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Implementing Rapid Testing on Labor and Delivery Units in San Diego County, Lessons Learned

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@ucsd.edu. San Diego California. 3.1 million residents 35,000 + births annually

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Implementing Rapid Testing on Labor and Delivery Units in San Diego County, Lessons Learned

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  1. 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@ucsd.edu

  2. 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%

  3. Perinatal HIV Testing in San Diego • Actively promoted since early 1990’s • 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

  4. Outreach to Promote Rapid HIV Testing on L&D • 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

  5. 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

  6. 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

  7. Rapid HIV Test • Acceptable Bulterys M, (MIRIAD) Study • L&D rapid testing logistically feasible CDC MIRIAD study & others • Reliable and reasonably priced rapid tests are licensed and available in the U.S. Lampe, 2004 • MTCTInterventions effective Wade, et al, 1999 NEJ M

  8. Lessons Learned:Planning 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 certificationfor rapid test

  9. Reactive Control Positive Positive Negative Read results in 20-40 minutes

  10. Lessons Learned:Implementing 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

  11. Lessons Learned:Planning 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

  12. 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

  13. 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

  14. 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

  15. Lessons Learned:Change takes time • Implement test • Monitor process • Evaluate and conduct CQI • Acknowledge results

  16. 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

  17. 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

  18. 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/rr5019References • 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/perinatal • 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-labor&delivery.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; 148:33-54 • HIV Counseling and Rapid Testing in Labor [PPT 376K]Date: 11/2003 Source: AETC National Resource Center, www.aidsetc.org

  19. 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

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