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Increasing HIV testing among pregnant Increasing HIV testing among pregnant women: Results from the Ontario women: Results from the Ontario HIV seroprevalence studyHIV seroprevalence study
Robert S. Remis, Carol Swantee, Maraki Fikre Merid, Robert Robert S. Remis, Carol Swantee, Maraki Fikre Merid, Robert W.H. Palmer, Mark Fisher, Keyi Wu, Susan King, Peggy Millson, W.H. Palmer, Mark Fisher, Keyi Wu, Susan King, Peggy Millson, Liviana Calzavara, Elaine Whittingham and Carol Major Liviana Calzavara, Elaine Whittingham and Carol Major
Department of Public Health Sciences, University of TorontoDepartment of Public Health Sciences, University of Toronto
Laboratories Branch, Ontario Ministry of Health and Long-Term CareLaboratories Branch, Ontario Ministry of Health and Long-Term Care
Hospital for Sick ChildrenHospital for Sick Children
15th International Conference on AIDS15th International Conference on AIDS
Bangkok, Thailand, July 11-16, 2004Bangkok, Thailand, July 11-16, 2004
BackgroundBackground
• 1991: HIV prevalence 0.23/1,000 in childbearing 1991: HIV prevalence 0.23/1,000 in childbearing womenwomen
• 1994: ZDV found to reduce HIV transmission 1994: ZDV found to reduce HIV transmission • 1997: Modeled HIV prevalence 0.70/1,0001997: Modeled HIV prevalence 0.70/1,000 and 20- and 20-
25% of 25% of pregnant women tested for HIVpregnant women tested for HIV
Ontario HIV screening programOntario HIV screening program
• 1995: Advisory to physicians to consider HIV test for 1995: Advisory to physicians to consider HIV test for pregnant women at increased riskpregnant women at increased risk
• December 1998: Program to offer HIV testing to all December 1998: Program to offer HIV testing to all pregnant womenpregnant women
• Sep 2001 - Jan 2002: Memo sent with test report to Sep 2001 - Jan 2002: Memo sent with test report to physicians when HIV test prescribedphysicians when HIV test prescribed
• Sep 2003: Memo reinstated with refinementsSep 2003: Memo reinstated with refinements
Study objectives Study objectives
• Quantify and characterize HIV prevalence amongQuantify and characterize HIV prevalence among women of childbearing age in Ontariowomen of childbearing age in Ontario
• Evaluate the Ontario HIV screening programEvaluate the Ontario HIV screening program
Data managementData management
• Data extracted fromData extracted from LAByrinth LAByrinth • Prenatal testing records linked to HIV diagnostic databasePrenatal testing records linked to HIV diagnostic database• Matching allowed for different spelling and structure of Matching allowed for different spelling and structure of
name and reversal of month-day in birthdatename and reversal of month-day in birthdate• Tests aggregated into episode equivalent to gestation period Tests aggregated into episode equivalent to gestation period
and HIV test uptake analysed for pregnanciesand HIV test uptake analysed for pregnancies
Unlinked seroprevalence studyUnlinked seroprevalence study
• For 2002, specimens from women not HIV tested were For 2002, specimens from women not HIV tested were tested after personal identifiers removed (anonymous, tested after personal identifiers removed (anonymous, unlinked study)unlinked study)
• Data on age group and health region of test retained Data on age group and health region of test retained • HIV prevalence examined and compared to that among HIV prevalence examined and compared to that among
women testedwomen tested
Proportion of pregnancies tested for Proportion of pregnancies tested for HIV by health region, 1st quarter 2004HIV by health region, 1st quarter 2004
88%38,708 43,881 Total
87%88%90%87%92%90%89%91%
10,1869,191 4,6256,1293,2202,9702,216
171
11,741 10,427
5,162 7,055 3,5043,310
2,494 188
TorontoCentral East, otherSouthwestCentral WestOttawaEastern, otherNorthernN/A or OFP
Proportion tested
HIVtested
Number of preg’s
HIV testing among pregnancies by timing HIV testing among pregnancies by timing of HIV test, Ontario, Jan 1999-Mar 2004of HIV test, Ontario, Jan 1999-Mar 2004
0
10
20
30
40
50
60
70
80
90
1001
99
9-
Q1
19
99
- Q
2
19
99
- Q
3
19
99
- Q
4
20
00
- Q
1
20
00
- Q
2
20
00
- Q
3
20
00
- Q
4
20
01
- Q
1
20
01
- Q
2
20
01
- Q
3
20
01
- Q
4
20
02
- Q
1
20
02
- Q
2
20
02
- Q
3
20
02
- Q
4
20
03
- Q
1
20
03
- Q
2
20
03
- Q
3
20
03
- Q
4
20
04
- Q
1
Current
Prior
Any test
Pro
port
ion
of
pre
gn
an
cie
s (
%)
HIV testing among pregnancies forHIV testing among pregnancies forselected health regions, Jan 1999-Mar 2004selected health regions, Jan 1999-Mar 2004
0
10
20
30
40
50
60
70
80
90
1001
99
9-
Q1
19
99
- Q
2
19
99
- Q
3
19
99
- Q
4
20
00
- Q
1
20
00
- Q
2
20
00
- Q
3
20
00
- Q
4
20
01
- Q
1
20
01
- Q
2
20
01
- Q
3
20
01
- Q
4
20
02
- Q
1
20
02
- Q
2
20
02
- Q
3
20
02
- Q
4
20
03
- Q
1
20
03
- Q
2
20
03
- Q
3
20
03
- Q
4
20
04
- Q
1
Pro
po
rtio
n o
f s
pe
cim
en
s (
%)
Metro Toronto
Central East, Other
Southwest
Central West
HIV testing among pregnancies forHIV testing among pregnancies forselected health regions, Jan 1999-Mar 2004selected health regions, Jan 1999-Mar 2004
0
10
20
30
40
50
60
70
80
90
1001
99
9-
Q1
19
99
- Q
2
19
99
- Q
3
19
99
- Q
4
20
00
- Q
1
20
00
- Q
2
20
00
- Q
3
20
00
- Q
4
20
01
- Q
1
20
01
- Q
2
20
01
- Q
3
20
01
- Q
4
20
02
- Q
1
20
02
- Q
2
20
02
- Q
3
20
02
- Q
4
20
03
- Q
1
20
03
- Q
2
20
03
- Q
3
20
03
- Q
4
20
04
- Q
1
Pro
po
rtio
n o
f s
pe
cim
en
s (
%)
Ottawa
Eastern, Other
Northern
Number of PHU’s in each region by proportion Number of PHU’s in each region by proportion tested for HIV, 1st quarter 2004 tested for HIV, 1st quarter 2004
1
50- 59% 90- 100%80- 89%70- 79%60- 69%
3714212Total
843Northern
523Eastern other
11Ottawa
725Central West
9441Southwest
65Central Eastother
1Toronto
Total PHU’sNumber of PHU’s by proportion of HIV testing uptake
1
1
Number of HIV-positive pregnanciesNumber of HIV-positive pregnancies
Prior
2
6
17
6
16
4
51
Current
10
20
32
29
48
11
150
Total
12
26
49
35
64
15
201
1999
2000
2001
2002
2003
2004
TOTAL
HIV-positive and number of pregnancies by HIV-positive and number of pregnancies by test status, anonymous unlinked study 2002test status, anonymous unlinked study 2002
Not tested Tested AllHIV-positive 21 35 56Number of pregnancies 33,625 113,786 147,411
Rate / 1,000 0.62 0.31 0.38
Relative rate 2.03
HIV-positive and number of pregnancies by HIV-positive and number of pregnancies by test status, anonymous unlinked study 2002test status, anonymous unlinked study 2002
0.00
0.20
0.40
0.60
0.80
1.00
< 20 20-24 25-29 30-34 35-39 40-44 45+
Age group (years)
Rat
e (/
1,00
0)
Untested
Tested
HIV-positive and number of pregnancies by HIV-positive and number of pregnancies by test status, anonymous unlinked study 2002test status, anonymous unlinked study 2002
HIV+Rate
/1,000 HIV+Rate
/1,000 HIV+Rate
/1,000
Northern 0 0.00 0 0.00 0 0.00
Eastern, other 0 0.00 1 0.11 1 0.09
Ottawa 4 1.84 4 0.42 8 0.68
Central Eastern, other 1 0.13 3 0.12 4 0.12
Toronto 13 1.31 22 0.74 35 0.89
Southwest 2 0.52 1 0.07 3 0.17
Central West 0 0.00 4 0.22 4 0.17
Unknown 1 10.64 0 0.00 1 1.90
Total 21 0.62 35 0.31 56 0.38
Not tested Tested All
InterpretationInterpretation
• Based on recent analysis, actual uptake of HIV testing Based on recent analysis, actual uptake of HIV testing was slightly greater than our results suggest due to was slightly greater than our results suggest due to non-matches (for anonymous and coded HIV testing) non-matches (for anonymous and coded HIV testing)
• Estimated difference is 2%Estimated difference is 2%• Study does not indicate Study does not indicate whywhy HIV test was not carried HIV test was not carried
outout
Conclusions Conclusions
• Critical to capture data from HIV diagnostic database in Critical to capture data from HIV diagnostic database in addition to prenatal database addition to prenatal database
• HIV testing increased from 40% to 50% from January to HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September 2001May 1999, with modest increase until September 2001
• Impact of memo: from 60% to 75%Impact of memo: from 60% to 75%• Uptake in latest quarter 90%, though slightly less (85%) Uptake in latest quarter 90%, though slightly less (85%)
for current pregnancy only for current pregnancy only • Less regional variation in HIV test uptake Less regional variation in HIV test uptake • In five years, 201 women identified as HIV-positive, In five years, 201 women identified as HIV-positive,
51 previously diagnosed, 150 newly diagnosed51 previously diagnosed, 150 newly diagnosed
Conclusions (continued)Conclusions (continued)
• Based on results of 2002 unlinked seroprevalence studyBased on results of 2002 unlinked seroprevalence study
• HIV prevalence higher (almost double) among HIV prevalence higher (almost double) among women not testedwomen not tested
• In 2002, though ~ 82% of pregnant women tested, In 2002, though ~ 82% of pregnant women tested, only ~ 63% of HIV-infected pregnant women testedonly ~ 63% of HIV-infected pregnant women tested
• According to the preliminary results from a model According to the preliminary results from a model (data not shown), about 6-8 mother-infant HIV (data not shown), about 6-8 mother-infant HIV transmissions occurred in 2003transmissions occurred in 2003
AcknowledgmentsAcknowledgments
• Prenatal HIV Screening Evaluation Committee Prenatal HIV Screening Evaluation Committee • Frank McGee, coordinator AIDS BureauFrank McGee, coordinator AIDS Bureau• Janis Tripp, consultant AIDS BureauJanis Tripp, consultant AIDS Bureau• FundingFunding
• AIDS Bureau, Ontario Ministry of Health AIDS Bureau, Ontario Ministry of Health and Long-Term Careand Long-Term Care
• Centre for Disease Prevention and Control, Centre for Disease Prevention and Control, Health Protection, Health CanadaHealth Protection, Health Canada
