PowerPoint Presentation

Perinatal Hotline: 1-888-448-8765

Rapid Testing in Labor and Delivery

•Missed Opportunities For Prevention of Mother to Child Transmission of HIV through Routine Rapid Testing in Labor and Delivery

•

•National Perinatal HIV Consultation and Referral Service

•Shannon Weber, MSW

•sweber @nccc.ucsf.edu <= /span>

•June 2007

<= span style=3D'color:#FFFFCC;visibility:hidden'>•

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Perinatal Hotline: 1-888-448-8765

A= bout this Presentation

These slides were developed using current cases submitted b= y California clinicians involved in the RTLD project. The intended audience is clinicians and hospital staff involved with the= development, implementation and evaluation of Rapid Testing= in Labor and Delivery initiatives in California.

Users are cautioned that due to the rapidly changing field = of Perinatal HIV care, this information could become outdated quickly. Difficult clinical situations should be managed with local consultati= on or through the Perinat= al Hotline. It is intended that= these slides be used as prepared, without changes in either content or attribution.= Users are asked to honor this intent.

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Perinatal Hotline: 1-888-448-8765

National HIV/AIDS Clinicians’ Consultation Cen= ter
UCSF – San Francisco General Hospital

<= b>

Perinatal Hotline (888) 448 - 8765<= /span>

National Perinatal HIV Consultation &= Referral Service

Advice on testing and care of HIV-infected pregnant <= /i>= women and their infants

= Referral to HIV specialists and regional resources

Warmline= (800) 933 - 3413

National HIV Telephone Consultation Service

= Consultation on all aspects of HIV testing and clinical care

&= #13;

PEPline (888) 448 - 4911 =

National Clinicians’ Post-Exposure Prophylaxis Hotline

= Recommendations on managing occupational exposures to HIV and

= hepatitis B & C <= /b>

HRSA AIDS ETC Program & Community B= ased Programs, HIV/AIDS Bureau &#= 13;

&&= nbsp; Centers for Disease Control and Prevention (CDC)

=

•The National HIV/AIDS Clinicians’ Consultation Center (the NCCC) is a free telephone consultation service available to clinicians in the United States.

•The Perinatal Hotline offers clinicians= 24-hour advice on testing and care of HIV-infected pregnant women and their expos= ed infants.

•The Perinatal HIV Clinicians’ Net= work can connect Perinatal Hotline callers with specialists and regional resources= .

•NCCC brochures, one-page ads, and telep= hone stickers are available by contacting sweber@nccc.ucsf.edu.

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Perinatal Hotline: 1-888-448-8765

Pacif= ic AETC
Rapid Testing in Labor and Delivery Project

•Staff training and technical assistance related to all aspects of implementing HIV Rapid Testing in= Labor & Delivery (RTLD) are available fr= om the Paci= fic AIDS Education and Training Center (PAE= TC).

•<= /span>Resources & References for HIV Rapid Testing in Labo= r & Delivery:
http://www.ucsf.edu/sfaetc/R= TLD/RTLDManual/index.html

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Perinatal Hotline: 1-888-448-8765

•29 year old immigrant from Central America
<= span style=3D'color:#FFFFCC'>•Declined HIV test during prenatal care •Presented at 32 wee= ks GA with fever and altered mental status
•Rapid HIV test positive

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #1

•This patient is a 29 year old immigrant from Centr= al America.

•The patient had declined an HIV test du= ring prenatal care.

•She presents to the hospital at 32 weeks gestational age with a fever and altered mental status.

•A rapid HIV test is performed by the La= bor and Delivery staff. The results return positive.<= br>

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Perinatal Hotline: 1-888-448-8765

•Confi= rmatory HIV test positive, CD4 count 103, Viral load 232,000,Head CT showed Toxoplasmosis, ARVs started immed= iately

•After= 4 days of ARVs, patient’s viral load went from 232,000 to 19,000

•Non-r= eassuring fetal heart tracing at 33+weeks, c/section

•Infant HIV negative

•Pt la= ter reported that 1st husband died of AIDS 10 yrs ago and she was terrified to be tested

•Pt di= ed 4 months postpartum of AIDS-related illness

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #1

•A confirmatory HIV test was quickly ret= urned, also positive.

•The patient’s blood work revealed= a CD4 count of 103, Viral load of 232,000.

•A head CT showed Toxoplasmosis.<= br>

•The patient was started on Antiretrovir= als immediately.

•After 4 days of antiretrovirals deliver= ed as directly observed therapy, the patient’s viral load dropped from 232,000 to 19,000.

•Even a few days of ARV use has been sho= wn to dramatically reduce a patient’s viral load.

•Directly observed therapy is one form o= f ARV administration, considered in cases where perinatal HIV transmission is at increased risk.

•A non-reassuring fetal heart tracing at= 33+ weeks indicated a c-section for obstetrical reasons.

•The infant has tested HIV negative.

•The patient later reported that her fir= st husband died of AIDS 10 years ago and she was terrified to be tested for = her own HIV status.

•The patient died 4 months postpartum of AIDS-related illness.

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Perinatal Hotline: 1-888-448-8765

=

=

•What were the missed opportunities?

HIV test during pregnancy

ARV prophylaxis <= /i>

ARV for maternal heal= th

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•An HIV test during pregnancy.

•The patient declined the HIV test offer= ed to her. It is important to con= tinue to build rapport and follow up with patients who initially decline HIV te= sts.

•Antiretroviral prophylaxis during pregn= ancy

•Antiretroviral medications for maternal= health

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Perinatal Hotline: 1-888-448-8765

•32 year old presented to care at 37+ weeks GA, positive HIV antibody test

•<= /span>Admitted for DOT/HAART for 5 days before c-section at 38 weeks

•<= /span>Infant is HIV negative.&nb= sp; Review of her medical chart revea= led a positive HIV antibody test 2 yea= rs prior during a previous pregnancy

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #2

•This patient is a 32 year old who first presented to care at 37+ weeks gestational age.

•Her routine HIV screen returned positiv= e.

•The patient was admitted for directly o= bserved therapy on highly active antiretroviral therapy for 5 days.

•A cesarean section was performed at 38 = weeks.

•The infant has tested HIV negative.

•A review of the medical chart revealed a positive HIV antibody test 2 years prior during a previous pregnancy.

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Perinatal Hotline: 1-888-448-8765

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #2

&#= 8226;During her previous pregnancy she presented f= or prenatal care at 37 weeks and was tested for HIV. The results came back two weeks later, on the= day she delivered at another hospital. Neither the patient nor the hospital were aware of her results. •Her first child tested positive for HIV after= her HIV w= as rediscovered and disclosed in her second pregnancy.

•During her previous pregnancy she had f= irst presented to care at 37 weeks and was tested for HIV.

•The results returned two weeks later, o= n the day she delivered at another hospital.

•Neither the patient nor the hospital we= re aware of her HIV test results.

•Her first child tested positive for HIV= after her HIV was rediscovered and disclosed in her second pregnancy.

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Perinatal Hotline: 1-888-448-8765

=

First pregnancy: =

• HIV test results to patient, attending clinician, and L&D staff

• Rapid test on L&D

• ARV prophylaxis

• ARV for positive infant

Second Pregnancy: = ;

• Adequate prenatal care

•<= /span> Timely HIV test

=

=

•What were the missed opportunities?

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•First Pregnancy

This case has several missed opportunities during two pregnancies.<= br>

•HIV test results to patient, attending clinician and L&D staff.

During the first pregnancy, the patient was tested for HIV. However, the test results were n= ot delivered to the patient, her OB, or the labor and delivery staff.

•Rapid test on L&D

With out a documented HIV test result, the patient should be offered a rapid H= IV test upon presenting to care.

•ARV prophylaxis

•ARV medications for positive infant

Without the test results the patient missed antiretroviral medications for prophylaxis and the infant missed antiretroviral medications.<= br>

•Second Pregnancy

During her second pregnancy, the patient missed adequate prenatal care resulting= in a late HIV test result.

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Perinatal Hotline: 1-888-448-8765

•Couple want to conceive.&n= bsp; Both get tested and are HIV Ab negative.
•3-4 months later they conceive
•Mother was offered testing at a prenatal visit but declined because “I just got tested” = and “Neither of us has had outside relations <= /span>since we’ve been together.”

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #3

•A couple want to conceive and both are = tested for HIV - both HIV tests return with negative results.

•Three to four months later they conceiv= e.

•During prenatal care, the mother was of= fered an HIV test but declined stating “I just got tested” and “neither of us has had outside relations since we’ve been together.”

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Perinatal Hotline: 1-888-448-8765

•Baby delivered full term and breast-fed for <= span style=3D'position:absolute;top:35.0%;left:12.17%;width:79.4%;height:6.75%'= >one month •Admitted at 3 months with respiratory distress, failure to thrive, severe thrush, <= span style=3D'position:absolute;top:57.5%;left:12.17%;width:79.4%;height:6.75%'= >axillary adenopathy, big liver •Then confirmed to have PCP, CMV and HIV

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #3

•The baby is delivered at full term and breast-fed for one month.

•At three months old, the baby is admitt= ed to the Children’s Hospital with respiratory distress, failure to thrive syndrome, severe thrush, axillary adenopathy, and big liver.

•The infant is confirmed to have PCP, CM= V and HIV.

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Perinatal Hotline: 1-888-448-8765

HIV test during pregnancy

Rapid test on L&D

ARV prophylaxis <= /i>

Formula feeding for infant

=

=

•What were the missed opportunities?

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•HIV test during pregnancy

•Rapid test on Labor and Delivery=

In the absence of an HIV test result, a rapid HIV test should be performed on labor and delivery.

•ARV prophylaxis

•Formula feeding for infant

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Perinatal Hotline: 1-888-448-8765

•Couple together for 5 years.
•Prenatal care throu= gh large HMO. Group counseling about ‘testing for lots of things;” no individual counseling.&= nbsp; •Patient says, “I signed to have everything done.” Patient never asked for or saw her test results and presumed all was fine.

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #4

•This couple has been together for five = years.

•The prenatal care is offered through a = large HMO. Group counseling was g= iven about “testing for lots of things,” the patient reports. There was no individual HIV test counseling.

•The patient reports “I signed to = have everything done.”

•The patient never asked for or saw her = test results and presumed everything was ok.

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Perinatal Hotline: 1-888-448-8765

•Baby born at 32 weeks
•Diagnosed with fail= ure to thrive, severe thrush, axillary adenopathy •Then confirmed to have PCP, CMV and HIV •A review of mom’s consent forms reveals “I decline HIV testing.”

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #4

•The infant is delivered at 32 weeks.

•The baby is diagnosed with failure to t= hrive syndrome, severe thrush, and axillary adenopathy.

•The baby is confirmed to have PCP, CMV,= and HIV.

•A review of the mother’s medical = charts reveals a consent form stating “I decline HIV testing.”

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Perinatal Hotline: 1-888-448-8765

=

=

HIV counseling and test during pregnancy

Rapid Test on L&D

ARV prophylaxis

=

=

•What were the missed opportunities?

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•HIV counseling and test during pregnanc= y

•Rapid HIV test on Labor and Delivery

In the absence of a documented HIV test result, a rapid HIV test should be offered and performed when the patient presents to Labor and Delivery.

•ARV prophylaxis

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Perinatal Hotline: 1-888-448-8765

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #5

•A pregnant women, whose partner is known HIV <= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:88%;color:#FFFFCC'>positive, is tested for HIV in early pregnancy with a negat= ive test result.

•One w= eek prior to her delivery, she is retested using a = standard HIV test.

•The positive test result was not communicated to the hospital or patient prior to the delivery.= 3;

•The patient delivered at term with a vacuum assisted vaginal delivery and breast-fed. <= /span>

•<= /span>The infant later tested positive for HIV.

•A pregnant woman with a known HIV-posit= ive partner is tested for HIV in early pregnancy with a negative test result.=

•One week prior to her delivery date, sh= e is retested using a standard HIV test.

•The positive test result was not commun= icated to the hospital or patient prior to the delivery.

•The patient delivered at term with a va= cuum assisted vaginal delivery and breast-fed the infant.

•The infant later tested positive for HI= V.

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Perinatal Hotline: 1-888-448-8765

=

3rd trimester HIV test results delivered to patient = and L&D staff

ARV prophylaxis

Non-instrumented delivery

Formula feeding for infant

=

=

•What were the missed opportunities?

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•Third trimester HIV test results delive= red to patient and L&D staff

•ARV prophylaxis

•Non-instrumented delivery

•Formula feeding for infant

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Perinatal Hotline: 1-888-448-8765

&#= 8226;A 23-year old pregnant woman is incarcerated = and = presents to labor and delivery in active labo= r at term. •Several hours after delivery, she consents to= an HIV test which returned positive several days later.
<= span style=3D'font-size:88%;color:#FFFFCC'>•The infant was started on triple therapy.
•The w= oman had been a patient at the pediatric HIV clinic and was lost to care, never tested for= HIV while incar= cerated or during prenatal care.
<= span style=3D'font-size:88%;color:#FFFFCC'>•The infant tested positive for HIV.

Elimi= nating Perinatal HIV Transmission
Missed Opportunities: Case = #6

•A 23 year old pregnant woman is incarce= rated and presents to labor and delivery in active labor at term.

•Several hours after delivery, she conse= nts to an HIV test which returned positive several days later.

•The infant was started on triple therap= y.

•The woman had been a patient at the ped= iatric HIV clinical and was lost to care.

•She was never tested for HIV while inca= rcerated or during prenatal care.

•The infant tested positive for HIV.

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Perinatal Hotline: 1-888-448-8765

HIV test during pregnancy

Rapid test before delivery

ARV prophylaxis <= /i>

ARV for maternal heal= th

=

=

•What were the missed opportunities?

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•HIV test during pregnancy

•Rapid test prior to delivery

•ARV prophylaxis

•ARV for maternal health

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‹header›

‹date/time›

Click to edit Master text styles

Second level

Third level

Fourth level

Fifth level

‹footer›

‹#›

I= nstructions to trainers/presenters:

•These slides are intended for = use by an experienced HIV trainer and prepared for an advan= ced audience preparing to implement rapid HIV testing in labor and delivery units.

•Users are welcome to excerpt enti= re cases for use. The individua= l case presentations were designed to stand individually, and in whole the entire set will contain repetitive points.

•The cases maybe inserted in an HIV testing curriculum or a curriculum specifically on Rapid HIV testing in the Labor and Delivery setting.

•Depending on the teaching scenari= o, all the cases presented in this slide set may not be helpful or f= it within the available time frame.

•Trainers are welcome to plan in advance a telephone consultation with the Perinatal Hotline to occur during the training session.&nbs= p; Call the Perinatal Hotline or e-mail the Hotline Coordinator at sweber@nccc.ucsf.edu to coordinate a live telephone consultation during a specific training session.

•The National HIV/AIDS Clinicians’ Consultation Center (the NCCC) is a free telephone consultation service available to clinicians in the United States.

•The Perinatal Hotline offers clinicians 24-hour advice on testing and care of HIV-infected pregnant women and their exposed infants.

•The Perinatal HIV Clinicians̵= 7; Network can connect Perinatal Hotline callers with specialists and regional resources.

•NCCC brochures, one-page ads, and telephone stickers are available by contacting sweber@nccc.ucs= f.edu.

•This patient is a 29 year old immigrant from Central America.

•The patient had declined an HIV t= est during prenatal care.

•She presents to the hospital at 32 weeks gestational age with a fever and altered mental status.&= #13;

•A rapid HIV test is performed by = the Labor and Delivery staff. Th= e results return positive.

•A confirmatory HIV test was quick= ly returned, also positive. = 3;

•The patient’s blood work revealed a CD4 count of 103, Viral load of 232,000.

•A head CT showed Toxoplasmosis.&#= 13;

•The patient was started on Antiretrovirals immediately.

•After 4 days of antiretrovirals delivered as directly observed therapy, the patient’s viral load dropped from 232,000 to 19,000.

•Even a few days of ARV use has be= en shown to dramatically reduce a patient’s viral load. <= /span>

•Directly observed therapy is one = form of ARV administration, considered in cases where perinatal HIV transmission is at increased risk.

•A non-reassuring fetal heart trac= ing at 33+ weeks indicated a c-section for obstetrical reasons.

•The infant has tested HIV negative.

•The patient later reported that h= er first husband died of AIDS 10 years ago and she was terrified t= o be tested for her own HIV status.

•The patient died 4 months postpar= tum of AIDS-related illness.

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•An HIV test dur= ing pregnancy.

•The patient declined the HIV test offered to her.&nbs= p; It is important to continue to build rapport and follow up with patients who initially decline HIV tests.

•Antiretroviral prophylaxis during pregnancy

•Antiretroviral medications for maternal health

•This patient is a 32 year old who first presented to care at 37+ weeks gestational age.

•Her routine HIV screen returned positive.

•The patient was admitted for dire= ctly observed therapy on highly active antiretroviral therapy for 5 days.

•A cesarean section was performed = at 38 weeks.

•The infant has tested HIV negative.

•A review of the medical chart revealed a positive HIV antibody test 2 years prior during a previous pregnancy.

•During her previous pregnancy she= had first presented to care at 37 weeks and was tested for HIV.

•The results returned two weeks la= ter, on the day she delivered at another hospital.

•Neither the patient nor the hospi= tal were aware of her HIV test results.

•Her first child tested positive f= or HIV after her HIV was rediscovered and disclosed in her second pregnancy.

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•First Pregnancy

= This case has several missed opportunities during two pregnancies.

•HIV test results to patient, attending clinician and L&D staff.

= During the first pregnancy, the patient was tested for HIV. However, the test results were not delivered to the patient, her OB, or the labor and delivery staff= .

•Rapid test on L&D

= With out a documented HIV test result, the patient should be offered a rapid HI= V test upon presenting to care.

•ARV prophylaxis

•ARV medications for positive infant

= Without the test results the patient missed antiretroviral medications for prophylaxis and the infant missed antiretroviral medications.

•Second Pregnancy

= During her second pregnancy, the patient missed adequate prenatal care resulting in a late HIV test result.

•<= /span>

•A couple want to conceive and both are tested for HIV - both HIV tests return with negative results.

•Three to four months later they conceive.

•During prenatal care, the mother was offered an HIV test but declined stating “I just got tested” and “neither of us has had outside relations since we’ve been together.”

•The baby is delivered at full term and breast-fed for one month.

•At three months old, the baby is admitted to the Children’s Hospital wi= th respiratory distress, failure to thrive syndrome, severe thrush, axillary adenopathy, = and big liver.

•The infant is confirmed to have PCP, CMV and HIV.

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•HIV test during pregnancy

•Rapid test on Labor and Delivery

= In the absence of an HIV test result, a rapid HIV test should be performed on= labor and delivery.

•ARV prophylaxis

•Formula feeding for infant

•This couple has been together for five years.

•The prenatal care is offered through a large HMO. Group counseling was given about “testing for lots of things,” the patient reports. There was no individual HIV test counseling.

•The patient reports “I signed to have everything done.”

•The patient never asked for or saw her test results and presumed everything was ok.

•

•The infant is delivered at 32 weeks.

•The baby is diagnosed with failure to thrive syndrome, severe thrush, and axil= lary adenopathy.

•The baby is confirmed to have PCP, CMV, and HIV.

•A review of the mother’s medical charts reveals a consent form stating “I decline HIV testing.”

PROMPT QUESTION

•What were the missed opportunities?

•

CLICK TO REVEAL

•HIV counseling and test during pregnancy

•Rapid HIV test on Labor and Delivery

= In the absence of a documented HIV test result, a rapid HIV test should be offered and performed when the patient presents to Labor and Delivery.

•ARV prophylaxis

=

=

=

=

=

=

= •

=

•A pregnant woman with a known HIV-positive partner is tested for HIV in earl= y pregnancy with a negative test result.

•One week prior to her delivery date, she is retested using a standard HIV test.

•The positive test result was not communicated to the hospital or patient prior= to the delivery.

•The patient delivered at term with a vacuum assisted vaginal delivery and brea= st-fed the infant.

•The infant later tested positive for HIV.

PROMPT QUESTION

•What were the missed opportunities?

CLICK TO REVEAL

•Third trimester HIV test results delivered to patient and L&D staff

•ARV prophylaxis

•Non-instrumented delivery

•Formula feeding for infant

•A 23 year old pregnant woman is incarcerated and presents to labor and deliv= ery in active labor at term.

•Several hours after delivery, she consents to an HIV test which returned positive = several days later.

•The infant was started on triple therapy.

•The woman had been a patient at the pediatric HIV clinical and was lost to care.

•She was never tested for HIV while incarcerated or during prenatal care. <= /span>

•The infant tested positive for HIV.

PROMPT QUESTION

•What were the missed opportunities?

•

CLICK TO REVEAL

•HIV test during pregnancy

•Rapid test prior to delivery

•ARV prophylaxis

•ARV for maternal health

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cG9ydGFudDt9DQphOnZpc2l0ZWQNCgl7Y29sb3I6I0IyQjJCMiAhaW1wb3J0YW50O30NCn== ------=_NextPart_01C80C0B.EB8A1D90 Content-Location: file:///C:/22CBB113/RTLDMissedOpportunities_files/script.js Content-Transfer-Encoding: quoted-printable Content-Type: application/javascript; charset="us-ascii" function LoadSld() { var sld=3DGetObj("SlideObj") if( !g_supportsPPTHTML ) { =09 sld.style.visibility=3D"visible" return } if( MakeNotesVis() ) return runAnimations =3D _InitAnimations(); =09 if( IsWin("PPTSld") ) parent.SldUpdated(GetSldId()) g_origSz=3DparseInt(SlideObj.style.fontSize) g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis()=20 { var fTrans=3Dg_showAnimation && SldHasTrans() if( fTrans )=09 { if( g_bgSound ) { idx=3Dg_bgSound.indexOf(","); pptSound.src=3Dg_bgSound.substr( 0, idx ); pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1))); } SlideObj.filters.revealtrans.Apply()=09 } SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId()=20 { var regExp =3D /file:\/\/\//i var pos =3D location.href.search(regExp) if (MHTMLPrefix !=3D "" && pos !=3D -1) sId =3D location.href.substring(pos) else { sId =3D RemoveFilePrefixFromHref(location.href); var regExp =3D /\// var fixedHref =3D sId var pos =3D -1 =09 pos =3D fixedHref.search(regExp) while (pos !=3D -1) { fixedHref =3D fixedHref.replace(regExp, "\\") pos =3D fixedHref.search(regExp) } =09 if (g_fBaseHyperlink =3D=3D true) sId =3D "file:///" + fixedHref; else sId =3D fixedHref.substring(fixedHref.lastIndexOf('\\') + 1) } =09 return sId } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } }function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames= Mode() ) || (event && event.keyCode=3D=3D32) ) { =09 if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex= t ) return; parent.GoToNextSld(); } } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"End of slide show, click to exit.", SCREEN_MODE=3D"Fram= es", gIsEndShow=3D0, NUM_VIS_SLDS=3D20, SCRIPT_HREF=3D"script.js", FULLSCR_= HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var g_fBaseHyperlink =3D false; var gMainDoc=3Dnew Array(new hrefList("slide0018.htm",1,-1,1),new hrefList(= "slide0019.htm",1,-1,1),new hrefList("slide0001.htm",1,-1,1),new hrefList("= slide0013.htm",1,-1,1),new hrefList("slide0003.htm",1,-1,1),new hrefList("s= lide0004.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("sl= ide0006.htm",1,-1,1),new hrefList("slide0007.htm",1,-1,1),new hrefList("sli= de0025.htm",1,-1,1),new hrefList("slide0008.htm",1,-1,1),new hrefList("slid= e0009.htm",1,-1,1),new hrefList("slide0026.htm",1,-1,1),new hrefList("slide= 0010.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide0= 027.htm",1,-1,1),new hrefList("slide0020.htm",1,-1,1),new hrefList("slide00= 28.htm",1,-1,1),new hrefList("slide0021.htm",1,-1,1),new hrefList("slide002= 9.htm",1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function RemoveFilePrefixFromHref(href) { var regExp =3D /^file:\/\/\//i; return href.replace(regExp, "") } function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if (MHTMLPrefix !=3D "") href =3D RemoveFilePrefixFromHref(href) if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; =09 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(obj.mSldHref= )) else PPTSld.location.replace(obj.mSldHref) =09 if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 if (MHTMLPrefix !=3D "") PPTSld.location.replace(MHTMLPrefix+RemoveFilePrefixFromHref(href)) else PPTSld.location.replace(href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('

' + ENDSHOW_MESG + '
') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Next",sPrev=3D"Previous",sEnd=3D"End Show",sFont=3D"Arial",sAr= row=3D"Arrow",sFreeform=3D"Freeform",sRect=3D"Rectangle",sOval=3D"Oval" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; 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charset="us-ascii" PowerPoint Presentation ------=_NextPart_01C80C0B.EB8A1D90 Content-Location: file:///C:/22CBB113/RTLDMissedOpportunities_files/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"

No= tes

Slide Show

Outline

1

Rapid Testing in= Labor and Delivery

Missed Opportunities For Prevention of Mother to Child Transmission = of HIV through Routine Rapid Testing in Labor and Delivery

National Perinatal HIV Consultation and Referral Service

Shannon Weber, MSW

sweber @nccc.ucsf.edu

June 2007

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National HIV/AIDS Clinicians’ Consultation Center
UCSF – San Francisco General Hospital

Perinatal Hotline   (888) 448 - 8765

National Perinatal HIV Consultation & Referral Service

Advice on testing and care of HIV-infected pregnant     women and their infants

Referral to HIV specialists and regional resources

Warmline   (800)= 933 - 3413

National HIV Telephone Consultation Service

Consultation on all aspects of HIV testing and clinical care

PEPline   (888) = 448 - 4911

National Clinicians’ Post-Exposure Prophylaxis Hotline

Recommendations on managing occupational exposures to HIV and

hepatitis B & C

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Pacific AETC
Rapid Testing in Labor and Delivery Project

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Eliminating Peri= natal HIV Transmission
Missed Opportunities: Case #1

29 year old immigrant from Central America

Declined HIV test during prenatal care

Presented at 32 weeks GA with fever and altered mental status

Rapid HIV test positive

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Eliminating Peri= natal HIV Transmission
Missed Opportunities: Case #1

Confirmatory HIV test positive, CD4 count 103, Viral load 232,000,He= ad CT showed Toxoplasmosis, ARVs started immediately

After 4 days of ARVs, patient’s viral load went from 232,000 to 19,000

Non-reassuring fetal heart tracing at 33+weeks, c/section

Infant HIV negative

Pt later reported that 1^st husband died of AIDS 10 yrs ago and she was terrified to be tested

Pt died 4 months postpartum of AIDS-related illness

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"What were = the missed opportunities"

What were the missed opportunities?

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Eliminating Peri= natal HIV Transmission
Missed Opportunities: Case #2

32 year old presented to care at 37+ weeks GA, positive HIV antibody test

Admitted for DOT/HAART for 5 days before c-section at 38 weeks

Infant is HIV negative. Review of her medical chart revealed a positive HIV antibody = test 2 years prior during a previous pregnancy

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Eliminating Peri= natal HIV Transmission
Missed Opportunities: Case #2

During her previous pregnancy she presented for prenatal care at 37 weeks and was tested for HIV. The results came back two weeks later, on the day she deliver= ed at another hospital. N= either the patient nor the hospital were aware of her results.

Her first child tested positive for HIV after her HIV was rediscover= ed and disclosed in her second pregnancy.

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #3

Couple want to conceive. Both get tested and are HIV Ab negative.

3-4 months later they conceive

Mother was offered testing at a prenatal visit but declined because “I just got tested” and “Neither of us has had out= side relations since we’ve been together.”

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #3

Baby delivered full term and breast-fed for one month

Admitted at 3 months with respiratory distress, failure to thrive, severe thrush, axillary adenopathy, big liver

Then confirmed to have PCP, CMV and HIV

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #4

Couple together for 5 years.

Prenatal care through large HMO. Group counseling about ‘testi= ng for lots of things;” no individual counseling.

Patient says, “I signed to have everything done.” Patient never asked for or = saw her test results and presumed all was fine.

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #4

Baby born at 32 weeks

Diagnosed with failure to thrive, severe thrush, axillary adenopathy=

Then confirmed to have PCP, CMV and HIV

A review of mom’s consent forms reveals “I decline HIV testing.”

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #5

A pregnant women, whose partner is known HIV positive, is tested for= HIV in early pregnancy with a negative test result.

One week prior to her delivery, she is retested using a standard HIV test.

The positive test result was not communicated to the hospital or pat= ient prior to the delivery.

The patient delivered at term with a vacuum assisted vaginal delivery and breast-fed.

The infant later tested positive for HIV.

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Eliminating Per= inatal HIV Transmission
Missed Opportunities: Case #6

A 23-year old pregnant woman is incarcerated and presents to labor a= nd delivery in active labor at term.

Several hours after delivery, she consents to an HIV test which retu= rned positive several days later.

The infant was started on triple therapy.

The woman had been a patient at the pediatric HIV clinic and was los= t to care, never tested for HIV while incarcerated or during prenatal car= e.

The infant tested positive for HIV.

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	Instructions to trainers/presenters:
	•These slides are intended for use by= an experienced HIV trainer and prepared for an advanced audience preparing to implement rapid HIV testing in labor and delivery units.
	•Users are welcome to excerpt entire cas= es for use. The individual case presentations were designed to stand individually, and in whole the entire set will contain repetitive points.
	•The cases maybe inserted in an HIV test= ing curriculum or a curriculum specifically on Rapid HIV testing in the Labor= and Delivery setting.
	•Depending on the teaching scenario, all= the cases presented in this slide set may not be helpful or fit within the available time frame.
	•Trainers are welcome to plan in advance= a telephone consultation with the Perinatal Hotline to occur during the training session. Call the Perinatal Hotline or e-mail the Hotline Coordinator at sweber@nccc.ucs= f.edu to coordinate a live telephone consultation during a specific training session.


	•The National HIV/AIDS Clinicians’ Consultation Center (the NCCC) is a free telephone consultation service available to clinicians in the United States.
	•The Perinatal Hotline offers clinicians= 24-hour advice on testing and care of HIV-infected pregnant women and their expos= ed infants.
	•The Perinatal HIV Clinicians’ Net= work can connect Perinatal Hotline callers with specialists and regional resources= .
	•NCCC brochures, one-page ads, and telep= hone stickers are available by contacting sweber@nccc.ucsf.edu.


	•This patient is a 29 year old immigrant from Centr= al America.
	•The patient had declined an HIV test du= ring prenatal care.
	•She presents to the hospital at 32 weeks gestational age with a fever and altered mental status.
	•A rapid HIV test is performed by the La= bor and Delivery staff. The results return positive.<= br>


	•A confirmatory HIV test was quickly ret= urned, also positive.
	•The patient’s blood work revealed= a CD4 count of 103, Viral load of 232,000.
	•A head CT showed Toxoplasmosis.<= br>
	•The patient was started on Antiretrovir= als immediately.
	•After 4 days of antiretrovirals deliver= ed as directly observed therapy, the patient’s viral load dropped from 232,000 to 19,000.
	•Even a few days of ARV use has been sho= wn to dramatically reduce a patient’s viral load.
	•Directly observed therapy is one form o= f ARV administration, considered in cases where perinatal HIV transmission is at increased risk.
	•A non-reassuring fetal heart tracing at= 33+ weeks indicated a c-section for obstetrical reasons.
	•The infant has tested HIV negative.
	•The patient later reported that her fir= st husband died of AIDS 10 years ago and she was terrified to be tested for = her own HIV status.
	•The patient died 4 months postpartum of AIDS-related illness.


	PROMPT QUESTION
	•What were the missed opportunities?

	CLICK TO REVEAL
	•An HIV test during pregnancy.
	•The patient declined the HIV test offer= ed to her. It is important to con= tinue to build rapport and follow up with patients who initially decline HIV te= sts.
	•Antiretroviral prophylaxis during pregn= ancy
	•Antiretroviral medications for maternal= health


	•This patient is a 32 year old who first presented to care at 37+ weeks gestational age.
	•Her routine HIV screen returned positiv= e.
	•The patient was admitted for directly o= bserved therapy on highly active antiretroviral therapy for 5 days.
	•A cesarean section was performed at 38 = weeks.
	•The infant has tested HIV negative.
	•A review of the medical chart revealed a positive HIV antibody test 2 years prior during a previous pregnancy.


	•During her previous pregnancy she had f= irst presented to care at 37 weeks and was tested for HIV.
	•The results returned two weeks later, o= n the day she delivered at another hospital.
	•Neither the patient nor the hospital we= re aware of her HIV test results.
	•Her first child tested positive for HIV= after her HIV was rediscovered and disclosed in her second pregnancy.


	•A couple want to conceive and both are = tested for HIV - both HIV tests return with negative results.

	•Three to four months later they conceiv= e.

	•During prenatal care, the mother was of= fered an HIV test but declined stating “I just got tested” and “neither of us has had outside relations since we’ve been together.”


	•The baby is delivered at full term and breast-fed for one month.

	•At three months old, the baby is admitt= ed to the Children’s Hospital with respiratory distress, failure to thrive syndrome, severe thrush, axillary adenopathy, and big liver.

	•The infant is confirmed to have PCP, CM= V and HIV.


	•This couple has been together for five = years.
	•The prenatal care is offered through a = large HMO. Group counseling was g= iven about “testing for lots of things,” the patient reports. There was no individual HIV test counseling.
	•The patient reports “I signed to = have everything done.”
	•The patient never asked for or saw her = test results and presumed everything was ok.


	•The infant is delivered at 32 weeks.
	•The baby is diagnosed with failure to t= hrive syndrome, severe thrush, and axillary adenopathy.
	•The baby is confirmed to have PCP, CMV,= and HIV.
	•A review of the mother’s medical = charts reveals a consent form stating “I decline HIV testing.”


	•A pregnant woman with a known HIV-posit= ive partner is tested for HIV in early pregnancy with a negative test result.=
	•One week prior to her delivery date, sh= e is retested using a standard HIV test.
	•The positive test result was not commun= icated to the hospital or patient prior to the delivery.
	•The patient delivered at term with a va= cuum assisted vaginal delivery and breast-fed the infant.
	•The infant later tested positive for HI= V.


	•A 23 year old pregnant woman is incarce= rated and presents to labor and delivery in active labor at term.
	•Several hours after delivery, she conse= nts to an HIV test which returned positive several days later.
	•The infant was started on triple therap= y.
	•The woman had been a patient at the ped= iatric HIV clinical and was lost to care.
	•She was never tested for HIV while inca= rcerated or during prenatal care.
	•The infant tested positive for HIV.

1	Rapid Testing in= Labor and Delivery Missed Opportunities For Prevention of Mother to Child Transmission = of HIV through Routine Rapid Testing in Labor and Delivery National Perinatal HIV Consultation and Referral Service Shannon Weber, MSW sweber @nccc.ucsf.edu June 2007
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3	National HIV/AIDS Clinicians’ Consultation Center UCSF – San Francisco General Hospital Perinatal Hotline (888) 448 - 8765 National Perinatal HIV Consultation & Referral Service Advice on testing and care of HIV-infected pregnant women and their infants Referral to HIV specialists and regional resources Warmline (800)= 933 - 3413 National HIV Telephone Consultation Service Consultation on all aspects of HIV testing and clinical care PEPline (888) = 448 - 4911 National Clinicians’ Post-Exposure Prophylaxis Hotline Recommendations on managing occupational exposures to HIV and hepatitis B & C
4	Pacific AETC Rapid Testing in Labor and Delivery Project
5	Eliminating Peri= natal HIV Transmission Missed Opportunities: Case #1 29 year old immigrant from Central America Declined HIV test during prenatal care Presented at 32 weeks GA with fever and altered mental status Rapid HIV test positive
6	Eliminating Peri= natal HIV Transmission Missed Opportunities: Case #1 Confirmatory HIV test positive, CD4 count 103, Viral load 232,000,He= ad CT showed Toxoplasmosis, ARVs started immediately After 4 days of ARVs, patient’s viral load went from 232,000 to 19,000 Non-reassuring fetal heart tracing at 33+weeks, c/section Infant HIV negative Pt later reported that 1^st husband died of AIDS 10 yrs ago and she was terrified to be tested Pt died 4 months postpartum of AIDS-related illness
7	"What were = the missed opportunities" What were the missed opportunities?
8	Eliminating Peri= natal HIV Transmission Missed Opportunities: Case #2 32 year old presented to care at 37+ weeks GA, positive HIV antibody test Admitted for DOT/HAART for 5 days before c-section at 38 weeks Infant is HIV negative. Review of her medical chart revealed a positive HIV antibody = test 2 years prior during a previous pregnancy
9	Eliminating Peri= natal HIV Transmission Missed Opportunities: Case #2 During her previous pregnancy she presented for prenatal care at 37 weeks and was tested for HIV. The results came back two weeks later, on the day she deliver= ed at another hospital. N= either the patient nor the hospital were aware of her results. Her first child tested positive for HIV after her HIV was rediscover= ed and disclosed in her second pregnancy.
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11	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #3 Couple want to conceive. Both get tested and are HIV Ab negative. 3-4 months later they conceive Mother was offered testing at a prenatal visit but declined because “I just got tested” and “Neither of us has had out= side relations since we’ve been together.”
12	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #3 Baby delivered full term and breast-fed for one month Admitted at 3 months with respiratory distress, failure to thrive, severe thrush, axillary adenopathy, big liver Then confirmed to have PCP, CMV and HIV
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14	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #4 Couple together for 5 years. Prenatal care through large HMO. Group counseling about ‘testi= ng for lots of things;” no individual counseling. Patient says, “I signed to have everything done.” Patient never asked for or = saw her test results and presumed all was fine.
15	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #4 Baby born at 32 weeks Diagnosed with failure to thrive, severe thrush, axillary adenopathy= Then confirmed to have PCP, CMV and HIV A review of mom’s consent forms reveals “I decline HIV testing.”
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17	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #5 A pregnant women, whose partner is known HIV positive, is tested for= HIV in early pregnancy with a negative test result. One week prior to her delivery, she is retested using a standard HIV test. The positive test result was not communicated to the hospital or pat= ient prior to the delivery. The patient delivered at term with a vacuum assisted vaginal delivery and breast-fed. The infant later tested positive for HIV.
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19	Eliminating Per= inatal HIV Transmission Missed Opportunities: Case #6 A 23-year old pregnant woman is incarcerated and presents to labor a= nd delivery in active labor at term. Several hours after delivery, she consents to an HIV test which retu= rned positive several days later. The infant was started on triple therapy. The woman had been a patient at the pediatric HIV clinic and was los= t to care, never tested for HIV while incarcerated or during prenatal car= e. The infant tested positive for HIV.
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