Broward County’s 2014 population estimate of 1,869,235, represents 9% of the Florida’s population (US Census). Its residents represent more than 200 different countries speaking more than 130 languages. 31.5% of the residents are foreign-born. Broward County is a minority/majority county, its 2014 population by race (Black 28.8%, Asian 3.6%, Hispanic 27.4%, other .5%=60.3% and White 39.7%).
The Florida Department of Health in Broward County (DOH-Broward) is the official lead Public Health Agency in Broward County and is part of the Integrated Florida Department of Health (DOH) which provides core public health functions and essential services as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.
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 who were HIV positive. In 2014, there were 103 and to date in 2015 there are 102. There is a heightened concern if they are unaware of their pregnancy, not in care, or are not virally suppressed. Many of these women receive limited or no prenatal care at any time during their pregnancy and may transmit the HIV virus to their baby. The public health issue is the perinatal transmission of HIV.
The goal and objective of this practice is to determine the pregnancy status of every HIV female client of childbearing age and offer a pregnancy test kit for those unaware of their pregnancy status. The objectives are 1) the prevention of perinatal transmission of HIV and 2) to link pregnant HIV-positive women to care after establishing that they are pregnant, not in prenatal care, or not in HIV care. There were 2 perinatal transmissions in 2012 and one HIV perinatal transmission in 2015 (before this initiative commenced).
After a baby was born with HIV in May 2015, DOH-Broward sought to find a simple, easily deployable, and cost effective method to identify pregnant women living with HIV and refer to the DOH-Broward perinatal prevention team for linkage to care. Communicable Disease staff created a process map of HIV Perinatal Program’s processes and determined that all HIV positive women of childbearing age would be offered a pregnancy test to determine pregnancy status and all LHD departments that serve HIV positive women must be included. Any female HIV client obtaining services from the pharmacy or Aids Drug Assistance Program (ADAP) who did not know their pregnancy status would be offered a free pregnancy test kit with instructions to call back with the results. In May 2015, staff in Pharmacy and ADAP began to ask all female HIV clients their pregnancy status. Clients that did not know their status were offered a free Over-The-Counter (OTC) pregnancy test kit and were asked to report the results to the staff. Positive results would be referred to the Director of Perinatal Prevention for case management to ensure the client was receiving prenatal medical care. The staff document pregnancy test distribution, test results, and appropriate referrals in the Electronic Medical Record system (HMS).
The practice began in May 2015 and has effective in identifying pregnant women that were unaware of their pregnancies. One client was found to be pregnant. This practice has also effectively identified women that were aware of their pregnancies, but were not receiving prenatal care or perinatal case management thereby raising the awareness of the importance of prenatal care and enhancing case management.
The specific factors that led to the success of this practice were the purchase of the initial supply of pregnancy test kits, training staff to ask client’s pregnancy status, determining the pregnancy status of every female HIV client, and the accessibility of the pregnancy test kits at clinic pharmacies and ADAP offices to quickly determine pregnancy status so they may be immediately referred to the Perinatal Program for case management and linkage to care.
Public Health impact of practice was a reduction of the number of perinatal infections. The Public Health impact of this practice was that there were no HIV positive births in Broward County from any client of the DOH-Broward pharmacy since May 2015.
Web Address (if applicable) www.broward.floridahealth.gov
The Public health issue addressed is the perinatal transmission of HIV and Syphilis through the creative use of an existing practice. There were 2,977 women of childbearing age who were living with HIV/AIDS in Broward County in 2013. All pregnant women should be screened for HIV as early as possible. According to the CDC, women with HIV who take antiretroviral medication (ARVs) during pregnancy can reduce the risk of transmitting HIV to their babies to less than 1%.
The reduction of perinatal HIV infection in the US represents an important public health achievement. Perinatal HIV transmissions have been reduced to 1.5% since 2006. In 2014, 127 HIV-positive pregnant women who were case managed by DOH-Broward Perinatal Prevention Program. During 2013 and 2014, Broward County had zero cases of perinatal HIV transmission.
What target population is affected by problem:There were approximately 2,977 women of childbearing age, ages 13-49, living with HIV/AIDS in Broward County in 2013. All pregnant women should be screened for HIV as early as possible. From the DOH-Broward Pharmacy’s target population of 1,146 female HIV positive female clients who received services. ADAP has 1,259 female clients of which 706 are of childbearing age.
Percentage reached:100% HIV female clients are asked their pregnancy status by the pharmacy staff and ADAP staff at the time of service.
What has been done in the past to address the problem?There was been no specific organized approach utilized in the DOH-Broward pharmacy or ADAP program regarding this issue. Prior to implementing this proactive program, clients were referred to treatment adherence services and the perinatal program only when they were identified as pregnant and not compliant with antiretroviral therapy.
Why is current/proposed practice better?The DOH-Broward practice is better because it reduces missed opportunities to link pregnant clients to prenatal care. When clients visit the ADAP office to determine program eligibility, this may be the only time that DOH-Broward has contact with them for six months. Once pregnancy status is determined, a referral is completed and the client is case managed and linked the clients to HIV and perinatal care by the Perinatal Program.
Is current practice innovative? How so/explain?To our knowledge, DOH-Broward is the only Health Department that utilizes this practice. The process of utilizing pharmacy and ADAP staff to determine client pregnancy status and deploy free pregnancy tests is innovative and new to the field of public health and addresses the CDC Winnable Battles of ‘Mother-to-Child Transmission of HIV and Syphilis.
What tool or practice did you use in an original way to create your practice? We used the PCSI (Program Collaboration System Integration Model) model. For this practice to be successful, internal stakeholders must be willing to collaborate on a daily basis. The message is consistent when clients were asked about their pregnancy status. The ADAP, Pharmacy, and Perinatal staff works collaboratively to coordinate referrals and case management. In addition, it is important to note that this practice is derived from internal case studies and process maps for the Perinatal Program.
Is current practice evidence-based?Although not evidence based, the practice is working very well. For example, there was an ADAP client in September 2015 who came to recertify for her benefits. When the public assistance specialist was completing her eligibility, she asked the client if she was pregnant. The client responded, “Well, I don’t know...” The specialist gave the client a pregnancy test. The client came back a few minutes later; very surprised that she was pregnant. Afterwards, the specialist escorted the client to the Perinatal Prevention Program who linked the client to care immediately. All HIV positive pregnant women are tracked through DOH-Broward’s secure database, which is used to ensure that HIV positive mothers stay in care and keep their perinatal and infectious disease doctor appointments which reduces the opportunity for perinatal transmission.
HIV in the U.S.|Mother-to-Child Transmission of HIV and Syphilis
Goal(s) and objectives of practice:The goal and objective of this practice is to determine the pregnancy status of every HIV female client of childbearing age and offer an Over-The-Counter pregnancy test kit for those unaware of their pregnancy status. The objective is the prevention of perinatal transmission of HIV and to link pregnant HIV-positive women to care after establishing that they are pregnant, not in prenatal care, or not in HIV care. There was one transmission to date in 2015 (before this initiative commenced) and there were zero transmission in 2014.
What did you do to achieve the goals and objectives?Steps taken to implement the program included a series of multidisciplinary staff meetings within DOH-Broward, in which we endeavored to find a simple, easily deployable, and cost effective method to identify LHD clients who are pregnant and HIV positive and to subsequently refer each client’s information to the DOH-Broward perinatal prevention team for investigation to assure proper prenatal care of the client. The multidisciplinary staff meetings included sessions on process mapping every activity related to perinatal prevention. It was determined that the LHD Departments that serve HIV positive women include the Pharmacy and ADAP – both of which interact with female clients on a monthly basis. Staff in both departments was tasked with ascertaining the pregnancy status of every female HIV client with immediate notification, by phone or email, of the Perinatal Prevention staff of every pregnant HIV client.
Female HIV clients who did not know their pregnancy status would be offered a free pregnancy test kit with instructions to call back as soon as possible with the results. There is no need for clients to visit another clinic or medical provider. There is no waiting as all staff considers a pregnant HIV female a high alert and candidate for immediate action. The Pharmacy purchased an initial supply of test kits, a portion of which were deployed to the ADAP program.
Pharmacy and ADAP program managers met with their respective teams to explain the initiative and the process and in May 2015 whereupon Pharmacy/ADAP staff started to ask female HIV clients, during the client’s visit/appointment, their pregnancy status and issue pregnancy test kits as appropriate. During this initial deployment, seven clients received an OTC pregnancy test kit from the pharmacy. Of those, four clients received the two test/kit product and three clients received the one test/kit product. The two pregnancy test kit is an additional means to determine pregnancy status in that the client may take the extra test home for future use. Clients are educated on the importance of safe sex.
The Director of Pharmacy compiles a monthly report of every female client served by pharmacy that was referred to the Director of Perinatal Prevention. This report is reconciled by the Director of Perinatal Prevention against an internal secure database such that any unrecognized pharmacy client could be identified and subsequently researched (by the perinatal prevention staff) to ensure adequate prenatal medical care. Immediate notification to the LHD Perinatal Prevention team commenced immediately thereafter.
Any criteria for who was selected to receive the practice (if applicable)?The criteria for those selected to receive the practice were any woman of child bearing age that are HIV positive and did not know their pregnancy status. The timeframe for the practice is implementation in May 2015, is ongoing, and is now a routine part of DOH-Broward process. The Pharmacy and ADAP staff started to immediately ascertain the pregnancy status of HIV positive female clients irrespective of the ordering and receiving of pregnancy test kits, some of which were ordered and received within one day. The local wholesaler’s inventory of pregnancy test kits was exhausted by DOH-Broward and supplemental orders were required. Due to availability, products were purchased as either one or two pregnancy tests per package.
Were other stakeholders involved? What was their role in the planning and implementation process? Stakeholders involved with this program were the perinatal prevention manager and supervisors, DOH-Broward Organizational Development team, LHD Director and Deputy Director. The Organizational Development team conducted the process mapping process. The Pharmacy Department purchased the pregnancy tests. The ADAP and Pharmacy staff offered the pregnancy tests to any women of child bearing age that was unaware of being pregnant. The Perinatal Program offered case management and linkage services for prenatal and HIV care. o What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
We have strong partnerships with our stakeholders that are involved in the system of care in Broward County. These include, but are not limited to the grantees for Ryan White Part A, Ryan White Part C, and Ryan White Part D; Community Based Organization’s; Case Management agencies; Food Banks; and Substance Abuse Facilities, birthing hospital and obstetricians.
Any start up or in-kind costs and funding services associated with this practice? Specific factors that led to the success of this practice included the purchase of pregnancy test kits and the staff efforts and performance to ascertain the pregnancy status of every female HIV client. Start up costs consisted of the purchase of 520 pregnancy test kits by the pharmacy using the State of Florida Department of Health’s contracted pharmaceutical products wholesaler. The total cost was $1,240.64.
What did you find out? To what extent were your objectives achieved?The goal and objective is the prevention of perinatal transmission of HIV. The ‘outcome evaluation’ of this program is such that there has been no HIV perinatal transmission of HIV for a LHD pharmacy or ADAP client since this process started in May 2015 and the pharmacy and ADAP teams continue to ascertain the pregnancy status of every female HIV client.
Did you evaluate your practice? Data analysis of HIV positive women to ensure zero perinatal transmissions. There were 2 perinatal transmissions in 2012 and one HIV perinatal transmission in 2015 (before this initiative commenced).Primary data sources include: internal secure database, electronic HIV/AIDS reporting system (eHARS), Patient Reporting Investigating Surveillance Manager (PRISM), electronic lab reporting. Data was collected by the Pharmacy, ADAP, and perinatal staff. No secondary data sources used. Performance measures utilized include number of HIV positive women of childbearing age, HIV positive females, perinatal transmissions, postpartum care.
Describe how results were analyzed.:
Our objective of preventing perinatal transmission of HIV is being achieved and due to its success, the process continues by the perinatal program director. Whereas every Florida LHD has staff that interacts and/or serves HIV female clients, this program may have potential worth to all LHD’s. We learned that there is an improvement in knowledge and awareness by pharmacy and ADAP staff regarding the importance of clients knowing their pregnancy status and receiving effective prenatal care so as to reduce or eliminate the risk of perinatal transmission of HIV. Due to the sucess of this innovative practice, no modifications were made as a result of the data findings.
Lessons learned in relation to practice:
Lessons learned were such that there was an improvement in knowledge and awareness by pharmacy and ADAP staff regarding the importance of clients knowing their pregnancy status and receiving effective prenatal care so as to reduce or eliminate the risk of perinatal transmission of HIV. We have very strong relations with our partners and are able to refer and link clients into care very effectively.
Lessons learned in relation to partner collaboration:
We have very strong relations with our partners and are able to refer and link clients into care very effectively.
Did you do a cost/benefit analysis?
The cost benefit analysis is such that the cost for staff to briefly interact with a female HIV client to ascertain the pregnancy status and refer as appropriate coupled with the cost of an OTC pregnancy test kit ($3.75 for a kit with two tests; $3.02 for a kit with one test) is nominal compared with the cost of care and treatment of an HIV positive baby.
Is there sufficient stakeholder commitment to sustain the practice? Yes, the community has been supportive of this initiative.
Describe sustainability plans:
The cost of maintaining a supply of pregnancy test kits is minimal (approximately $1,000) and there is significant stakeholder interest and commitment, therefore this process is sustainable at a nominal cost.
Colleague in my LHD|NACCHO website