) At delivery2 (20) After birth5 (50) Total10 (100) * These two mothers refused HIV testing and neither revealed her HIV status to her health care provider(s) – therefore no antiretroviral therapy was provided to mother or child. † Mother did not comply with her medication regimen during pregnancy.

6. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Births to HIV-Infected Women and Perinatal HIV Infections by Mother’s Race/Ethnicity, Minnesota 1996-2002 Perinatal HIV Infections (n=10) Births to HIV-infected Women (n=168) Amer Ind = American Indian Afr Amer = African American (Black, not African-born) Afr born = African-born (Black, African-born)

7. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Births to HIV-Infected Women and Perinatal HIV Infections by Mother’s Region of Birth, Minnesota 1996-2002 Mother’s Region of Birth Births to HIV- Infected Women No. (%) Perinatal HIV Infections No. (%) United States115 (69)5 (50) Africa32 (19)2 (20) Asia4 (2)1 (10) Caribbean/Mexico/ South America 8 (5)2 (20) Total159* (100)10 (100) * Excludes 9 births to women with an unknown region of birth.

8. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Births to HIV-Infected Women and Perinatal HIV Infections by Mother’s Race/Ethnicity, Minnesota 1996-2002 Mother’s Race/Ethnicity Births to HIV Infected Women No. (%) Perinatal HIV Infections No. (%) White51 (30)1 (10) African-American60 (36)3 (30) African-born35 (21)3 (30) Hispanic10 (6)2 (20) American Indian8 (5)0 (0) Asian4 (2)1 (10) Total168 (100)10 (100)

9. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Perinatal HIV Infections (n=10) Births to HIV-infected Women (n=168) Births to HIV-Infected Women and Perinatal HIV Infections by Mother’s Region of Birth, Minnesota 1996-2002 Car = Caribbean, Mex = Mexico, S. America = South America

10. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Births to HIV-Infected Women and Perinatal HIV Infections by Mother’s Residence, Minnesota 1996-2002 Perinatal HIV Infections (n=10) Births to HIV-infected Women (n=168) Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (except Minneapolis), Ramsey (except St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties, outside the seven-county metro area.

11. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Compliance with PHS Guidelines among Cases of Perinatal HIV Infection in Minnesota 1996-2002 In 5 of 10 cases of perinatal HIV infection, the mother was not diagnosed with HIV infection until after the child’s birth.  4 of the 5 mothers diagnosed after the child’s birth received prenatal care. Among the 5 cases of perinatal HIV infection whose mothers were diagnosed with HIV at or prior to birth, 3 received prenatal care.  In the 2 cases without prenatal care, both infants were treated with ART  Of the 3 cases with prenatal care:  1 mother received ART, but did not consistently take the medications  2 mothers refused HIV testing and neither revealed her HIV status to her health care provider(s) – no ART was provided to mother or child PHS = Public Health Service

12. Enhanced Perinatal Surveillance Project Summary

13. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Enhanced Perinatal HIV Surveillance (EPS) Project Initiated in summer of 2001. Project goals:  To improve completeness and accuracy of perinatal HIV/AIDS surveillance records, and  To evaluate implementation of 1994/1995 PHS* guidelines related to universal HIV testing of pregnant women and zidovudine treatment to prevent perinatal transmission. All Minnesota births to HIV-infected women between 1/1/1999 and 8/31/2001 were included. For each birth, medical care and vital statistics records were abstracted; including additional detail not collected in routine HIV/AIDS surveillance. The project identified 70 eligible births in Minnesota and data collection was completed in June 2002.

14. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Mothers’ Demographics January 1999 – August 2001 Race/Ethnicity (n = 70) Region of Birth (n= 70) Amer Ind = American Indian Afr Amer = African American (Black, not African-born) Afr born = African-born (Black, African-born)

15. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Mothers’ Demographics January 1999 – August 2001 Place of Residence (at birth) NumberPercent Minneapolis 18(26) St. Paul 14(20) Suburban* 31(44) Greater Minnesota* 7(10) Total 70100 * Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (except Minneapolis), Ramsey (except St. Paul), Scott, and Washington counties. Greater MN = All other Minnesota counties, outside the seven-county metro area.

16. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project AGE (at delivery) NumberPercent < 20 5(7) 20 - 24 18(26) 25 - 29 18(26) 30 - 34 20(28) 35 + 9(13) Total 70(100) Minnesota EPS Project: Mothers’ Demographics January 1999 – August 2001

17. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Mode of TransmissionNumberPercent Injection Drug User 8(11) Heterosexual (total) 46(66) Heterosexual w/ IDU 4-- Other 2(3) Unspecified 14(20) Marital StatusNumberPercent Single 39(56) Married 26(37) Separated / Divorced 4(6) Unknown 1(1) Minnesota EPS Project: Mothers’ Demographics January 1999 – August 2001 (n = 70)

18. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Mother’s Clinical Status by Time of Diagnosis January 1999 – August 2001 (n = 70) Time of Mother’s Diagnosis Before Pregnancy During Pregnancy At Time of Delivery Clinical Status No.% % % HIV, not AIDS 28(76)28(94)1(33) AIDS: CD4 < 200 uL 7(19)2(6)0(0) AIDS: Opp. illness 2(5)0(0)0 Unknown 0(0)0 2(67) Opp. Illness = Opportunistic illness

19. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Prenatal Care ART Prior to Pregnancy ART During Pregnancy ART During Labor/Delivery Time of DiagnosisYesNoYesNoYesNoYesNo Before Pregnancy 361307361 1 During Pregnancy 3000 0282 At Time of Delivery 12030303 Minnesota EPS Project: Prenatal Care and Antiretroviral Therapy (ART) by Time of Mother’s Diagnosis January 1999 – August 2001 (n =70) Minnesota EPS Project: Prenatal Care and Antiretroviral Therapy (ART) by Time of Mother’s Diagnosis January 1999 – August 2001 (n =70)

20. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Birth Characteristics January 1999 – August 2001 (n = 70) Mode of DeliveryNumberPercent Vaginal 39(56) Elective C-section 22(31) Non-Elective C-section 8(11) Unknown 1(1) Type of BirthNumberPercent Single 64(91) Twin 6(9)

21. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Birth Characteristics: C-section* Deliveries January 1999 – August 2001 (n = 30) C-section Type ElectiveNon-Elective Reason † #%#% HIV Indication15(68)-- Previous C-section8(36)-- Malpresentation6(27)1(13) Prolonged Labor-- 4(50) Fetal Distress1(5)5(63) Placenta Abruptia/Previa1(5)-- Other9(41)3(38) Unknown-- * C-section = Caesarian-section † Participant may have more than one reason for C-section

22. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Birth Characteristics – Neonatal Antiretroviral Therapy (ART) by Time of Mother’s Diagnosis January 1999 - August 2001 (n = 70) Neonatal ART Time of DiagnosisYesNo Before Pregnancy 370 During Pregnancy 300 At Time of Delivery 21 Overall 98.6% (69/70) of children received antiretroviral therapy during the neonatal period.

23. Data Source: Minnesota HIV/AIDS Surveillance System Enhanced Perinatal Surveillance Project Minnesota EPS Project: Other Perinatal Characteristics January 1999 - August 2001 (n = 70) CharacteristicNumberPercent No Prenatal Care 4(4) Prenatal Care began 3 rd trimester 7(10) Drug Use* During Pregnancy 14(20) Positive Toxicology Screen Mother 9(13) Infant 2(2) STD Dx During Pregnancy 18(26) Ruptured Membranes for > 4 hrs 21(30) * Drug use includes any illegal substance STD = Sexually transmitted disease (non-HIV) Dx = Diagnosed

24. Conclusions (I) The rate of perinatal HIV transmission in Minnesota is very low. During 2000-2002 no perinatal HIV transmission occurred in Minnesota among mothers receiving antiretroviral therapy (ART) during pregnancy or labor/delivery.  During this time 2 cases of perinatal HIV infection occurred among 90 births to HIV-infected women (2% transmission), in both cases neither mother nor infant received ART. The annual number of births to HIV-infected women living in Minnesota has been steadily increasing since 1996. ART was provided to over 95% of mothers and infants during 2000- 2002.

25. Conclusions (II) Surveillance data show that overall the Public Health Service Guidelines of 1994/1995 have been successfully implemented among HIV-infected women in Minnesota. However, women of color and those born outside the U.S. were more likely to be diagnosed with HIV after the birth of an infected child.  Efforts are needed to make universal HIV testing during pregnancy more accepted by women of all races and cultures; likewise such testing needs to be offered in a culturally and linguistically appropriate manner. As a result of the Enhanced Perinatal Surveillance Project the uninfected status of 62 perinatally exposed children and the infected status of 1 child were updated.  The Minnesota Department of Health will work with health care providers and clinics to improve reporting. Accurate monitoring of the HIV/AIDS epidemic is dependent on accurate, complete, and timely reporting of disease status.