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

State: FL Type: Model Practice Year: 2017

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Florida Department of Health in Broward County
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Getting to Zero HIV Perinatal Transmission and Congenital Syphilis in Broward County FL
Broward County is located in Florida with a 2016 population of 1,809,604 plus hosts an estimated 10 million annual visitors. Broward County is a minority/majority county demonstrated by its 2016 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%). 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. Public Health issue: In 2013, the Broward County Fort Lauderdale metropolitan statistical area ranked 10th in United States for newly diagnosed HIV cases and ranked 2nd in HIV case rates. In 2014, Broward County had the 2nd highest number of new HIV cases of all 67 Florida counties. In 2014, Broward County had 104 pregnant women of childbearing ages of 15-55 who were HIV positive. In 2015, there were 126 and to date in 2016 there are 100. Seventy-five percent of these women receive limited or no prenatal care during their pregnancy, however the lack of prenatal care is not due to a lack of insurance or access to care. The majority of these women are receiving 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 decreases to 1%. As a result of this process, reported cases of Perinatal HIV Transmission went from 2 in 2012, zero in 2013, zero in 2014, one in 2015 from a perinatally infected mother that refused care and treatment and zero for 2016. Goals and objectives: The goal was to reduce perinatal HIV transmission to zero in Broward County. The goal is in addressed in the DOH-Broward strategic plan. Practice objectives are: 1) Ensure that all labor and delivery hospitals have the most 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 Exposed newborns are screened for HIV after birth. Practice implemented: HIV positive women are identified through several components within the DOH-Broward public health system: 1. Electronic HIV/AIDS reporting system (eHARS), 2. Patient Reporting Investigating Surveillance Manager (PRISM), 3. Referred through private providers and labor and delivery hospital 4. AIDS Drug Assistance Program (ADAP) 5. Dental Program 6. DOH- Pharmacy 7. Healthy Start Coalition In 2012, DOH-Broward implemented a STD tracking system that allows for the monitoring of HIV positive women in Broward County. For those with unknown pregnancy status, the Perinatal HIV Disease Intervention Specialist (HIVDIS) contacted the provider to determine pregnancy status. If still unknown, perinatal HIVDIS contacts 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 which consists of the Perinatal Director, a Perinatal Coordinator, two Perinatal HIVDIS, and two Linkage Coordinators, begins case management services. The DOH-Broward Perinatal Prevention Program 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 prescribed, viral load, CD4 results and other relevant lab results. The team keeps maintains a clinical flow sheet on each case to ensure that the clients are 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. Results: As a result of this process, reported cases of Perinatal HIV Transmission went from 2 in 2012 to zero in 2016 Even one is one too many. Objectives met? All objectives were met. Factors led to the success: The Team has effectively targeted, tracked and monitored HIV positive pregnant women and reduces perinatal HIV transmission in Broward County. Public Health Impact: From 2012 to 2015 cases of perinatal HIV have been reduced from 2 in 2012 to zero in 2016. Website for your program, or LHD http://broward.floridahealth.gov/
What target population is affected by problem (please include relevant demographics): The population in Broward County is 39.8% White, 28.9% Black, 3.8% Asian/Native American, and 27.5% Hispanic. In 2014 the perinatal team case managed 104 HIV positive pregnant women which were 85% black . In 2015, 125 HIV positive pregnant women were followed and 87% were Black. Transmission is disproportionately affecting our minority population because the total Black population in Broward County is 28.9% and the HIV pregnant women are over 85%. What percentage did you reach?: In 2016, out of the 100 HIV positive pregnant cases, DOH-Broward had three cases that delivered and were unknown to the DOH-Broward Perinatal Team. The DOH-Broward Perinatal program was able to reach 97% of the HIV Positive pregnant women. To date, Broward has zero HIV Perinatal transmissions and all babies born this year had at least one negative PCR test at birth. 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. HIV Pregnant women were not case managed throughout their pregnancy. If they were tested during their pregnancy, the STD program would go out into the community to provide partner notification and attempt to link the client to care. 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 two in 2012 to zero in 2016. 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), which is a component of the National Incident Management System (NIMS), to provide structure and guidance when we have a situation with HIV positive pregnant women that refuses our care and treatment services. DOH-Broward also follows the Healthy People 2020 to guide our practice.
HIV in the U.S.
Goals and objectives of practice: The goal was to reduce perinatal HIV transmission to zero cases 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 exposed infants are tested and screened for HIV. 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), referred through private providers and labor and delivery hospitals. In 2012, DOH-Broward implemented an STD tracking system 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). This system contains information for use by the DOH-Broward Perinatal Team regarding the client's estimated date of delivery, medications prescribed, viral load, CD4 results and other relevant lab results. This allows the team to keep a clinical flow sheet on each case to ensure that the clients are in maintained in care. This 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 and providers of services to HIV positive women (OB/GYNs, Infectious Disease physicians, Neonatologists, and labor and delivery hospitals) in the Broward County area. What was the timeframe for the practice? The timeframe for this practice started in July 2013. Due to the processes success and the importance of eliminating perinatal HIV transmissions, the process will continue due to the number of positive women in the county. Were other stakeholders involved? The practices involved other stakeholders including OB/GYNs, Infectious Disease physicians, Neonatologists, Pediatricians, labor and delivery hospital staff, and any other medical provider that follows HIV positive women. What was their role in the planning and implementation process? In 2016, the Perinatal Director, visited and provided education to more than 96 OB/GYN's, 103 pediatricians, 10 Infectious Disease physicians, 3 Neonatologists, 8 labor and delivery hospital staff, and numerous other medical providers' in Broward County. The education included information from the American College of Obstetrics and Gynecology (ACOG) recommendations on HIV testing in pregnancy and The Health and Human Services guidelines on medication in pregnancy to reduce perinatal HIV transmission. The Perinatal Director chairs the Perinatal HIV Providers Network (PHPN) meeting that is held monthly. 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 Health Mothers, Healthy Babies March of Dimes What does the LHD do to foster collaboration with community stakeholders? The Perinatal HIV Providers Network (PHPN) annual work plan consists of the following priority items for year 2016 - 2017: ? 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 was developed that includes information on HIV Testing, treatment options, protocols for care and treatment of pregnant HIV positive women, substance abuse, infant testing and other related information. This tool kit will be distributed to al 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: o What to expect during prenatal care o Testing and Laboratory interpretations? o Nutrition in Pregnancy o Medication Adherence o Birthing Options for the Pregnant HIV positive woman o Delivery, Vaginal vs Cesarean Section (CS)” o Postpartum care and medication adherence o Infant medication and testing o 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 with other maternal child health providers and HIV providers. 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 two cases in 2012 to zero in 2016. The process is continuous. To what extent were your objectives achieved? Please re-state your objectives from the methodology section. 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 eight 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 information regarding American College of Obstetrics and Gynecology (ACOG) recommendations on HIV testing and pregnancy and the Department of Health and Human Services guidelines on medication for HIV positive pregnant women This process is continuously 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 Exposed infants are tested and screened for HIV after birth. Did you evaluate your practice? List any primary data sources, who collected the data, and how (if applicable) 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 HIV testing (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: 1. Hospitals reporting deliveries within 24 hours in 2016: 100 deliveries, 2. adoption of protocols: report cards are provided quarterly to the eight laboring hospitals, 3. number of clients linked to care: 97 of 100 pregnant cases linked to care, 4. number of clients on appropriate antiretroviral medication: 97 of 100 clients on appropriate treatment in pregnancy, 5. number of symposiums in 2016: two symposiums conducted, 6. number of grand rounds provided and/or participated in 2016: 14 grand rounds. 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 with all DOH-Broward leadership and supervisory staff attending. Underperforming measures are discussed with correction actions developed, implemented and approved. in 2016, the perinatal program was awarded Outstanding for exceeding all measures. 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 labor and delivery hospitals. In addition, some clients require more intensive follow-up and case management such as those that refuse care and/or treatment. Often when women refuse care, they are found to have a substance abuse problem or are young perinatally infected women. Finally, any pregnant woman, without prenatal care, presenting to labor and delivery with an unknown HIV status and refusing HIV rapid testing, will immediately trigger a call from the infectious disease director at the eight laboring hospitals to contact the DOH-Broward Perinatal Director.
Lessons learned in relation to practice: Yearly updates and follow up visits to medical providers are necessary to keep client's current on the most recent Department of Health and Human Services guidelines for HIV in pregnancy because these change 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): DOH-Broward determined the need for 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 than $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 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 these 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 more than $42,000 plus per client. With 100 women followed in 2016 results in a potential savings of $4,200,000.
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