Getting to Zero: HIV Perinatal Transmissions and Congenital Syphilis in Broward County FL

State: FL Type: Neither Year: 2016

:
:
:
Broward County is located in the southeastern portion of the State of Florida. Broward County’s 2014 population estimate of 1.87 million people. It is the second most populous county of the 67 counties in the State of Florida (US Census). Its diverse population includes residents from 200 different countries and speaking more than 130 different languages and 31.4% of the residents are foreign-born. Broward County is a minority/majority county demonstrated by its 2014 population by race (White 39.8%, Black 28.9%, Asian/Native American 3.8%, and Hispanic 27.5%). The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County and has been operational since 1936. It is located in Ft. Lauderdale Florida near the Ft. Lauderdale International airport. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward provides population/community-based services to the county’s 1.87 million residents and over 10 million annual visitors. DOH-Broward provides services to individuals’ in vital statistics, clinics, dental, ADAP program (HIV medication), pharmacy and Family Planning. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts.  Public Health issue: In 2013, the Fort Lauderdale metropolitan statistical area ranked 10 in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. In 2014, in the State of Florida, Broward County had the 2nd highest number of new HIV cases of all 67 counties. In 2013, Broward County had 127 pregnant women of childbearing age (aged 15-55) who were HIV positive. In 2014, there were 103 and to date in 2015 there are 102. Many of these women receive limited or no prenatal care at any time during their pregnancy, however the lack of prenatal care is not due to a lack of insurance or access to care. The majority of this subset also does not receive antiretroviral medications. Research has shown that neonates born to HIV positive pregnant women, who are not on antiretroviral medications, have a 35% chance of mother to child HIV transmission. With medication, that risk of transmission becomes 1%. As a result, reported cases of Perinatal HIV Transmission went from 2 in 2012 to 1 in 2015. Goals and objectives: The goal was to reduce perinatal HIV transmission to zero in Broward County. Practice objectives are: 1) Ensure that all labor and delivery hospitals have the current public health service guidelines and protocols for HIV positive pregnant women; 2) Ensure that all OB/GYN practitioners in Broward County have the latest public health service guidelines for treating HIV positive pregnant women; 3) Ensure that all labor and delivery hospitals participate in an continuous quality improvement process to identify missed opportunities and further reduce mother to child transmission of HIV; 4) Provide continuous education to OB/GYN practitioners regarding new and emerging HIV medications effective for HIV positive pregnant women;5) Identify and link all HIV positive pregnant women to perinatal and infectious disease providers; and, 6) Ensure that HIV positive pregnant women remain in care through their 6 week post-partum checkup. Practice implemented: HIV positive women are identified through electronic HIV/AIDS reporting system (eHARS), Patient Reporting Investigating Surveillance Manager (PRISM), and referred through private providers and labor and delivery hospitals. DOH-Broward implemented an STD tracking system in 2012 that allows for the monitoring of HIV positive women. For those with unknown pregnancy status, Perinatal HIV Disease Intervention Specialist (HIVDIS) contact the provider to determine pregnancy status. If still unknown, perinatal HIVDIS contact the client and if pregnancy still unknown, a pregnancy test is provided to the client to self-administer. If client is pregnant, the perinatal team (consisting of the Perinatal Director, a Perinatal Coordinator, two Perinatal HIVDIS, and two Linkage Coordinators) begins case management services. DOH-Broward Perinatal Prevention Program has developed and implemented a secure HIV Prevention Care Coordination Tracking System (HPCC). HPCC contains information for use by the DOH-Broward Perinatal Team (Team) regarding the client’s estimated date of delivery, medications prescribe, viral load, CD4 results and other relevant lab results. The Team keeps a clinical flow sheet on each case to ensure that the clients are in maintained in care. The Team identifies and removes barriers to care, links client’s to care and treatment, case management and follow-up throughout pregnancy and postpartum. As a result, reported of Perinatal HIV Transmission went from 2 in 2012 and 1 in 2015 and all objectives were met. Factors led to the success include effectively targeting, tracked and monitored HIV positive pregnant women and reduces perinatal HIV transmission. Public Health Impact: From 2012 to 2015 cases of perinatal HIV have been reduced from 2 in 2012 to 1 in 2015.  The website for DOH-Broward is http://broward.floridahealth.gov/    
In 2013, the Fort Lauderdale metropolitan statistical area ranked 10 in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. In 2014, in the State of Florida, Broward County had the 2nd highest number of new HIV cases of all 67 counties. In 2013, Broward County had 127 pregnant women of childbearing age (aged 15-55) who were HIV positive. In 2014, there were 103 and to date in 2015 there are 102. Many of these women receive limited or no prenatal care at any time during their pregnancy, however the lack of prenatal care is not due to a lack of insurance or access to care. The majority of this subset also does not receive antiretroviral medications. Research has shown that neonates born to HIV positive pregnant women, who are not on antiretroviral medications, have a 35% chance of mother to child HIV transmission. With medication, that risk of transmission becomes 1%. As a result of this process, reported cases of Perinatal HIV Transmission went from 2 in 2012 to 1 in 2015.  What target population is affected by problem: The population in Broward County is 39.8% White, 28.9% Black, 3.8% Asian/Native American, and 27.5% Hispanic. In 2013 the Team case managed 127 HIV positive pregnant women, 90% are black and in 2014 the Team case followed 103 pregnant women, 85% were black. As of September, 2015, the Team is case managing 102 HIV positive pregnant women, 87% are Black. Transmission is disproportionately affecting our minority population. What percentage did you reach?: Out of the 102 HIV positive pregnant cases this year we have had seven cases that delivered and were unknown to the DOH-Broward Team. We reached 93% of the HIV Positive pregnant women. To date we only had one positive HIV transmission in utero because mom refused care and treatment. What has been done in the past to address the problem?: The sexually transmitted disease (STD), HIV, TB and Hepatitis Programs conducted individual surveillance because they were stand-alone programs with minimal coordination of activities across programs. The services provided and referrals were a manual process; which made the process slower, fragmented, duplicative, and ineffective. Why is current/proposed practice better? DOH-Broward adopted the Program Collaboration and Service Integration (PCSI) model which is a mechanism for organizing and blending interrelated health issues, activities, and prevention strategies to facilitate comprehensive delivery of services. This process has improved continuity of care for HIV positive pregnant women. As a result of this process, reported cases of Perinatal HIV Transmission went from 2 in 2012 to 1 in 2015. Is current practice innovative?: The provision of case management to all HIV positive pregnant women in Broward County by the DOH-Broward Perinatal Team is an innovative practice. The Team’s continuous outreach and education has enhanced communication and collaboration with the provider community. The Perinatal Director chairs the perinatal task force, which meets monthly to bring together internal and external partners providing maternal and child health services. The practice has enhanced the Team’s access to many providers in the county that seek our expertise and guidance. It has also provided OB/GYNs and Infectious Disease physicians in Broward County the information needed to refer clients to appropriate care and treatment. Creative use of existing tool or practice: DOH- Broward uses the Incident Command System (ICS), a component of the National Incident Management System to provide structure and guidance when we have a situation with pregnant women. We also follow HP 2020 to guide our practice. Is current practice evidence-based?: This practice is evidence based as outlined in the latest DHHS guidelines for HIV treatment and care for HIV positive pregnant women. (www.AIDSinfo.gov) . We address mother-to-child transmission of HIV by following CDC guidelines for care and treatment of their babies. The use of PCSI model is a best practice methodology being utilized across DOH-Broward programs.
HIV in the U.S.|Mother-to-Child Transmission of HIV and Syphilis
Goals and objectives of practice:The goal was to reduce perinatal HIV transmission to zero in Broward County. Practice objectives are: 1) Ensure that all labor and delivery hospitals have the current public health service guidelines and protocols for HIV positive pregnant women; 2) Ensure that all OB/GYN practitioners in Broward County have the latest public health service guidelines for treating HIV positive pregnant women; 3) Ensure that all labor and delivery hospitals participate in an continuous quality improvement process to identify missed opportunities and further reduce mother to child transmission of HIV; 4) Provide continuous education to OB/GYN practitioners regarding new and emerging HIV medications effective for HIV positive pregnant women;5) Identify and link all HIV positive pregnant women to perinatal and infectious disease providers; and, 6) Ensure that HIV positive pregnant women remain in care through their 6 week post-partum checkup. What did you do to achieve the goals and objectives? Steps taken to implement the program: HIV positive women are identified through electronic HIV/AIDS reporting system (eHARS), Patient Reporting Investigating Surveillance Manager (PRISM), and referred through private providers and labor and delivery hospitals. DOH-Broward implemented an STD tracking system in 2012 that allows for the monitoring of HIV positive women. For those with unknown pregnancy status, Perinatal HIV Disease Intervention Specialist (HIVDIS) contact the provider to determine pregnancy status. If still unknown, perinatal HIVDIS contact the client and if pregnancy still unknown, a pregnancy test is provided to the client to self-administer. If client is pregnant, the perinatal team (consisting of the Perinatal Director, a Perinatal Coordinator, two Perinatal HIVDIS, and two Linkage Coordinators) begins case management services. DOH-Broward Perinatal Prevention Program has developed and implemented a secure HIV Prevention Care Coordination Tracking System (HPCC). HPCC contains information for use by the DOH-Broward Perinatal Team (Team) regarding the client’s estimated date of delivery, medications prescribe, viral load, CD4 results and other relevant lab results. The Team keeps a clinical flow sheet on each case to ensure that the clients are in maintained in care. The Team identifies and removes barriers to care and links client’s to care and treatment, case management and follow-up throughout pregnancy and postpartum. Any criteria for who was selected to receive the practice?: The criteria for who was selected to receive the practice are all HIV positive pregnant women, providers of services to HIV positive women, (OB/GYNs, Infectious Disease physicians, Neonatologists, and labor and delivery hospitals). What was the timeframe for the practice? The timeframe for this practice is July 2013 and is ongoing. Were other stakeholders involved? : The practices involved other stakeholders including OB/GYNs, Infectious Disease physicians, Neonatologists, Pediatricians, labor and delivery hospitals, and other medical providers. What was their role in the planning and implementation process? In 2013, the Perinatal Director, visited and provided education to more than 96 OB/GYN’s, 103 pediatricians, Infectious Disease physicians, Neonatologists, labor and delivery hospitals, and other medical providers’ in Broward County. This included provision of information regarding American College of Obstetrics and Gynecology (ACOG) recommendations on HIV testing and pregnancy, case reporting, and medication and their role in the process. This process is ongoing. The Perinatal Director chairs the Perinatal HIV Providers Network (PHPN) meeting that is held every third Thursday of the month. This community group is comprised of at least one member from the following institutions that work with Maternal-child-health: • Broward Health Medical Center• Broward Health at Coral Springs• Health Start coalition• 211 Broward• Broward Addiction recovery Center (BARC)• Susan B. Anthony Addiction Center• DOH- Broward STD• DOH- Broward HIV Surveillance• DOH- Broward HIV prevention Program• Children’s Diagnostic and Treatment Center• Holy Cross Hospital group• Black Infant Birth Health Initiative What does the LHD do to foster collaboration with community stakeholders? The Perinatal HIV Providers Network (PHPN) has an annual work plan that consists of the following items for Year 2015-2016: Host two annual Perinatal HIV Symposiums at one of the eight laboring hospitals. Presentations are provided on the latest trends in Perinatal HIV and other factors associated with perinatal HIV Transmission To ensure that all OB/GYN providers are visited at least once a year and provided with the latest information and guidelines. A perinatal Tool Kit will be developed that includes information on HIV Testing, Treatment options, copies of protocols for care and treatment of pregnant HIV positive women, and other related information. This tool kit will be distributed to all  OB/GYNs and Pediatricians in Broward County. To provide Perinatal Classes specific to HIV pregnant women and their neonate. These classes will be held every other week and include the following: What to expect during prenatal care Testing and Laboratory interpretations? Nutrition in Pregnancy Medication Adherence Birthing Options for the Pregnant HIV positive woman Delivery, “Vaginal vs Cesarean Section (CS)” Postpartum care and medication adherence Infant medication and testing Continuity of Care for the Positive Woman Describe the relationship(s) and how it furthers the practice goal(s): Members of the Perinatal HIV Providers Network (PHPN) are updated on the latest public service guidelines for HIV-positive pregnant women and babies at the monthly meetings. They are presented with the latest statistics on the number of pregnancies which DOH-Broward follows and the number of deliveries per hospital. Progress on annual work plan activities is presented and discussed. Best practices and treatment guidelines are also shared in this forum. These meetings have assisted in enhancing communication and collaborative planning. There is no fee involved in providing this meeting because it is held at the Florida Department of Health in Broward County conference room.  
What did you find out? Utilizing Perinatal HIV DIS to identify, link to care, continuously monitor, and provide education has assisted DOH-Broward to reduce perinatal HIV transmission from 2 cases in 2012 to 1 case in 2015. The process continues. To what extent were your objectives achieved? DOH-Broward’s Perinatal Team has met Objective 1) Ensure that all labor and delivery hospitals have the current public health service guidelines and protocols for HIV positive pregnant women by providing annual protocol updates to labor and delivery and newborn nursing staff at all 8 facilities. Objective 2) Ensure that all OB/GYN practitioners in Broward County have the latest public health service guidelines for treating HIV positive pregnant women has been met by visited and provided education to more than 96 OB/GYN’s, 103 pediatricians, Infectious Disease physicians, Neonatologists, labor and delivery hospitals, and other medical providers’ in Broward County. This included provision of information regarding American College of Obstetrics and Gynecology (ACOG) recommendations on HIV testing and pregnancy, case reporting, and medication and their role in the process. This process is ongoing. Objective 3) Ensure that all labor and delivery hospitals participate in a continuous quality improvement process to identify missed opportunities and further reduce mother to child transmission of HIV has been met and is ongoing by conducting formal chart reviews for each HIV positive exposed infant. Objective 4) Provide continuous education to OB/GYN practitioners regarding new and emerging HIV medications effective for HIV positive pregnant women is met by conducting field visits to OB/GYN practices to disseminate information. Objective 5) Identify and link all HIV positive pregnant women to perinatal and infectious disease providers has been met by adding clients to the HPCC database and linking to needed services; and, Objective 6) Ensure that HIV positive pregnant women remain in care through their 6 week post-partum checkup is met by documenting the testing of HIV exposed infants at six weeks.. Did you evaluate your practice? Program data is collected through the statewide Florida Department of Health (DOH) Health Management Systems (HMS) and the STD PRISM system. The Perinatal Prevention Director reviews the data entered into PRISM to ensure it meets the established programmatic guidelines. The Director has a local program database (HPPC) that collects demographics, testing history, number of births, date of treatment, type of treatment, etc. We also collect viral load and CD4 on all the perinatal cases and the PCRs done on the infants. Data is collected by every perinatal team member. We have an ongoing spreadsheet and database where information is gathered.  List any secondary data sources used (if applicable) none at this time List performance measures used. Include process and outcome measures as appropriate.: Performance measures for the Perinatal HIV Program include: reporting timeliness, adoption of protocols, number of clients linked to care, number of clients on appropriate antiretroviral medication, number of symposiums conducted; number of field visits completed; number of grand rounds provided and/or participated in, etc. Describe how results were analyzed?: Active Strategy software is the DOH-Broward internal performance management system that provides ongoing programmatic reporting of measures that includes measures related to the perinatal program. These measures are reviewed at the monthly business review meeting of all DOH-Broward leadership and supervisory staff. Underperforming measures are discussed with correction actions developed, implemented and approved. Were any modifications made to the practice as a result of the data findings? A chart review process was added to provide an opportunity to identify missed opportunities and provide education to the labor and delivery hospital. In addition, some clients require more intensive follow-up and case management such as that that refuse care and/or treatment (often having substance abuse problem or were perinatal infected at birth). Finally, any pregnant women, without prenatal care, presenting to labor and delivery with an unknown HIV status, refusing HIV rapid testing, will immediately trigger DOH-Broward contact.
Lessons learned in relation to practice: Yearly updates and follow up visits to the medical providers is necessary to keep them current on the most recent public health service guidelines for HIV in pregnancy changes on a yearly basis. Continuous collaboration with providers enhances the relationship between DOH-Broward and the providers in Broward County. Through intensive case management of clients builds rapport and trust with clients. Lessons learned in relation to partner collaboration (if applicable): We need Infection Control Practitioners (ICP) to navigate in through the hospital hierarchy. Consistent follow up with providers builds trust and rapport. Did you do a cost/benefit analysis? If so, describe. No, we did not do a cost base analysis however research has shown the approximate medical cost for care is more $42,000 per year for a newly identified HIV positive individual. Finding HIV positive pregnant females linking them to care and preventing perinatal transmission mother to child saves additional more than $42,000 plus. Is there sufficient stakeholder commitment to sustain the practice? Describe sustainability plans: Continuous development of the program and relationship with the community partners enhances local policies and protocols which help medical providers achieve long term improvements in providing care to HIV positive pregnant women. Engaging community partners ensures sustainability because members define the work to be done and creates a vision for future plans that prevents mother to child transmission of HIV. Through continuous education and case management of clients empowers them to understand their disease and the importance of staying in care.The approximate medical cost for care is more $42,000 per year for a newly identified HIV positive individual. Finding HIV positive pregnant females linking them to care and preventing perinatal transmission mother to child saves additional more than $42,000 plus.  
Colleague in my LHD|NACCHO website
 
Processing...


Driving Walking/Biking Public Transit  Get Directions