Trends in the Perinatal HIV Epidemic in the U.S. - Updates from Routine and Enhanced Surveillance
Joann Schulte, DO; Teresa Hammett, MPH
2002 Perinatal HIV Prevention Grantees Meeting February 13-14, 2002; Atlanta, GA
Reporting the Spectrum of HIV/AIDS Morbidity and Mortality
CORE SURVEILLANCE
HIV exposure HIV infection
1st positive confidential test
1st CD4 Count
1st Viral Load Test 1st CD4 Count <200 (IMM-AIDS) AIDS-OI Death
Perinatal Surveillance Objectives
• Characterize recent trends in perinatal HIV/AIDS • Assess implementation and impact of PHS perinatal prevention guidelines • Assess resource needs for prevention and care • Assess missed opportunities for prevention • Targeting and evaluating prevention efforts
Reporting of HIV-Exposed Infants
• CDC Recommendation
MMWR 1999;48(No. RR-13)
• CSTE • American Academy of Pediatrics
Policy Statement in 1998
• Congress
Methods: Data Collected Through Routine Perinatal HIV Surveillance • • • • • Maternal HIV status Timing and number of PNC visits Receipt of antiretroviral therapy Type of delivery Birth defects in infant
2 1
Pediatric AIDS Cases Reported in 2000 N=196
0 0 0 0 0 0 0 1 1 1 0 1 11 1 3 0 0 11
0
1
PR 2
VI 0 Guam 0
0 1 2 1 2 3 0 0 26 15 7 3 0
1 24 3
MA RI CT NJ DE MD DC
1 0 3 16 0 4 2
0
0 4 10
24
6
Number of Cases
<5 5 - 10 >10
Children <13 Years of Age Living with HIV Infection* and AIDS, Reported through 2000
11
0
13 5 3 0 0 1 21 10 155
1 1 1 1 5 4
5 24 9 17 11 73 23 5 5 107 27 13 54 36 4 4 503 152 2 4 MA 58 RI 6 CT 74 58 NJ 314185 DE 13 MD 129 84 DC
6 3 18 1 10 3 28 9 35 16
14 54 17
61 69 93 37
0 6
11 6
15 20 38 23 32 17 84
82 26
HIV
AIDS
N=1,662** N=2,703**
236 125 88 49 0 1 5
PR VI GUAM
165 475
Confidential HIV Reporting
Required Pediatric only
89
2 7
1 0
* For areas with confidential HIV infection surveillance reported by patient name. Age based on current age as of December 2000. ** Total includes cases missing state of residence data.
AIDS-Defining Conditions by Age at Diagnosis for Perinatally-Acquired AIDS Cases Reported through 2000, United States
450 400
Number of Cases
350 300 250 200 150 100 50 0 0 2 4 6
Pneumocystis carinii pneumonia Other AIDS-defining conditions
8
10
12
14
16
18
20
22
24
Age in Months
Time of Maternal HIV Testing among Children Perinatally Exposed or Infected or with AIDS, Reported in 2000, United States
Perinatally Acquired AIDS* N=177 Time of maternal HIV test Before or at birth After birth Unknown No. 75 60 42 % 42 34 24 HIV Exposed** N=3,325 No. 3,167 94 64 % 95 3 2 HIV Infected** N=196 No. 105 53 38 % 54 27 19
* Excludes 19 children with AIDS reported in 2000 whose HIV exposure category was unknown or other than perinatal ** From 36 areas with confidential pediatric HIV infection surveillance
300 250
Perinatally Acquired AIDS Cases by Quarter-Year of Diagnosis,* 1985-2000, United States
Number of Cases
200 150 100
s a C f o r e b m u N
50 0
1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Quarter-Year of Diagnosis
*Adjusted for reporting delays and estimated proportional redistribution of cases initially reported without a risk data reported through December 2001
Perinatally-Acquired AIDS by Half Year of Diagnosis: U.S. Receipt of Any ZDV (prenatal, intrapartum, neonatal) among HIV+ Women Tested before/at Birth:
32 HIV reporting states
100 % any ZDV 80 60 40 20 0
87 89 90 91 92 95 96 97 85 86 88 93 94 98
500 400 300 200 100 0 Receipt of Any ZDV Perinatal AIDS Incidence
99
No. of Cases
Perinatal HIV infection rates by birth year: infants with 1st HIV evaluation < 2 months*
100% 80% 60% 40% 20% 0%
I
Indeterminate HIV infected Not infected
=9 28
68
19 95
19 97
* States: 32 states with HIV infection reporting
19 98
N =1 08 19 6 99 N =9 76 20 00 N =5 67
N =
19 94
19 96
N =9 98
N =7
84 6
N
Pregnancy Rates* Among HIV-Infected Women in Adult/Adolescent Spectrum of HIV Disease Project, 1992-1999
9 8 7 6 5 4 3 2 1 0 1992 1993 Rate per 100 Person-Years
Zidovudine (USPHS† Guidelines)
HAART
1994
1995
1996
1997
1998
1999
Year of Observation
Type of Delivery by Birth Year, 1994–2000, 27 states with Named HIV Reporting Since 1994
800 700 600 500 400 300 200 100 0 1994 1995 1996 1997 1998 1999 2000
C Section Vaginal Unknown
Year of birth
Enhanced Perinatal Surveillance – An Update
Project Sites: Enhanced Perinatal HIV Surveillance and Perinatal HIV Prevention
New York City Philadelphia Chicago Washington D.C.
Los Angeles
Houston
Enhanced Perinatal Surveillance (EPS) only Perinatal Prevention Project (PPP) only BOTH EPS and PPP sites
Perinatal HIV Surveillance Methods
! Routine surveillance
" "
Population-based case reporting HIV-exposure, HIV infection, and AIDS
! Enhanced Surveillance "Active Case Ascertainment "Multiple Sources of Data for Mother and Infant "Birth Cohorts: 1999, 2000, 2001, forward
Methods for Enhanced Perinatal Surveillance
! In States with Name-Based HIV Reporting "Population-based HIV-exposure data ! In States without Name-Based HIV Reporting "Facility-based IRB approved protocols "Collaboration with PSD, Medicaid, etc
Methods: Data Collected Through Enhanced Perinatal Surveillance (EPS)
• More data on timing and receipt of prenatal care, birth history, and combination ART
• • • • • • Maternal and infant disease screening Maternal reproductive history Maternal drug use and STDs during pregnancy Rapid testing at delivery Antiretroviral resistance testing in infant Assessment of maternal and infant care
Status of EPS Data Collection as of February 6, 2002
• EPS data abstraction completed on 1,879 HIV-exposed infants in 17 project areas; 1999-2001 • EPS data submitted from:
! ! !
13 of 16 project areas with named HIV reporting 1 of 5 project areas with HIV reporting using a unique code 3 of 4 project areas with no HIV reporting
Prenatal Care Visits By Illicit Drug Use During Pregnancy
Birth Years 1999-2001; Preliminary Data 16 of 25 EPS Project Areas
100 80 60 40 20 0 None n=173 1-2 visits 3-6 visits
n=110 No. Prenatal Care Visits
No Illicit Drug Use Illicit Drug Use
7+ visits n=1,238
* 164 women with unknown number of PNC visits excluded from this table.
Maternal HIV testing by Birth Year
Preliminary Data; 16 of 25 EPS Project Areas
Birth Year 1999 (N=770) Maternal HIV test * Before Birth At Delivery After Birth Time unknown 94% 2% 4% 1% 2000 (N=524) 90% 5% 5% 1% 2001 (N=108) 94% 4% 3% <1%
* Mothers of 3 infants born in 1999, refused HIV testing
Receipt of Prenatal ZDV By Number of Prenatal Care Visits, Birth Years 1999-2001;
Preliminary Data 16 of 25 EPS Project Areas
100 80 60 40 20 0 None n=173 1-2 visits 3-6 visits
n=110 No. Prenatal Care Visits
Receipt of prenatal ZDV
7+ visits n=1,238
* 164 women with unknown number of PNC visits excluded from this table.
Receipt of Zidovudine for Prevention of HIV Infection, by Infant Birth Year
Preliminary Data; 16 of 25 EPS Project Areas
Birth Year 1999 ZDV Component * Prenatal Intrapartum Neonatal 84% 79% 93% 2000 80% 78% 93% 2001 86% 81% 96%
* 17 mothers refused prenatal ZDV; 7 refused intrapartum ZDV; 2 refused neonatal ZDV
Sexually Transmitted Diseases During Pregnancy Birth Years 1999-2001;
Preliminary Data from 16 of 25 EPS Project Areas
Overall, 503 (30%) of mothers were diagnosed with at least one STD during pregnancy
"77% of women had one STD, 18% had two and 6% had three or more STDs "42% of women had trichomonas, 41% chlamydia, 17% syphilis, 17% herpes, 13% gonorrhea, and 2% PID
Documentation of Mother’s HIV Status Birth Years 1999-2001;
Preliminary Data from 16 of 25 EPS Project Areas • Of mothers who received prenatal care, HIV status was documented in 90% of the prenatal care records. • Mother’s HIV status was documented in 92% of labor and delivery records. • Mother’s HIV status was documented in 93% of infant birth records.+
An Example for Monitoring Prevention Failures 217 HIV-infected Children Born 1999-2001
Preliminary Data; 16 of 25 EPS Project Areas
• Prenatal Care
! 22% had none; 27% unknown ! Of those who received care, 14% had <2 visits
• Maternal HIV testing
! 7% tested at delivery ! 20% tested after delivery
• Antiretroviral therapy
! Of mothers tested before delivery and who received prenatal care, 30% were not prescribed prenatal ZDV
Enhanced Perinatal Surveillance Recent Publications
! Progress Towards Elimination of Perinatal HIV Infection – Michigan, 1993-2000
! http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5105a1.htm
! Zidovudine and Perinatal HIV-1 Transmission: A Population-Based Approach (Data from SC); Due out April 2002 at www.pediatrics.org ! Successful Implementation of Perinatal HIV Prevention Guidelines: A Multistate Surveillance Evaluation
! www.cdc.gov/mmwr/preview/mmwrhtml/rr5006a2.htm
Preliminary EPS Data Show:
!Many HIV+ women are still not receiving prenatal care, especially those using drugs !Over 90% of HIV+ women who receive 7+ visits receive ZDV !There are high levels of prenatal, intrapartum, and neonatal antiretroviral use for HIV+ women tested before the child’s birth
Conclusions
!Many infants still perinatally exposed to HIV
! women living longer with HIV ! Evidence of increasing pregnancy rates among HIV+ women
!Surveillance data crucial for prevention planning and targeting of activities. !Surveillance data contribute to assessing missed prevention opportunities.