Uptake of HIV testing among pregnant Uptake of HIV testing among pregnant women in Ontario: Results from the women in Ontario: Results from the HIV seroprevalence study to June 2002HIV seroprevalence study to June 2002Robert S. Remis, Carol Swantee, Carol Major, Margaret Fearon, Robert S. Remis, Carol Swantee, Carol Major, Margaret Fearon, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Elizabeth Rea, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Elizabeth Rea, Susan King, Marion Vermeulen, Elaine Whittingham and Susan King, Marion Vermeulen, Elaine Whittingham and

Robert PalmerRobert PalmerDepartment of Public Health Sciences, University of Toronto;Department of Public Health Sciences, University of Toronto;

Laboratories Branch and Public Health Branch, Laboratories Branch and Public Health Branch, Ontario Ministry of Health and Long Term-Care;Ontario Ministry of Health and Long Term-Care;

Toronto Public Health; Hospital for Sick ChildrenToronto Public Health; Hospital for Sick Children

Ontario HIV Treatment Network, 4th Annual Research Day,Ontario HIV Treatment Network, 4th Annual Research Day,

Toronto, Ontario, November 28, 2002Toronto, Ontario, November 28, 2002

AcknowledgmentsAcknowledgments

• Central Public Health Laboratory, Central Public Health Laboratory, Ontario Ministry of Health and Long-Term CareOntario Ministry of Health and Long-Term Care

• Keyi Wu, programmingKeyi Wu, programming• Mark Fisher, systems consulting and custom downloadMark Fisher, systems consulting and custom download• Prenatal Screening Evaluation Committee Prenatal Screening Evaluation Committee • Frank McGee, co-ordinatorFrank McGee, co-ordinator• Janis Tripp, consultantJanis Tripp, consultant

• FundingFunding• AIDS Bureau, Ontario Ministry of Health and Long-Term CareAIDS Bureau, Ontario Ministry of Health and Long-Term Care• Bureau of HIV/AIDS, STD and TB, Health CanadaBureau of HIV/AIDS, STD and TB, Health Canada

BackgroundBackground

• 1989-91: Ontario HIV seroprevalence study 1989-91: Ontario HIV seroprevalence study

(Coates et al), 0.23 / 1,000 (Coates et al), 0.23 / 1,000 • February 1994: ACTG 076 showed ZDV reduced February 1994: ACTG 076 showed ZDV reduced

mother-infant HIV transmission by 67%mother-infant HIV transmission by 67%• 1997: Modelled HIV prevalence, 0.70/1,0001997: Modelled HIV prevalence, 0.70/1,000 and and estimated estimated

uptake of prenatal HIV testing 1994-96, 20–25%uptake of prenatal HIV testing 1994-96, 20–25%

Ontario HIV screening programOntario HIV screening program

• Spring 1995: Advisory to physicians to consider HIV testing Spring 1995: Advisory to physicians to consider HIV testing of pregnant women at increased HIV riskof pregnant women at increased HIV risk

• August 1997: Committee formed to plan programAugust 1997: Committee formed to plan program• December 1998: Minister announced program to offer HIV December 1998: Minister announced program to offer HIV

testing to all pregnant womentesting to all pregnant women• January 1999: Promotional materials and requisitions sent to January 1999: Promotional materials and requisitions sent to

physiciansphysicians• September 2001: Memo included with prenatal test report to September 2001: Memo included with prenatal test report to

physicians who had not prescribed an HIV testphysicians who had not prescribed an HIV test

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 universal HIV screening programEvaluate the Ontario universal HIV screening program

Data managementData management

• Data extracted from LAByrinth Data extracted from LAByrinth (prenatal and HIV diagnostic databases)(prenatal and HIV diagnostic databases)

• Study period: January 3, 1999 to June 30, 2002Study period: January 3, 1999 to June 30, 2002• Records from HIV prenatal database matched to records in Records from HIV prenatal database matched to records in

HIV diagnostic databaseHIV diagnostic database• Matching allowed for different spelling and structure of Matching allowed for different spelling and structure of

name (“double-barrelled” first and last names) and reversal name (“double-barrelled” first and last names) and reversal

of month/day in birth dateof month/day in birth date• Separate prenatal tests aggregated into episode equivalent to the Separate prenatal tests aggregated into episode equivalent to the

gestation period; HIV uptake analysed for each pregnancygestation period; HIV uptake analysed for each pregnancy

Data analysisData analysis

• Number of women tested at prenatal visit included:Number of women tested at prenatal visit included:• Women for whom HIV test ordered on prenatal requisition, Women for whom HIV test ordered on prenatal requisition,

or tested though HIV diagnostic serviceor tested though HIV diagnostic service• Tests categorized as current or previous to pregnancy Tests categorized as current or previous to pregnancy

• Analysis in SAS of:Analysis in SAS of:• Trends over time in proportion tested Trends over time in proportion tested • Testing rates by health region and age groupTesting rates by health region and age group• HIV-positive women: number and rates by type of test, HIV-positive women: number and rates by type of test,

region and quarterregion and quarter

Number of pregnancies by health regionNumber of pregnancies by health regionJanuary 1999 to June 2002January 1999 to June 2002

Number pregnancies Proportion

TorontoCentral East, otherSouthwestCentral WestOttawaEastern, otherNorthernN/A or OFP

130,604 108,237

64,171 76,455

37,696 40,215 31,6492,045

27%22%13%16%

8%8%6%

Total 491,072 100%

HIV testing among pregnancies by timing HIV testing among pregnancies by timing of HIV test, Ontarioof HIV test, Ontario

0

10

20

30

40

50

60

70

80

90

1001999-Q

1

1999-Q

2

1999-Q

3

1999-Q

4

2000-Q

1

2000-Q

2

2000-Q

3

2000-Q

4

2001-Q

1

2001-Q

2

2001-Q

3

2001-Q

4

2002-Q

1

2002-Q

2

Quarter (1999-2002)

CurrentPreviousAny test

Pro

port

ion

of

pre

gn

an

cie

s (

%)

HIV testing among pregnancies forHIV testing among pregnancies forselected health regionsselected health regions

0

10

20

30

40

50

60

70

80

90

100Q

1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Quarter (1999-2002)

Pro

port

ion

of

pre

gn

an

cie

s (

%)

Metro TorontoCentral East, otherSouthwestCentral West

HIV testing among pregnancies forHIV testing among pregnancies forselected health regionsselected health regions

0

10

20

30

40

50

60

70

80

90

100

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Q3

Q4

Q1

Q2

Quarter (1999-2002)

Pro

port

ion o

f sp

eci

mens

(%)

Ottawa Eastern, Other Northern

Proportion of pregnancoes tested for Proportion of pregnancoes tested for HIV by health region, Quarter 2, 2002HIV by health region, Quarter 2, 2002

76%29,292 38,352 Total

76%76%78%72%81%82%79%70%

8,1286,553 3,5294,3502,5312,2971,802

102

10,762 8,611 4,536 6,081 3,1082,816

2,293 145

TorontoCentral East, otherSouthwestCentral WestOttawaEastern, otherNorthernN/A or OFP

Proportion tested

HIVtested

Number of preg’s

Number of PHUs in each region by proportion Number of PHUs in each region by proportion tested for HIV, Quarter 2, 2002tested for HIV, Quarter 2, 2002

1

50-59% 90-100%80-89%70-79%60-69%

371111951Total

832Northern

55Eastern, other

1Ottawa

761Central West

911421Southwest

615Central East, other

1Toronto

Total PHUsNumber of PHUs by proportion of HIV testing uptake

1

3

Number of HIV-positive pregnanciesNumber of HIV-positive pregnancies

Previous

HIV+

4

7

19

5

35

Current

HIV+

11

21

31

15

78

Total

HIV+

15

28

50

20

113

1999

2000

2001

2002

TOTAL

HIV-positive pregnancies HIV-positive pregnancies by time of diagnosis and quarterby time of diagnosis and quarter

-1

1

3

5

7

9

11

13

15

Q11999

Q31999

Q12000

Q32000

Q12001

Q32001

Q12002

By Quarter

Nu

mb

er

of

pre

gn

an

cie

s

CurrentPrevious

InterpretationInterpretation

• Actual uptake of HIV testing is somewhat higher due to false Actual uptake of HIV testing is somewhat higher due to false non-matches (especially in anonymous and coded HIV testing) non-matches (especially in anonymous and coded HIV testing)

• Study does not indicate why HIV test uptake is less than ideal Study does not indicate why HIV test uptake is less than ideal (qualitative research of pregnant women and physician survey (qualitative research of pregnant women and physician survey have been done)have been done)

• Study does not indicate number of HIV-infected women Study does not indicate number of HIV-infected women undiagnosedundiagnosed

• Unlinked component of HIV seroprevalence study among Unlinked component of HIV seroprevalence study among women not HIV tested is (finally!) under waywomen not HIV tested is (finally!) under way

Conclusions 1Conclusions 1

• Critical to capture data from HIV diagnostic database as well as Critical to capture data from HIV diagnostic database as well as from prenatal database from prenatal database

• HIV testing increased from 40% to 50% from January to May HIV testing increased from 40% to 50% from January to May 1999, with modest increase until September, 20011999, with modest increase until September, 2001

• Impact of memo: from 60 to 76%! Impact of memo: from 60 to 76%! • Important regional differences in HIV test uptakeImportant regional differences in HIV test uptake• Over 3.5 years, 113 women identified as HIV-positive, 35 Over 3.5 years, 113 women identified as HIV-positive, 35

previously diagnosed, 78 newly diagnosedpreviously diagnosed, 78 newly diagnosed• Data suggests more high risk pregnant women are being offered Data suggests more high risk pregnant women are being offered

and accepting HIV testingand accepting HIV testing

Conclusions 2Conclusions 2• According to model (not presented)According to model (not presented)

• Birth rate among diagnosed HIV-infected women is lowBirth rate among diagnosed HIV-infected women is low• ~40% of HIV-infected women undiagnosed at conception ~40% of HIV-infected women undiagnosed at conception

remain undiagnosedremain undiagnosed• An estimated 8-10 preventable mother-infant HIV An estimated 8-10 preventable mother-infant HIV

transmissions occurred in 2001transmissions occurred in 2001