Acknowledgments

Uptake of HIV testing among Uptake of HIV testing among pregnant women in Ontario: pregnant women in Ontario: Results from the Results from the HIV seroprevalence study HIV seroprevalence study to December 2000to December 2000Robert S. Remis, Carol Major, Margaret Fearon, Robert S. Remis, Carol Major, Margaret Fearon, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Evelyn Wallace, Peggy Millson, Liviana Calzavara, Elisabeth Rea, Susan King, Marion Vermeulen and Elisabeth Rea, Susan King, Marion Vermeulen and Elaine WhittinghamElaine WhittinghamDepartment of Public Health Sciences, University of TorontoDepartment of Public Health Sciences, University of Toronto

Laboratories Branch, Public Health Branch, Laboratories Branch, Public Health Branch, Ontario Ministry of Health and Long Term-Care Ontario Ministry of Health and Long Term-Care Toronto Public HealthToronto Public HealthHospital for Sick Children, TorontoHospital for Sick Children, Toronto

Canadian Association of HIV/AIDS ResearchCanadian Association of HIV/AIDS ResearchTenth Annual Scientific ConferenceTenth Annual Scientific ConferenceToronto, Ontario May 31-June 2, 2001Toronto, Ontario May 31-June 2, 2001

MOHLTC, Laboratories Branch, IMC – 2001

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 Mark Fisher, systems consulting and custom

downloaddownload• Carol Swantee, program supportCarol Swantee, program support

• Prenatal Screening Evaluation Committee Prenatal Screening Evaluation Committee • Frank McGee, coordinatorFrank McGee, coordinator• Janis Tripp, consultantJanis Tripp, consultant

• FundingFunding• AIDS Bureau, Ontario Ministry of HealthAIDS Bureau, Ontario Ministry of Health• Bureau of HIV/AIDS, STD & TB, Health CanadaBureau of HIV/AIDS, STD & 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 67% February 1994: ACTG 076 showed 67%

decrease in mother-infant HIV transmissiondecrease in mother-infant HIV transmission• 1997: Modeled HIV prevalence, 0.70/1,0001997: Modeled HIV prevalence, 0.70/1,000

and and estimated uptake of prenatal HIV testing estimated uptake of prenatal HIV testing

1994-96, 20–25%1994-96, 20–25%


Ontario screening programOntario screening program• Spring 1995: Advisory to physicians to Spring 1995: Advisory to physicians to

consider HIV testing of pregnant womenconsider HIV testing of pregnant women• August 1997: Committee formed to plan August 1997: Committee formed to plan

programprogram• December 1998: Minister announced program December 1998: Minister announced program

to offer HIV testing to all pregnant womento offer HIV testing to all pregnant women• January 1999: Promotional materials and January 1999: Promotional materials and

requisitions sent to physiciansrequisitions sent to physicians


Study objectives Study objectives • Quantify and characterize HIV prevalence Quantify and characterize HIV prevalence

among women in Ontario, and among women in Ontario, and • Evaluate the Ontario universal HIV screening Evaluate the Ontario universal HIV screening

programprogram


Data managementData management• Data extracted from Labyrinth Data extracted from Labyrinth

(prenatal and HIV diagnostic)(prenatal and HIV diagnostic)• Study period Jan 3, 1999 to Dec 30, 2000Study period Jan 3, 1999 to Dec 30, 2000• Specimens from prenatal database included only Specimens from prenatal database included only

if no previous specimen in the previous 6 monthsif no previous specimen in the previous 6 months• Records for which HIV testing not prescribed Records for which HIV testing not prescribed

on requisition matched to records in HIV on requisition matched to records in HIV diagnostic databasediagnostic database

• Matching allowed for different spelling and Matching allowed for different spelling and structure of name (double-barrelled first and last structure of name (double-barrelled first and last names) and reversal of month/day in birth datenames) and reversal of month/day in birth date


Data analysisData analysis• Number of women tested at prenatal visit Number of women tested at prenatal visit

included:included:• Women for whom test ordered on prenatal Women for whom test ordered on prenatal

requisition, andrequisition, and• Women tested though diagnostic service on Women tested though diagnostic service on

same day as prenatal specimensame day as prenatal specimen• 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 HIV-positive women: number and rates by

type of test, region and quartertype of test, region and quarter


Number of prenatal specimens by health Number of prenatal specimens by health region, January 1999 to December 2000region, January 1999 to December 2000

Number Number specimensspecimens ProportionProportion

TorontoToronto

Central East, otherCentral East, other

SouthwestSouthwest

Central WestCentral West

OttawaOttawa

Eastern, otherEastern, other

NorthernNorthern

N/A or OFPN/A or OFP

76,223 76,223

61,409 61,409

37,355 37,355

40,035 40,035

21,133 21,133

23,310 23,310

18,083 18,083

1,335 1,335

27%27%

22%22%

13%13%

14%14%

8%8%

8%8%

7%7%

TotalTotal 278,883278,883 100%100%


Number of prenatal specimens Number of prenatal specimens and and number testing for HIV by quarternumber testing for HIV by quarter

Prenatal Prenatal specimensspecimens Prenatal visitPrenatal visit

Diagnostic Diagnostic serviceservice

ProportionProportiontestedtested

19991999

Q1Q1 33,661 33,661 31%31% 12%12% 43%43%

Q2Q2 31,578 31,578 38%38% 10%10% 49%49%

Q3Q3 34,320 34,320 40%40% 10%10% 50%50%

Q4Q4 34,383 34,383 40%40% 10%10% 50%50%

Total 1999Total 1999 133,942 133,942 37%37% 10%10% 48%48%

20002000

Q1Q1 35,877 35,877 40%40% 11%11% 50%50%

Q2Q2 34,115 34,115 40%40% 10%10% 50%50%

Q3Q3 37,583 37,583 40%40% 11%11% 51%51%

Q4Q4 37,365 37,365 40%40% 12%12% 52%52%

Total 2000Total 2000 144,940 144,940 40%40% 10%10% 51%51%


HIV testing among women who HIV testing among women who submitted a prenatal specimensubmitted a prenatal specimen

0%

10%

20%

30%

40%

50%

60%Ja

n

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec

Month (1999-2000)

Pro

port

ion

of

speci

men

s

PrenatalHIV diagnosticAny HIV test



0

10

20

30

40

50

60

70

80

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec

Month (1999-2000)

Pro

port

ion

of

speci

men

s (%

)

Metro TorontoCentral East, otherSouthwestCentral West



0

10

20

30

40

50

60

70

80

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec Jan

Feb

Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec

Month (1999-2000)

Pro

port

ion

of

speci

men

s (%

)

Ottawa-CarletonEastern, otherNorthern


Proportion of pregnant women testing for Proportion of pregnant women testing for HIV by health region, last quarter 2000HIV by health region, last quarter 2000

Number of Number of womenwomen HIV testedHIV tested

Proportion Proportion testedtested

TorontoToronto

Central East, otherCentral East, other

SouthwestSouthwest


OttawaOttawa

Eastern, otherEastern, other

NorthernNorthern

N/A or OFPN/A or OFP

9,866 9,866

8,110 8,110

4,860 4,860

6,234 6,234

2,790 2,790

2,913 2,913

2,395 2,395

197 197

4,917 4,917

4,221 4,221

2,543 2,543

2,685 2,685

1,727 1,727

1,698 1,698

1,426 1,426

94 94

50%50%

52%52%

52%52%

43%43%

62%62%

58%58%

60%60%

48%48%

Total Total 37,365 37,365 19,311 19,311 52%52%


Number of PHUs in each region by Number of PHUs in each region by proportion of HIV testing, last quarter proportion of HIV testing, last quarter 20002000

Number of PHUs by proportion of HIV testing uptakeNumber of PHUs by proportion of HIV testing uptake

Total Total PHUsPHUs20-29%20-29% 30-39%30-39% 40-49%40-49% 50-59%50-59% 60-69%60-69% 70-79%70-79%

TorontoToronto 11 11

Central East, Central East, otherother 11 44 11 66

SouthwestSouthwest 11 22 33 11 11 11 99

Central WestCentral West 11 66 77

OttawaOttawa 11 11

Eastern, Eastern, otherother 22 33 55

NorthernNorthern 11 33 22 22 88

Total Total 11 44 1111 1010 88 33 3737


Number of HIV-positive womenNumber of HIV-positive women

Prenatal screeningPrenatal screeningPreviously Previously diagnoseddiagnosed TotalTotal

19991999 HIV+HIV+ HIV+HIV+ HIV+HIV+

Q1Q1

Q2Q2

Q3Q3

Q4Q4

2 2

3 3

3 3

1 1

2 2

2 2

2 2

2 2

4 4

5 5

5 5

3 3

Total 1999Total 1999 9 9 8 8 17 17

20002000

Q1Q1

Q2Q2

Q3Q3

Q4Q4

3 3

5 5

11 11

4 4

2 2

1 1

1 1

3 3

5 5

6 6

12 12

7 7

Total 2000Total 2000 23 23 7 7 30 30

Both yearsBoth years 32 32 15 15 47 47


HIV-positivity rates by time of HIV-positivity rates by time of diagnosis and quarterdiagnosis and quarter

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Q11999

Q2 Q3 Q4 Q12000

Q2 Q3 Q4

Period

Ra

te (

per

1,0

00)

Prenatal screeningPreviously diagnosed


HIV-positivity rates (per 1,000) HIV-positivity rates (per 1,000) by time of diagnosis and periodby time of diagnosis and period

Jan 1999 to Jan 1999 to Mar 2000 Mar 2000

raterate

Apr to Dec Apr to Dec 2000 2000 raterate

Relative Relative riskrisk p-valuep-value

HIV+ identified through:HIV+ identified through:

Prenatal Prenatal screeningscreening 0.20 0.20 0.45 0.45 2.32 2.32 0.0280.028

Previous Previous diagnosisdiagnosis 0.47 0.47 0.40 0.40 0.87 0.87 NSNS

TotalTotal 0.27 0.27 0.44 0.44 1.67 1.67 0.015 0.015


HIV-positivity rates (per 1,000) by HIV-positivity rates (per 1,000) by health region and period for health region and period for diagnoses at prenatal screeningdiagnoses at prenatal screening

RegionRegionJan 1999 to Jan 1999 to

Mar 2000Mar 2000Apr to Dec Apr to Dec

20002000Relative Relative

riskrisk p-valuep-value

Northern Northern

OttawaOttawa

Eastern, OtherEastern, Other

TorontoToronto

Central East, OtherCentral East, Other


SouthwestSouthwest

0.20 0.20

0.57 0.57

0.00 0.00

0.39 0.39

0.00 0.00

0.14 0.14

0.11 0.11

0.00 0.00

0.76 0.76

0.25 0.25

0.91 0.91

0.41 0.41

0.33 0.33

0.00 0.00

0.00 0.00

1.33 1.33

InfiniteInfinite

2.30 2.30

InfiniteInfinite

2.32 2.32

0.00 0.00

NSNS

NSNS

NSNS

NSNS

0.0290.029

NSNS

NSNS

TotalTotal 0.20 0.20 0.45 0.45


InterpretationInterpretation• Actual uptake of HIV testing may be higher Actual uptake of HIV testing may be higher

due to false non-matches (e.g. anonymous due to false non-matches (e.g. anonymous HIV testing) HIV testing)

• Study does not indicate why uptake is less Study does not indicate why uptake is less than ideal (qualitative research of pregnant than ideal (qualitative research of pregnant women and physician survey are under way)women and physician survey are under way)

• Study does not indicate number of HIV-Study does not indicate number of HIV-infected women undiagnosedinfected women undiagnosed

• Unlinked component of HIV seroprevalence Unlinked component of HIV seroprevalence study among women not HIV tested is criticalstudy among women not HIV tested is critical

• This component has been delayedThis component has been delayed for almost for almost two yearstwo years by Ministry by Ministry


ConclusionsConclusions• Critical to capture data from HIV diagnostic Critical to capture data from HIV diagnostic

database as well as from prenatal database database as well as from prenatal database • HIV testing increased from 38% to 49% from HIV testing increased from 38% to 49% from

January to May 1999, with modest increase sinceJanuary to May 1999, with modest increase since• Important regional differences in HIV test uptakeImportant regional differences in HIV test uptake• Over 2 years, 47 women identified as HIV-Over 2 years, 47 women identified as HIV-

positive, 13 previously diagnosed, 32 newly positive, 13 previously diagnosed, 32 newly diagnoseddiagnosed

• Data suggests more high risk pregnant women Data suggests more high risk pregnant women are being offered and accepting HIV testingare being offered and accepting HIV testing


ConclusionsConclusions

• According to model (not presented)According to model (not presented)• Birth rate among diagnosed HIV-infected Birth rate among diagnosed HIV-infected

women is very lowwomen is very low• ~50% of HIV-infected women undiagnosed ~50% of HIV-infected women undiagnosed

at conception remain undiagnosedat conception remain undiagnosed• Approximately 6–8 preventable mother-Approximately 6–8 preventable mother-

infant transmissions occur annuallyinfant transmissions occur annually

Acknowledgments

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