A University of California, San Francisco program that uses certified nurse midwives and nurse practitioners as primary care givers has significantly reduced transmission of HIV from mother to child, according to a study presented today (July 10) at the XIII International AIDS Conference in Durban, South Africa.
The Bay Area Perinatal AIDS Center (BAPAC), based at the UCSF-affiliated San Francisco General Hospital Medical Center, implements a coordinated care model that includes consistent ongoing care, combination retroviral therapies, and extensive counseling and support, said Maureen Shannon, CNM, FNP, MS, UCSF associate clinical professor of family health care nursing and perinatal coordinator at BAPAC.
From 1995 to 1999 the HIV transmission rate from mother to child for 65 women who had more than three visits to the center was less than two percent. Women who had no prenatal care or fewer than three visits had higher perinatal transmission rates, she said.
Shannon explained that this model of care may have application in remote areas of the United States, where there are more limited resources, notably physicians, and in developing countries, where higher rates of HIV transmission mean that prevention programs have to reach a larger number of women. Nurse clinicians may help to close those gaps, said Shannon.
At BAPAC, nurse clinicians have developed a model that focuses on the reality of how HIV-infected mothers cope with their disease, said Shannon. Caring for a baby exposed to HIV in utero, while maintaining their own care, is often challenging for new mothers. Simple interventions such as coordinating the newborn infant's HIV drug regimen with the mother's medication schedule can help with adherence, especially during the first few weeks postpartum. The center offers mothers and their babies care by the same nurse clinicians (with physician consultation as needed) from pregnancy through the child's second year, if indicated, explained Shannon.
In traditional models of care (in which the mother is referred to a pediatrician after the birth of her child), mothers tend to neglect their own health care. For this reason, clinicians at BAPAC evaluate both mother and baby at the same time during clinic visits. This enables nurse clinicians and the social worker to assess the health of the mother and child, provide primary and gynecological follow-up care for the mother, provide HIV testing and primary care for the infant, monitor adherence to medication regimens, assess the mother's psychosocial well being, and address other family issues (such as HIV testing of partners). Shannon noted that the clinic also functions as a support system for HIV-infected mothers, who get to know each other when they come for treatment.
"These factors combine to improve care for patients who are at risk. Mothers are often dealing with fear and guilt associated with potentially having infected their child and isolation from family and friends who may not know about the disease," she said. "Our focus is really from a caregiving standpoint. How do we keep mothers well so their own response to HIV improves as they care for their babies effectively?"
BAPAC was one of the first programs in the country to provide coordinated care and services for HIV-positive pregnant women and their families. It was formed by a collaborative effort between Diane Wara, MD, UCSF professor of pediatrics, and the UCSF at SFGHMC Department of Obstetrics, Gynecology and Reproductive Sciences. It is the only perinatal AIDS treatment center in Northern California and serves women from hundreds of miles away. The center extends telephone outreach services to remote parts of California and is part of the HIV Warm Line consultant team, a national help line for clinicians. Current research at BAPAC is focusing on the long-term outcomes of children born to HIV-infected mothers, said Shannon.
Collaborators on this study include Joella Canales, a BAPAC administrative assistant, and Soraya Dahud, a BAPAC research assistant.