"Eliminating HIV Mother to Baby Transmission: A Status Report on Perinatal HIV in Florida "

1. "Eliminating HIV Mother to Baby Transmission: A Status Report on Perinatal HIV in Florida" Ana M. Puga, MD- Medical Director Comprehensive Family AIDS Program Ryan White Part D Program- Broward County Children’s Diagnostic & Treatment Center

2. Objectives • Participants will know the impact of Perinatal HIV in Florida • Participants will learn ways to reduce HIV transmissions from mothers to babies in their communities • Participants will understand the risks of HIV acquisition for women and infants. • Participants will know necessary management of HIV pregnant women in order to prevent perinatal transmission. 

3. Hi, I’m Marta • Married to first and only boyfriend for the past 2 years • Excited about starting a family now • As soon as she missed a period, she went to the doctor for prenatal care • Along with the ultrasound, she was told that her HIV test came back positive!

4. AIDS in the U.S. In the U.S. HIV/AIDS is the #2 cause of death in African Americans aged 25-44. In Florida, it is #1 ~An average 56,300 new HIV infections in the US per year. 530,757 AIDS DEATHS ~1.039 – 1.185 million people living with HIV in the US** Florida is #2 in the US for new cases in women and children. ~25% new HIV infections in people under 25. In 13 to 19-year-olds, male-to-female ratio = 1:1. ~125,000 people living with HIV in Florida.***

5. Scope of the Epidemic in the United States among Women and Children • AIDS in women has risen from 7% early in the epidemic to 24% - 26% of adult cases today • 73 new HIV/AIDS cases reported in children in 2007 • 181,802 AIDS cases in women reported through 2005 • 10,000–20,000 estimated children/youth living with HIV infection (8797 under the age of 13) • 100- 270 babies continue to be born each year with HIV infection

6. Florida HIV Rates 1 in 208 Floridians are known to be currently living with HIV infection. • 1 in 415 Whites are known to be infected • 1 in 67 Blacks are known to be infected • 1 in 230 Hispanics are known to be infected

7. Impact of Perinatal HIV in Florida • Florida has 114,057 people with AIDS and 43,814 people living with HIV • Statewide rate is 31.1 per 100,000 • All counties but 1 had at least 1 HIV case in 2009 • 10 counties had >100 cases of HIV in 2009 • Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas, Polk, and Volusia • 77% of all cases in first 9 counties above • 50% of cases in SE Florida

8. Impact of Perinatal HIV in Florida • Cases have shifted from 23% white to 34% white from 2002 to 2009 and from 62% black to 46% black • Black women 15 X higher than white women • Hispanic women 2.5 X higher than white women • 47% of cases occurred in 20 – 40 year old • Transmission risk for women: 90% heterosexual contact

9. Impact of Perinatal HIV in Florida • Florida ranks 2nd in Pediatric cases • Infected cases declined 96% from 201 in 1992 to 8 in 2008 • 601 babies were born to HIV positive women in Florida in 2008 (8- 1.3% were infected) • 7 of 8 new status before pregnancy • 5-63% had PNC only 3 of these had adequate PNC • 4-50% received ART during pregnancy • 4-50% received AZT at delivery • 7-87% received AZT for baby

10. Impact of Perinatal HIV in Florida • Of the 136 Infected babies born in Florida from 2000-2005: • 27% of all mothers that delivered an infected infant did not know they were positive prior to delivery. • 20% of all mothers that delivered an infected infants contracted HIV during the pregnancy. • The trend continues • Of the four infected infants born in 2010, one was born to a mother who had two negative HIV tests (1st and 3rd trimester) and 17 prenatal care visits during her pregnancy. • FL DOH Perinatal Prevent Project Surveillance Data, 2011

11. Case Rate per 100,000 0 0.1 to 15.0 15.1 to 30.0 > 30.0 HIV Cases Reported by County of Residence* Florida, 2008 N= 7,111 Based on 2008 statewide population estimates, the 2008 state rate is 47.1 per 100,000 population. *County totals exclude Department of Corrections cases (N=477). This map does not reflect HIV incidence. Numbers on counties are cases reported.

12. HIV/AIDS Pediatric Cases By Expanded Modes of Exposure Born in and Reported in 2000-2008 South Florida Counties (N=85), Florida Miami-Dade (N=41) Broward (N=29) Palm Beach (N=15) Mom IDU Mom-Sex Risk Mom’s Risk-Other/Unkn.

13. <1 year 1 year 2+ years HIV/AIDS Pediatric Cases By Age at First Diagnosis Born in and Reported in 2000-2008 South Florida Counties (N=85), Florida Miami-Dade (N=41) Broward (N=29) Palm Beach (N=15)

14. Pediatric AIDS Cases by Age Group and Year of Diagnosis, Florida, 1990-2008* N=1,430 These data represent a 81% decline in pediatric AIDS cases diagnosed from 1992 (N=178) to 2008 (N=34). *Due to reporting lags, 2008 data are provisional. Data as of 08/25/09

15. Hi, I’m Tom • I am 17 and have my first serious girlfriend • We just graduated high school and decided it was ok to have sex now. • Since it was the first time for both of us, we didn’t use protection- she was on the pill. • Later that month, I find out I was born with the AIDS virus

16. Perinatally Acquired HIV (not AIDS) Cases by Age at Diagnosis (N=618)Florida, Born through 2008 Number of Cases < 2 yrs of age Age in Months Age in Years *34% (N=210) were <6 mos. and 50% (N=308) were <2 yrs.. Furthermore, 24 (4%) were diagnosed after the age of 12, data as of 09/30/09.

17. Perinatally Acquired AIDS Cases by Age at Diagnosis (N=1,684)Florida, Born through 2008 Number of Cases < 2 yrs of age Age in Years Age in Months *21% (N=359) were <6 mos. and 52% (N=868) were <2 yrs.. Furthermore, 220 (13%) were diagnosed after the age of 12, data as of 09/30/09.

18. Living HIV/AIDS Cases 0 1 - 10 11 - 25 26 - 50 over 50 Living Perinatal AIDS or HIV (not AIDS)Born through 2008, by County of DiagnosisFlorida, (N=1,446) N=1,446 Florida reported 1,446 pediatric (<13 years) AIDS or HIV cases through 2008, with the majority (62%) of these cases reported from Miami-Dade (N=401), Broward (N=243) Palm Beach (N=151) and Hillsborough (N=99) counties. Data as of 09/30/09

19. Participants will learn ways to reduce HIV transmissions from mothers to babies in their communities

20. Maternal to Child Transmission

22. Perinatal HIV/AIDS Cases by Year of Birth Reported in Florida*, 1977-2008** (N=2,306) Note:These data represent a 96% decline in HIV-perinatally infected births from 1992 (N=204) to 2008 (N=9) *Includes all perinatal HIV/AIDS cases diagnosed in Florida, regardless of place of birth. **HIV Infection Reporting began July, 2007. 2008 data are provisional. Data as of 09/30/09.

24. Prenatal HIV Testing Among Women Delivering a Live Birth, Florida, 1996-2007 = 95% C.I. Comment: Florida’s percentage of childbearing women tested perinatally for HIV is the highest in the U.S., which has probably contributed to the continued decline in pediatric HIV/AIDS cases. Source: Florida Pregnancy Risk Assessment Monitoring System (PRAMS),(2006 or 2008 not available, 2007 had half of normal sample size).http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/PRAMS/Data_Books.htm

25. HIV Testing • Who should get tested? • CDC recommends routine testing of EVERYONE 13-64 years of age regardless of risk factor one time then annually based on risk.

26. HIV Testing Laws in Florida • Mandatory Offering of HIV test at initiation of Prenatal Care and at 28-32 weeks if initial test is negative • Mandatory Offering at Delivery or of newborn if no test available • Reporting of all HIV positive tests and exposed newborn testing < 18 months whether positive or negative • Super-confidential • HIV considered STD in Florida Statutes- youth > 12 years of age can seek testing and care on own

27. Types of HIV Tests • Antibody Tests- HIV ELISA/EIA and Western Blot • Blood or Oral • Standard or Rapid • Anonymous or Confidential • Viral Tests- HIV RNA-PCR, DNA-PCR, bDNA, Culture, p24 antigen • Blood • Quantitative and qualitative

28. New Perinatal Cases • Failed MTCT intervention opportunities • Late presenters/No Prenatal care • Non-adherent women • Substance using • Mental illness • Missed early childhood cases • Unexplained failures

29. FIMR is a Community Cycle of Improvement

30. Case Review Process Case Definition • HIV exposed infant/fetus > 24 weeks gestation and < 24 months of age at the time of review • Prioritized for each community, not randomly selected • Cases are selected based on key indicators of missed HIV prevention or treatment opportunities. (late maternal HIV diagnosis during prenatal period, lack of maternal hiv treatment or poor viral suppression during pregnancy)

31. FIMR/HIV by Ethnicity When examining the cases reviewed by mother’s ethnicity, the largest number of cases reviewed were African American, followed by Haitian.

32. FIMR/HIV by Zip Code

33. FIMR/HIV Cases and Time of Diagnosis More than half of the sample of mothers, were diagnosed HIV positive at this pregnancy.

34. FIMR/HIV by Entry to Prenatal Care Only 22% of the mothers entered prenatal care in the first trimester.

35. FIMR/HIV by Mother’s Age

36. FIMR/HIV Contributing Factors

37. Healthy Start data details • 12 of the 18 mothers received a Healthy Start screen • 2 out of the 12 declined Healthy Start services. • 3 mothers were not referred for service. • 7 mothers were referred but were unable to be found.

38. FIMR/HIV Identified Gaps • ♦ Lack of preconception care • ♦ No prenatal care • ♦ Inappropriate HIV Care during pregnancy • ♦ Services not linking: between incarceration, parole, and medical services among community providers in maternal/child health and HIV services • No resources for mental health care for HIV + women especially if they are pregnant • Poor knowledge of and ability to access care • Inconsistent Healthy Start referrals • Patients of private OB and pediatric providers not receiving appropriate follow up and management of HIV Care

39. FIMR/HIV Identified Gaps ♦ Labor and Delivery – • Timeliness of HIV medication delivery • Incomplete bilateral tubal ligation requests • Lack of screening for substance or alcohol abuse upon admission • Lack of substance abuse referrals on those with history of positive screen • Lack of psychiatry/psychology consults ordered for patients with mental health issues • No follow up on mental health referrals made • Lack of documentation of HIV medical follow up • Overall gaps between labor and delivery and post partum

40. Time of Maternal HIV TestingAmong Perinatal HIV/AIDS CasesBorn in and Reported in Florida, 2000-2008 (N=170) Note: 124 (73%) of the 170 mom’s knew they were infected prior to birth. *2008 data are provisional.

41. Percent of Pregnant Women Giving Birth To a Child Diagnosed with HIV in Florida and Were Known to be HIV Positive Prior to Delivery By Year of Birth 2000-2008* (124 of 170 births (73%)) *2008 data are not complete due to reporting lag.

42. Mothers of Perinatally HIV-Infected Cases According to Receipt of Prenatal Care and/or Prenatal ART* Born in and Reported in Florida, 2000-2008** And Mom’s HIV status was known prior to delivery (N=170) Yes No Adequate Prenatal Care Began by 4th month with 5+ visits Any Prenatal ART AZT and/or antiretrovirals *ART – Antiretroviral Therapy **2008 data are provisional.

43. Mothers of Perinatally HIV-Infected Cases According to Receipt of Caesarean Deliveryand/or ART at Delivery Born in and Reported in Florida, 2000-2008** And Mom’s HIV status was known prior to delivery (N=170) Yes No ART during Labor AZT and/or antiretrovirals Caesarean Delivery *ART – Antiretroviral Therapy **2008 data are provisional.

44. Percent of Mothers of Perinatally HIV-Infected Cases Who Abused Drugs or Had an STD During Pregnancy Born in and Reported in Florida, 2000-2008 (N=170) Abused Drugs Had an STD A total of 21 (12%) of the moms had both abused drugs and had an STD during pregnancy. *2008 data are not complete due to reporting lag.

45. Perinatally HIV-Infected Cases Status of Receiving Neonatal Drugs and Breastfeeding Born in and Reported in Florida, 2000-2008 (N=170) Received any Neonatal Drugs Breastfed *2008 data are provisional.

46. What Gaps Exist in Your Community?

47. Gaps identified by Comprehensive Family AIDS Program • Lack of HIV providers willing to serve HIV + pregnant women • OB providers unable to keep up with frequent changes in HIV management of pregnant women • Women avoiding care due to denial or stigma • Lack of education among women regarding HIV care during pregnancy • Co-morbidities affecting woman’s ability to adhere to prenatal care or HIV treatment

49. CFAP Perinatal Enhanced Service Program • Initiated in 2002 to further reduce perinatal transmission • Average transmission rate from 1996-2001 was 6.4% • After enhanced services initiated- transmission dropped significantly from 4.5% to 1.5% in first year • Average transmission rate from 2002-2009 was 1.8% (Transmission Rate for those linked to CFAP during these years = 0.2%) • Transmission in 2010 was ZERO!

50. CFAP Perinatal Program * Mother referred 21 days prior to delivery