Increasing HIV Testing Among Pregnant Women in Ontario: Results from the HIV Seroprevalence Study to June 2003

1. Increasing HIV testing among pregnant women in Ontario: Results from the HIV seroprevalence study to June 2003 Robert S. Remis, Carol Swantee, Carol Major, Margaret Fearon, Evelyn Wallace, Robert WH Palmer, Peggy Millson, Liviana Calzavara, Elizabeth Rea, Susan King, Keyi Wu, Marion Vermeulen, and Elaine Whittingham Department of Public Health Sciences, University of Toronto; Laboratories Branch and Public Health Branch, Ontario Ministry of Health and Long Term-Care; Toronto Public Health; Hospital for Sick Children Ontario HIV Treatment Network Research Conference Toronto, Ontario, November 3-4, 2003

2. Acknowledgments • Central Public Health Laboratory, Ontario Ministry of Health and Long-Term Care • Keyi Wu, programming • Mark Fisher, systems consulting and custom download • Prenatal Screening Evaluation Committee • Frank McGee, co-ordinator • Janis Tripp, consultant • Maraki Fikre Merid, slide preparation • Funding • AIDS Bureau, Ontario Ministry of Health and Long-Term Care • Bureau of HIV/AIDS, STD and TB, Health Canada

3. Background • 1989-91: Ontario HIV seroprevalence study (Coates et al), 0.23 / 1,000 • February 1994: ACTG 076 found ZDV reduced mother-infant HIV transmission by 67% • 1997: Modelled HIV prevalence, 0.70/1,000 and estimated uptake of prenatal HIV testing 1994-96, 20–25%

4. Ontario HIV screening program • Spring 1995: Advisory to physicians to consider HIV testing of pregnant women at increased HIV risk • August 1997: Committee formed to plan program • December 1998: Minister announced program to offer HIV testing to all pregnant women • January 1999: Promotional materials and requisitions sent to physicians • September 2001: Memo included with prenatal test report to physicians who had not prescribed an HIV test

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

6. Data management • Data extracted from LAByrinth (prenatal and HIV diagnostic databases) • Study period: January 3, 1999 to June 30, 2003 • Records from HIV prenatal database matched to records in HIV diagnostic database • Matching allowed for different spelling and structure of name (“double-barrelled” first and last names) and reversal of month/day in birth date • Separate prenatal tests aggregated into episode equivalent to the gestation period; HIV uptake analysed for each pregnancy

7. Data analysis • Number of women tested at prenatal visit included: • Women for whom HIV test ordered on prenatal requisition, or tested through HIV diagnostic service • Tests categorized as current or previous to pregnancy • Analysis in SAS of: • Trends over time in proportion tested • Testing rates by health region and age group • HIV-positive women: number and rates by type of test, region and quarter

8. Number of pregnancies by health regionJanuary 1999 to June 2003

9. HIV testing among pregnancies by timing of HIV test, Ontario Proportion of pregnancies (%)

10. HIV testing among pregnancies forselected health regions

11. HIV testing among pregnancies forselected health regions

12. Number of preg’s HIV tested Proportion tested Toronto Central East, other Southwest Central West Ottawa Eastern, other Northern N/A or OFP 11,233 9,368 4,691 6,468 3,134 2,941 2,345 152 9,141 7,671 4,691 6,468 3,134 2,941 2,345 109 82% 80% 84% 83% 87% 83% 81% 72% Total 40,332 33,155 82% Proportion of pregnancies tested for HIV by health region, Quarter 2, 2003

13. Number of PHUs in each region by proportion tested for HIV, Quarter 2, 2003 Number of PHUs by proportion of HIV testing uptake Total PHUs 50-59% 60-69% 70-79% 80-89% 90-100% 1 Toronto 1 1 5 Central East, other 6 Southwest 2 2 4 1 9 Central West 2 5 7 Ottawa 1 1 Eastern, other 5 5 1 2 Northern 5 8 Total 0 3 7 26 1 37

14. 1999 2000 2001 2002 2003 TOTAL Current HIV+ 10 20 32 29 19 110 Previous HIV+ 2 6 17 6 7 38 Total HIV+ 12 26 49 35 26 148 Number of HIV-positive pregnancies

15. HIV-positive pregnancies by time of diagnosis and quarter 15

16. Interpretation • Actual uptake of HIV testing is somewhat higher due to false non-matches (especially in anonymous and coded HIV testing) • Study does not indicate why HIV tests is not carried out • Study does not indicate number of HIV-infected women undiagnosed • Unlinked component of HIV seroprevalence study among women not HIV tested in 2002 is under way

17. Conclusions 1 • Critical to capture data from HIV diagnostic database as well as from prenatal database • HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September, 2001 • Impact of memo: from 60 to 76%! • Important regional differences in HIV test uptake • Over 3.5 years, 119 women identified as HIV-positive, 41 previously diagnosed, 88 newly diagnosed • Data suggests more high risk pregnant women are being offered and accepting HIV testing

18. Conclusions 2 • According to model (not presented) • Birth rate among diagnosed HIV-infected women is low • ~20% of HIV-infected women undiagnosed at conception remain undiagnosed • An estimated 5-10 preventable mother-infant HIV transmissions occurred in 2002