This document summarizes perinatal HIV in Texas and efforts through the Texas Consortium for Perinatal HIV Prevention (TCPHP) to address missed opportunities. Key points include: - Perinatal HIV rates in Texas have decreased from 2000-2008 due to prenatal care, earlier HIV diagnosis, and antiretroviral therapy. - Missed opportunities still exist, as some infected infants were born to women with no prenatal care or incomplete antiretroviral regimens. - TCPHP aims to reduce perinatal transmission through improved standards of care, education, and outreach. Work groups have developed guidelines, testing recommendations, and identified gaps in hospital pharmacies. - Case examples

1. Perinatal HIV in Texas &
Addressing Missed
Opportunities through the
Texas Consortium for Perinatal
HIV Prevention (TCPHP)
Presenters:
Elvia Ledezma, MPH
Leslie Conley, L.M.S.W.-I.P.R.
Janak Patel, M.D.
Judy Levison, M.D.

2. Perinatal HIV in Texas
Elvia Ledezma, Epidemiologist
HIV/STD Epidemiology and Surveillance
Texas Department of State Health Services
elvia.ledezma@dshs.state.tx.us
512-533-3045

3. Outline
Overview of perinatal HIV
Steps to prevention of perinatal HIV
Preventative factors

4. General Definitions
Perinatal Exposure-Any child born to an HIV
infected woman
• Infected-Any child born to an HIV infected woman and
determined to be HIV positive
• Uninfected Any child born to an HIV infected woman and
determined to be HIV negative
• Indeterminate- Any child born to an HIV infected woman
with insufficient test history to determine his/her HIV
status.

5. HIV Positive Women in Texas
2008
13,751 HIV+ women living in Texas
• 8,201 (60%) are women of childbearing age (15-44 years)
• 361 (4%) of women gave birth to an infant
2000-2008
9% increase in the number of HIV+ women of
childbearing age from 2000 to 2008
• 57% decrease in proportion of infected infants from 2000
to 2008

6. Race/Ethnicity, Texas
Black Hispanic White Other/Unknown
70
Percent (%) by Race/Ethnicity
60%
60
50
41%
40
32%
30
22% 22%
20
12%
10 6% 5%
0
HIV+ Women Delivering an HIV+ Women Delivering an
Exposed Infant, 2008 Infected Infant, 2005-2008
n=361 n=41

7. Prenatal Care*, Texas
96% of women delivering an infant in Texas
received prenatal care, 2008**
92% of HIV positive women delivering an
infant received prenatal care, 2008
• 55% (5/9) of HIV positive women delivering an
infected infant received no prenatal care, 2008
*Excluding women with unknown receipt of prenatal care
**Based on provisional vital statistics birth data for year 2008

8. Perinatal HIV in Texas, 2008
361 HIV+ women delivered 364 infants
• Uninfected: 122
• Indeterminate: 233
• Infected: 9

9. Perinatally Exposed and Infected
Children, Texas, 1999-2008
450 8
Exposures Infected
400 7
No. of Perinatal Exposures
350 n=21 6
n=21 n=22
Percent Infected
300
5
250 n=20
n=13 4
200 n=12
n=13 3
150
n=9 2
100 n=8
n=7
50 1
0 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year of Birth

10. No. Exposed=3,593
% of Total Births=
Numerator: No. of
HIV Exposed
Births by County
Denominator: No.
of HIV Exposed
Births for the State

11. No. Exposed=3,593
No. Infected=146
% of Total Births=
Numerator: No. of
HIV Exposed
Births by County
Denominator: No.
of HIV Exposed
Births for the State

12. Steps to Prevention Success
Woman receives prenatal care
Tested for HIV
Diagnosed before delivery
Receives ARV therapy at all three recommended timings
Pregnancy
Labor and delivery
Neonatally

13. Prevention of Perinatal HIV Transmission, TX, 2005-2008, cont.
No. of Women=1,461
Step 1: Missed Prenatal Care (N=1461) No. of Infected Infants=41
Opportunity
Infected=10 No Yes Unknown No Infected
(9%) n=113 (8%) n=1276 (87%) n=72 (5%) Infants
HIV Diagnosis Before Delivery
Step 2: Missed (N=1276)
Opportunity
Infected=6 No Yes Unknown No Infected
(10%) n=61 (5%) n=1211 (95%) n=4 (<1%) Infants
Prenatal Antiretroviral (ARV)
Step 3: Missed Therapy (N=1211)
Opportunity
Infected=6 No (None or IP No Infected
(9%) and/or Yes Unknown Infants
Neonatal, yes): n=1124 (93%) n=22 (2%)
n=65 (5%)
Any ARV Therapy Regimens
(N=1185)

14. Prevention of Perinatal HIV Transmission, TX, 2005-2008, cont.
Among deliveries with prenatal care,
HIV diagnosis before delivery,
and any ARV regimens
No. of Women=1,461
N=1185
No. of Infected Infants=41
Incomplete
Prevention
1-2 arm ARV 3 arm ARV Unknown No Infected
Infected=7 n=103 (9%) n=1082 (91%) n=0 (0%) Infants
(7%)
Infected Uninfected Indeterminate
n=18 (2%) n=615 (57%) n=449 (41%)
56% (23/41) had at least one missed opportunity
45% (18/41) had no missed opportunities

15. Prevention of Perinatal HIV
Transmission
Receipt of prenatal care
Timing of HIV diagnosis
Receipt of antiretroviral therapy (ARV)

16. Prenatal Care among HIV+ Women Delivering*
and Proportion of Infected Children, Texas, 2008
350 20%
n=307
No. of HIV+ Women Delivering
18% 18%
300
16%
% of Children Infected
250 Infected: 56% 14%
(5/9) received 12%
200 no prenatal
care 10%
150 8%
100 6%
4%
50 n=28
1% 2%
0 0%
Any Prenatal Care No Prenatal Care
Women Infected Children (n=9)
*Excluding women with unknown receipt of prenatal care

17. Timing of HIV Diagnosis among HIV+ Women
Delivering* and Proportion of Infected Children,
Texas, 2008
250 n=229 14%
No. of HIV+ Women Delivering
13%
12%
% of Children Infected
200
Infected: 33%
10%
150 (3/9) diagnosed at
delivery
8%
n=105
100 6%
3% 4%
50 n=24 2%
0%
0 0%
Prior to Pregnancy During Pregnancy At Delivery
Women Infected Children (n=9)
*Excluding women with unknown timing of diagnosis

18. Receipt of ARV* among HIV+ Women Delivering**
and Proportion of Infected Children, Texas,
2008
350 12%
No. of HIV+ Women Delivering
300 n=286
10% 10%
% of Children Infected
250
Infected: 78% 8%
(7/9) received
200 incomplete ARV
6%
150
4%
100 n=67
50 1% 2%
0 0%
All 3 Intervals None or 1-2 Intervals
Births Infected Children (n=9)
*ARV-Antiretroviral Therapy **Excluding women with unknown receipt of ARV

19. Summary
Decrease in proportion of perinatal HIV
transmission from 2000 to 2008
Among HIV+ women delivering an infected infant:
• Hispanic and White women were disproportionately
affected (2005-2008)
• Women predominantly received no prenatal care and
received incomplete ARV therapy (2008)
Perinatally HIV infected and exposed children are
distributed throughout Texas (2005-2008)

20. Summary
Missed opportunities continue to occur (2005-2008)
Earlier encounters with HIV positive pregnant
women decreases the likelihood of perinatally
infected children
• Early diagnosis of HIV
• Ensure ARV therapy intake
• Counseling on breastfeeding practices

21. Addressing Missed Opportunities
through the Texas Consortium for
Perinatal HIV Prevention
(TCPHP)
Leslie Conley, L.M.S.W.-I.P.R.
Janak Patel, M.D.
Judy Levison, M.D.

22. Examples of Perinatally HIV
Infected Cases
Leslie Conley, L.M.S.W.-I.P.R.
Case Manager/Inpatient Liaison
Parkland Health and Hospital System

23. Case #1
• 20yo BF, G1P0
• Chlamydia positive, HIV negative in April 2009
• Presented to ER in July 2009 (27 w EGA)
– Abdominal pain
– No previous prenatal care
– HIV positive diagnosis
• Presented for prenatal care in August 2009 (34 w EGA)
– Late entry into prenatal care *** 1st
– Refused HAART *** 2nd

24. Case #1 Continued
• Presented to private OB (August-October 2009)
– No HIV test *** 3rd
• Presented to rural hospital in October 2009
– 39 w EGA, C-section
– HIV diagnosis not disclosed *** 4th
– No HIV results at delivery (send out test) *** 5th
– Breastfeeding
– HIV positive results not known until after discharge
Baby’s initial PCR—HIV+, VL on 2/4/10 = 4,300,000 copies/ml
Baby is INFECTED with HIV.

25. Case #2
• HIV negative in July 2005
• Presented for OB care in August 2006 (14 w EGA)
– Positive trichomonas, chlamydia, and HIV
– Referred to UTMB Maternal-Child HIV Clinic
• Presented to hospital in Galveston County in Sept
2006
– Miscarriage
– No subsequent HIV care

26. Case #2 Continued
• Presented to same hospital in February 2008
– Active labor
– HIV diagnosis not disclosed, but seen in medical record from previous
visit *** 1st
– No prenatal care or HAART during pregnancy *** 2nd
– No IV zidovudine in stock for mother *** 3rd
– No oral zidovudine in stock for baby until > 24 hrs of age *** 4th
– Delay in obtaining zidovudine for discharge *** 5th
Baby’s initial VL at 10 days = 1,569 copies/ml, confirmed with
repeat tests. Baby is INFECTED with HIV.

27. Overview of the TCPHP
Janak Patel, M.D.
Professor, Department of Pediatrics
Director, Pediatric Infectious Disease and Immunology
University of Texas Medical Branch

28. What is the purpose of the TCPHP?
Reduce or prevent perinatal HIV transmission
in Texas through the collaborative efforts of
Perinatal HIV champions
28

29. Who makes up the TCPHP?
Hospitals/Clinics
• Maternal and pediatric HIV providers
• Administrators and case managers
DSHS departments
• Office of Title V and Family Health
• Mental Health and Substance Abuse Services
• HIV/STD Comprehensive Services Branch
• TB/HIV/STD Epidemiology and Surveillance Branch
HIV education/outreach/prevention agencies
• AIDS Education and Training Center
• Houston Regional HIV/AIDS Resource Group
• International AIDS Empowerment
Local health departments
• Surveillance staff

30. Project Components/Work Groups
Leadership
Standards of Care
Education
Outreach
30

31. Project Components/Work Groups
Leadership
• List of perinatal experts
• Identified gaps in membership
Standards of Care
• Guidelines for care for HIV+ pregnant women
Education
• In progress
Outreach
• In progress
31

32. Standards of Care
Component Products

33. Goal 1: Objective and Product
Goal 1: To improve access to necessary components
for perinatal HIV prevention
• Objective: Identify labor and delivery hospitals with access
to ARV therapy for mother and child
• Rational:
– 11% of women received no ARV at L&D (2005-2007)
– 1% of infants received no ARV at birth (2005-2007)
• Product: Developed a survey instrument for pharmacy staff
– 76 hospitals surveyed
– 15-20% do not stock IV AZT or oral AZT

34. Goal 2: Objectives
Goal 2: Improve SOC through enhanced
communication, knowledge, and cultural
competency among statewide stakeholders to
prevent perinatal HIV transmission
• Objective 1: Developed guidelines for care
• Objective 2: Develop prenatal HIV testing
recommendations to harmonize with national
testing guidelines
34

35. Obj. 1: Product (Guidelines for
Care)
Pre-conceptual counseling
• Counseling/education
Antepartum, intrapartum, and neonatal postnatal care
• Recommendations for ARV drugs during pregnancy,
labor & delivery and neonatally by the child
Breastfeeding practices
• Refrain from breastfeeding
35

36. Obj. 1: Product (Guidelines for
Care)
Mode of delivery
• Recommendations based on RNA levels
Postnatal care
• Referral to an HIV specialist
Access to HIV medication
• Familiarity with medication resources
• Stock IV AZT and liquid AZT
• 6 week course of AZT for the infant

37. Obj. 2: Product (Testing
Recommendations)
Universal opt-out screening of all pregnant
women
Timing of tests for pregnant women and infant
• 1st test at first health care visit
• 2nd test at 32-36 weeks gestation
• At labor and delivery (if no documentation of 2nd test)
• Infant testing (if mother’s HIV status is unknown)
Results available within 6 hours of collection
37

38. New Law-Amendments to 81.090
(Effective January 1, 2010)
Second test in third trimester
Sample of woman’s blood or other appropriate
specimen
Test at labor and delivery if no documentation of test
in 3rd trimester
• Make results available within 6 hours of collection
Test infant if no documentation of maternal test in 3rd
trimester or not tested prior to delivery
• Test infant w/in 2 hours after birth and results made
available w/in 6 hours of collection

39. Doing the Right Thing… The
Process
Judy Levison, M.D.
Associate Professor, Department of Obstetrics and Gynecology;
Department of Family and Community Medicine
Baylor College of Medicine

40. How we got started

41. Texas Law until 1/1/2010
Offer HIV testing to all pregnant women early in
pregnancy and in Labor and Delivery
So, all of us have been doing that but most
clinicians and institutions have been using the
standard ELISA
Works great for those who get prenatal care; with
treatment, HIV transmission drops from 25% to
<1%
Yet we are left with missed opportunities: those
women with no prenatal care AND those who
seroconvert during pregnancy

42. True Scenario
A woman presented to a local hospital in labor
and had had no prenatal care.
Routine HIV testing (ELISA=enzyme-linked
immunosorbent assay) was done. Results tend
to return in 24-48 hours and many labs do not
report the results before a confirmatory
Western blot is done, which may take 2-5
days.

43. True Scenario, cont.
The pediatricians were notified of this
woman’s positive ELISA and WB 5 days after
the baby was born, after the mother—who was
breastfeeding—was sent home.

44. A Missed Opportunity…
The majority of HIV transmission occurs at the
time of labor and delivery.
This baby had a 25% chance of being infected
with HIV. This mother’s risk of transmitting
HIV to her baby--if diagnosed as late as labor--
could have been reduced to 10% or less.

45. Some History
2007 Texas Department of State Health Services
funded the TRIAD project
TRIAD = Texas Rapid-testing Implementation At
Delivery
Goal was to educate physicians; midwives; labor
and delivery nurses; hospital labs, pharmacies,
risk management about their role in the
prevention of mother to child transmission of
HIV—with a focus on rapid HIV testing in Labor
& Delivery

46. Why rapid testing?
If a woman has HIV, the rapid test is more likely to
be positive than the ELISA (higher sensitivity)
If a woman does not have HIV, the rapid test is more
likely to be negative than the ELISA (higher
specificity)
Results are available immediately (20 minutes on
site/60 minutes in our lab)
Although confirmation is needed (Western blot), the
results are accurate enough to warrant action, i.e.
treating mother and baby

47. Why rapid testing? (cont.)
2006 CDC updated recommendations state:
• “A second HIV test during the third trimester,
preferably <36 weeks of gestation, is cost-effective
even in areas of low HIV prevalence”
Wouldn’t it make sense to maximize obtaining
test results during pregnancy and use rapid tests
for those who did not get a third trimester test?

48. So how do you change a law?
Start early… the Texas legislature meets from
January until June every two years
Find a sponsor… in this case Senator Rodney
Ellis of Houston had proposed a number of
bills related to routine HIV testing
Work with sponsor’s office

49. Changing Laws
Watch where the bill is in the process of review…
Senate bill proposal filed and sent to appropriate
committee for review, witnesses on each side
testify, financial impact is reviewed, and
suggested improvements are made
If passed in the Senate, then the bill is sent to the
House where similar process occurs; if decision is
made to attach the bill to another bill, then the
two must be relevant to one another
We watched “our” bill come to life and die
several times

50. House Bill 1795
Part 1: “Greyson’s Law”
• Expands newborn screening for enzyme
deficiencies as recommended by the American
College of Medical Genetics in 2005

51. House Bill 1795
Part 2: Perinatal HIV screening
• Test at first prenatal visit for syphilis, HIV, and
hepatitis B (as before)
• Perform the second test for HIV in the third
trimester (a change)
• Do expedited testing for HIV in Labor and
Delivery (results available within 6 hours) IF no
third trimester results available (a change)
• Test baby within 2 hours after birth if mother did
not get tested (a change)

52. Where are we now?
On June 1, 2009, the last day of the 2009
official legislative session, the Texas
legislature voted to change Texas law related
to HIV screening in pregnancy
Amends Section 81.090 of the Texas Health
and Safety Code

53. What does this mean to health care
providers?
Test twice in pregnancy—as we had been doing
Do second test at 32-36 weeks, e.g. when you do
GBS testing at 35 weeks. If positive, you have
time to start treatment and make decisions about
the most appropriate mode of delivery
If a woman presents in labor before the second
test has been done, then do rapid testing in Labor
and Delivery

54. What now?
Educate physicians, office staff, and hospital staff about
new law
Correct misconceptions
Lectures to groups vs. computer modules available to
all providers/institutions
Make proper prenatal HIV testing a quality indicator
Research the factors that contributed/barriers that
existed for the mothers whose babies were born HIV+
in last 5 years, e.g. why no prenatal care, why incorrect
test ordered in L&D, why + test in L&D not acted on

57. Questions/Suggestions

58. Perinatal HIV Interest Group
Session
When: Wednesday, May 26th
Time: 5 to 7pm
Where: Frio
58