Philadelphia FIMR-HIVOverview for the Office of

HIV Planning

January 8, 2015Kathleen Brady, MD

Medical Director / Medical EpidemiologistAIDS Activities Coordinating Office

Philadelphia Department of Public Health

Agenda Epidemiology Overview re: Perinatal HIV FIMR-HIV Background and Overview Philadelphia FIMR-HIV Processes, Key Findings

and Recommendations Example of CRT>>CAT>>Action Step>>Outcome Ongoing Issues and Next Steps

Perinatal Prevention CascadeMissed Opportunities Data Needs

HIV transmission rate and number of infected infants

HIV-infected woman

Become Pregnant

Inadequate Prenatal Care

No (or late) HIV Test

No ARV Prophylaxis

Child Infected

% of HIV+ women with ARV prophylaxis in pregnancy

% of all women (and HIV+) tested in pregnancy

Number of HIV-infected women of childbearing age by state, race/ethnicity

Number of HIV-infected women giving birth (or exposed infants)

% of all women (and HIV+) with adequate prenatal care

Female PLWHA of Child Bearing Age (15-45), 2005-2012

Philadelphia Perinatal Exposures, 2005-2012

Proportion of HIV-Infected Women of Child Bearing Age (15-45) who Delivered an Infant,

2005-2012

Philadelphia Perinatal Transmissions, 2005-2011

Quick Facts on HIV Pregnant Women in Philadelphia

• Racial disparities – 80% of pregnant women are black, 12% Latina

• 90% acquired HIV through Heterosexual transmission, 7% IDU

• Age distribution– 50% of deliveries occur in women

25-34– 25% each in women 16-24 and >35

• HIV Diagnosis– 74% diagnosed prior to pregnancy– 22% diagnosed during pregnancy– 2% diagnosed at delivery or within

1 month of birth

• Prenatal Care– 39% adequately engaged in

prenatal care– 38% intermediately engaged in

prenatal care– 23% inadequately in prenatal care

• Prenatal ART use– 89% in women diagnosed prior to

pregnancy– 73% in women diagnosed during

pregnancy• Viral suppression

– 73% suppressed prior to delivery in women diagnosed prior to pregnancy

– 46% suppressed prior to delivery in women diagnosed during pregnancy

Missed Opportunities for Perinatal HIV PreventionEnhanced Perinatal Surveillance

Philadelphia, 2005-2011

Missed Opportunity HIV Exposed infants (N=815)

HIV Infected infants (N=17)

HIV Uninfected infants (N=651)

No prenatal care 71 (8.7%) 7 (41.2%) 596 (7.8%)

No maternal HIV test

19 (2.3%) 4 (23.5%) 10 (1.5%)

No prenatal ART 108 (13.3%) 10 (58.8%) 81 (12.4%)

No L&D ART 80 (9.8%) 6 (35.3%) 57 (8.8%)

>1 missed opportunity

188 (23.1%) 11 (64.7%) 141 (21.2%)

Additional Missed Opportunity - Only 48% of HIV-infected women with a viral load >1,000 prior to delivery receive a schedule C-section.

HIV Care Continuum for HIV-infected women who gave birth to a live infant postpartum 2005-2011 (n=695)

Source: Enhanced Perinatal Surveillance System (EPS) and HIV/AIDS Reporting System (eHARS)AIDS Activities Coordinating Office, Philadelphia Department of Public Health

Percentage of postpartum women

HIV Care Continuum by year for HIV-infected women who gave birth to a live infant up to two

years postpartum (n=695), 2005-2011- Philadelphia

Source: Enhanced Perinatal Surveillance System (EPS) and HIV/AIDS Reporting System (eHARS)AIDS Activities Coordinating Office, Philadelphia Department of Public Health

Philadelphia FIMR-HIV Background One of 8 sites funded by CityMatCH/ACOG/CDC Starting December 2009, implementation

planning began (unfunded) Case abstractions began Summer 2010 First CRT meeting held in September 2010 Funding began 10/2010, ended 9/2012 Project continues via HFP and AACO staffing Graduate student intern support key to project

Leadership

AACO, Philadelphia Department of Public HealthKathleen Brady, MDMedical Director and Epidemiologist

Health Federation of PhiladelphiaDebra D’Alessandro, MPHPublic Health Project Manager

Crime Stoppers Model for Prevention of Perinatal Transmission of HIV

Decreasing amount of virus and time for it to get in

Decrease virus by high dose IV

Last chance to kill virus that made it through before infection established

AZT

Treatment

Prevention

Pre-natal care and HIV testing

HIV testing in labor and delivery and for baby

Ensure safe harbor for baby, HIV testing, early treatment for positives

J. Foster, 9/09

Elimination of Perinatal HIV—Why?

It is feasible We know how We have the tools

Missed opportunities account for most remaining transmissions

Cost reductions of approximately $25,000,000/yr Discounted lifetime medical care cost for an HIV-infected child= $250,000 > 100 perinatal infections per year remaining

It is the right thing to do

Elimination of Perinatal HIV Transmission Proposed Goals:

Achieve:

1) an incidence of <1 HIV-infected infant per 100,000 live births

(< 40 cases annually among a 4 million birth cohort)

and

2) a transmission rate of < 1%

[e.g., < 87 cases in 2006 (8700 HIV-exposed births) ]

Represents a decrease in >100 annual cases

What is FIMR?

The Fetal and Infant Mortality Review (FIMR) “is an action-oriented community process that continually assesses, monitors, and works to improve service systems and community resources for women, infants, and families. A fetal or infant death is the event that begins the process.”

What is FIMR?

Key Facts Introduced in the late 1980’s ACOG and MCHB at HRSA were co-leads Approximately 220 FIMR programs in 40

states Funding sources vary from community to

community

What is FIMR?

Community Action

Changes in Community

Systems

Cycle of Improvemen

t

Data Gathering

Case Review

Continuous Quality Improvement

What is FIMR-HIV?

The FIMR-HIV process, like the FIMR process, emphasizes broad community buy-in and involvement (e.g. providers, business groups, community advocacy groups, consumers, agencies providing services and resources for women, infants and families, etc.).

Overview of the FIMR-HIV Process

Case Identification and Selection Case Definition: Exposed infant/fetus ≥ 24 weeks

gestation Purposeful, not random selection Cases selected based on an indication of system gap:

HIV-infected infant Late maternal HIV diagnosis Inadequate or absence of prenatal care Lack of maternal treatment or poor viral

suppression Lack of antiretroviral prophylaxis during labor and

delivery (as applicable)

Overview of the FIMR-HIV Process Case Data Abstraction

All available medical, hospital, CM records Info collected: prenatal care, labor and delivery care,

post-partum/reproductive health care, maternal HIV care, newborn care, birth certificate and pediatric care

De-identified (case and health care setting) Maternal interview

Critical to the process Information not available in the medical record Obtain the woman’s unique perspective

Case ReviewMultidisciplinary case review team

MCH, HIV/AIDS, community, advocates, professional organizations, private agencies

Perinatal HIV prevention clinical experts

Regularly scheduled case reviews

Strengths, opportunities for improvements, general systems issues identified

Recommendations to improve systems

Community Action Community Action Team: Initiate systems change

based on findings and recommendations “Champions” within the community are important Include a broad-based, multi-partner range of

agencies and people (e.g. families, CBOs, consumer advocates, etc.) that represent the diverse ethnic and cultural groups in the community

Inclusive of HIV and MCH expertise Community leaders

CAT Purpose

The community action team (CAT) is charged with developing an annual community action plan based on the recommendations of the case review team.

Once a plan has been developed, team member(s) will accept responsibility for implementation, and the team as a whole will monitor progress of the plan during ongoing meetings.

Philadelphia FIMR Activities

• Case Review Team meets 10 times/yearSince September 2010:

Total CRT meetings = 43Total Cases reviewed = 111Total Maternal interviews = 43

• Community Action Team meets 2 or 3 times/year

Total CAT meetings since February 2011 = 8

CRT Themes/Issues Identified

• Lack of preconception counseling for HIV-positive women

• Continuity of/Engagement in care for those with MH/SA issues

• Lack of connection to prenatal care from ER

FIMR-HIV Community Action Team areas of focus:

• Contraception Committee

• Emergency Department Protocol Committee

• Engagement in Care Committee

• Behavioral Health Committee

Example of FIMR processCRT issue identified in 2010 and 2011 case reviews: •Need for dedicated Perinatal Medical Case Management PMCM for HIV-positive pregnant women

CAT Recommendation, 2011: •Dedicate funding and establish standards for PMCM

Action Steps: •AACO prepared RFP for PMCM•CAT Subcommittee developed standards for PMCM

Outcomes:•2012 ActionAIDS awarded PMCM grant, currently employs 2.5 FTE case managers who work with clients from pregnancy through baby’s first year of life

The Good News: What Philly is Doing Well…• Prenatal HIV testing at first visit and in third trimester are

standard practice at all OB/prenatal sites

• Clinical guidelines for appropriate use of ART in pregnancy are being followed by local providers

• Rapid HV testing is available and appropriately offered at Labor and Delivery to high risk patients of unknown HIV status

• Connection to follow-up by pediatric HIV specialty practice for prophylaxis and testing of exposed infants is occurring consistently

• ActionAIDS Perinatal Medical Case Managers have developed strong referral relationships with local HIV providers

Ongoing Issues/Next Steps Continue to analyze trends from chart reviews of

HIV-infected infants or high risk perinatal exposures

Develop action steps informed by changing healthcare landscape and needs

Engage policy and program leadership in completion of action steps

Strengthen programs serving HIV-infected or exposed women and children, pregnant women, and pertinent health systems

Thank you!

Kathleen Brady, MD Medical Director/Medical EpidemiologistAIDS Activities Coordinating Office Philadelphia Department of Public HealthKathleen.A.Brady@phila.gov(215) 685-4778

Tina J. Penrose, RN, MSN, MPHProject Coordinator PA/MidAtlantic AIDS Education & Training Center Health Federation of Philadelphia tpenrose@healthfederation.org(215) 246-5299

Debra D'Alessandro, MPHPublic Health Program Manager PA/MidAtlantic AIDS Education & Training Center Health Federation of Philadelphiaddalessandro@healthfederation.org(215) 246-5416