Postnatal transmission of AIDS-associated retrovirus from mother to infant

HIV infection and pregnancy

Although coexistent HIV infection and pregnancy are still rare in most communities, as the prevalence of HIV and AIDS continues to rise, the practicing physician can expect to see this more frequently. The internist plays a crucial role in educating these patients as to the importance of "safe sex" practices and pregnancy prevention. As with any complex medical problem, once pregnant, these patients are best managed with a team approach, involving the obstetrician, internist, neonatologist, and social worker.

Survival of patients with the acquired immunodeficiency syndrome in Australia

The duration of survival of all persons with the acquired immunodeficiency syndrome (AIDS) in Australia who were diagnosed to July 31, 1987 was analysed by means of standard Kaplan-Meier methods in order to construct survival curves, and by log-rank tests which were used to assess the significance of differences among the curves. The median duration of survival was 10.4 months. Significant (P less than 0.001) differences in the survival curves were found between men and women (median survival, 11.4 and 3.8 months, respectively) by the log-rank test. Patients who were aged 20-49 years at diagnosis had a longer (P less than 0.001) median survival (11.4 months) than did those who were older than 60 years of age (2.7 months) and those who were aged less than 20 years (0.5 months) at diagnosis. Those patients who were infected by way of blood transfusions had a shorter (P less than 0.001) median survival (1.6 months) than did those who were infected through homosexual activity (11.4 months). Median survival time, which was stratified by the disease stage at presentation, varied from 12.4 months in those patients with Kaposi's sarcoma alone to 7.0 months in those patients with lymphoma (P = 0.01). The median survival time for those patients who presented solely with Kaposi's sarcoma was shorter than was that which has been reported from other developed countries. Multivariate analysis of all male cases by means of the proportional-hazards model indicated that the presentation of cases at an age that was greater than 50 years (relative risk, 2.36; 95% confidence interval [CI], 1.63-3.42) was associated independently with a reduced survival time, while the presentation of cases solely with Kaposi's sarcoma (relative risk, 0.67; 95% Cl, 0.49-0.92) was associated independently with an increased survival time. When all cases were included in this analysis, these same predictors of survival were significant; in addition, cases of AIDS as a result of the receipt of a blood transfusion were associated independently with a reduced survival time.

Acquired Immunodeficiency Syndrome in Infants, Children, and Adolescents

The acquired immunodeficiency syndrome (AIDS) was first described as a disease of homosexual men. The first cases of AIDS in children were reported in 1982 and involved a transfusion recipient and four infants born to women at increased risk for AIDS. Infants may acquire their infection perinatally or possibly postnatally through infected breast milk. Parenterally acquired infection, through transfusion of blood or blood products, occurs in infants, children, and adolescents. Adolescents are also at risk for infection through sexual transmission and through shared needles among intravenous drug users. By January 1987, 1.4% of the AIDS cases were in children less than 13 years old, and 0.4% were in adolescents 13 to 19 years old. Additionally, 4.4% of the total AIDS cases were reported in 20 to 24 year olds, which most likely reflects infection which occured during adolescence. In children less than 13 years old, infection occurred primarily thorugh perinatal transmission from mothers who were intravenous drug users or sexual partners of intravenous drug users. Adolescent cases of AIDS have followed adult patterns of transmission with most cases resulting from sexual transmission. As the prevalence of infection with the human immunodeficiency virus increases, increases in drug-use-associated transmission in women followed by perinatal transmission to infants and sexual transmission in adolescents seems likely to occur. To prevent further spread, health agencies must develop and target extensive AIDS prevention campaigns at adolescents, young adults, and sexually active women.

Seronegativity and HIV infection

An African girl born to an HIV seropositive mother was seropositive during the neonatal period, became seronegative, and was again found to be seropositive at 18 and 20 months of age. We suggest that seronegative children born to seropositive mothers should be followed up for months or even years before HIV infection can be ruled out.

Acquired immunodeficiency syndrome: a new population of children at risk

Cases of AIDS in children have been described since 1982. Diagnosis is more complex in children than in adults owing to the more varied clinical presentations and the difficulty in interpretation of laboratory tests. Our current understanding of HIV infection in children is reviewed, as well as the controversies regarding medical, psychosocial, and public health issues.

HIV infection in Zimbabwe

A total of 188 children with positive serology for HIV were identified during an 18 month period. Two seronegative children with clinical features of AIDS had seropositive mothers. Ten children were asymptomatic on initial testing; one has since died with infection. The commonest presenting features were generalised lymphadenopathy, failure to thrive, chronic diarrhoea, and pneumonia. Thirty four children are known to have died.

Cutaneous manifestations of the acquired immunodeficiency syndrome in children

The acquired immunodeficiency syndrome (AIDS) in children is now known to be a clinical entity separate and distinct from AIDS in adults. In this article we present a review of the recent literature describing the history, definitions, epidemiology, differential diagnosis, and immunologic and clinical features of pediatric AIDS. Special emphasis is placed on the cutaneous manifestations of human immunodeficiency virus infection in children, which, to date, have not been the subject of a comprehensive review.

Prevention of AIDS and HIV infection: needs and priorities for epidemiologic research

By the end of 1987, almost 50,000 cases of acquired immunodeficiency syndrome (AIDS) will have been reported in the United States. Although the primary epidemiology of the disease has been described, much work remains to be done to complete our understanding of the dynamics of transmission and infection with the causative virus, human immunodeficiency virus (HIV). At the state and local level, the highest priorities for epidemiologic research are to understand better the precise populations at risk of prevalent and incident HIV infection, and to use this information to direct and monitor specific prevention programs that are likely to be effective for the populations at risk. These parallel efforts-sophisticated investigative epidemiologic research and applied epidemiologic and serosurveillance studies-must be expanded rapidly and continued for the forseeable future if we are to accomplish the goal of preventing further spread of HIV.

Infection of the fetus and the newborn: prevention, treatment and related handicap

Congenital infection is uncommon and the cause of only a small proportion of handicap seen in children but some infections may be preventable or even treatable. As an example, the congenital rubella syndrome first described in the 1940s is preventable by use of the vaccine but cases still occur. It is hoped that with the introduction of the measles, mumps, rubella immunization for young children, rubella will become as rare in the UK as it is in the USA. Cytomegalovirus is now a more common cause of handicap than rubella but no vaccine has been developed. Although antiviral drugs are available for herpes simplex virus and vaccinia, infection mortality in the newborn is high, even following the use of these agents; many HSV infections in the newborn arise following primary and asymptomatic maternal infections so that treatment may start late in the course of the illness. The obstetrician needs to understand the natural history as well as possible investigations available for congenital infections. There may be warning signs which require action, such as herpetic lesions in the genital tract of the mother. Less specific abnormalities during pregnancy, such as intra-uterine growth retardation and spontaneous onset of preterm labour, may point to congenital infection. This chapter describes both antenatal and postnatal management of the major congenital infections. We have included recent research data that should influence clinical practice; studies on HSV which suggest that, for women with a history of recurrent infection, routine viral culture of the genital tract at the end of pregnancy is unnecessary; reports from both the USA and the UK that rubella immunization performed inadvertently during early pregnancy has not resulted in the congenital rubella syndrome. The chapter would not have been complete without a discussion of human immunodeficiency virus, of concern to the obstetrician and midwife. There is still much to be learned about the natural history of this infection in both the mother and infant.

Human immunodeficiency virus infection in childhood

Acquired immunodeficiency syndrome is associated with considerable morbidity in infants and children. It is caused by human immunodeficiency virus (HIV) which can be transmitted vertically from mother to infant early in pregnancy. Transmission might also occur via breast milk. Although the exact transmission rate of HIV from mother to infant is not known, HIV can become a major threat to child survival. This threat is already present in Africa where high seroprevalences have been reported among infants and young children. Transmission via blood products is decreasing due to reliable methods of screening donors for HIV antibody. Where these tests are not available, parenteral transmission will increase the incidence of HIV infection. The clinical picture of HIV infection in children presents with failure to thrive, pulmonary interstitial pneumonitis, hepatosplenomegaly and recurrent bacterial infections. These are common manifestations of diseases prevalent in children in Africa where malnutrition and recurrent parasitic infections already cause immunosuppression. Recognition of the syndrome is therefore difficult. There is no available cure for HIV infection. Supportive treatment and relief of pain and suffering are the only means of management at present. Prevention of spread of the illness to infants and young children is therefore of paramount importance.

Milk-borne transmission of human T-cell leukemia virus type I in rabbits

The mode of vertical transmission of human T-cell leukemia virus type I (HTLV-I) was investigated by foster-nursing in rabbits. Two of five rabbits born to noninfected mothers and fostered by virus-infected females seroconverted for HTLV-I after 7 weeks, whereas all seven rabbits born to virus-infected mothers and fostered by noninfected females remained seronegative for the observation period of 6 months. Culture of peripheral blood lymphocytes gave rise to an HTLV-I-carrying T-cell line from each of the two seroconverted rabbits. These findings suggest that HTLV-I is transmitted through milk from mother to offspring.

The hazard of infection from the shared communion cup

Interest and concern that the shared communion cup may act as a vehicle for indirectly transmitting infectious disease was reawakened when the human immunodeficiency virus (HIV) was detected in the saliva of infected persons. Bacteriological experiments have shown that the occasional transmission of micro-organisms is unaffected by the alcoholic content of the wine, the constituent material of the cup or the practice of partially rotating it, but is appreciably reduced when a cloth is used to wipe the lip of the cup between communicants. Nevertheless, transmission does not necessarily imply inoculation or infection. Consideration of the epidemiology of micro-organisms that may be transmitted via saliva, particularly the herpes group of viruses, suggests that indirect transmission of infection is rare and in most instances a much greater opportunity exists for direct transmission by other means. There is substantial evidence that neither infection with hepatitis B virus nor HIV can be transmitted directly via saliva so that indirect transmission via inanimate objects is even less likely. No episode of disease attributable to the shared communion cup has ever been reported. Currently available data do not provide any support for suggesting that the practice of sharing a common communion cup should be abandoned because it might spread infection.

The AIDS crisis: a United States health care perspective

The unanticipated onset of Acquired Immunodeficiency Syndrome in the United States, followed by its gradual progression into a full-blown, uncontrollable epidemic, has had severe economic and organizational consequences for the American health care system. AIDS has taken its toll on the health workforce as well in terms of stress, anxiety and workload demands. In the absence of adequate community-based treatment and care resources for persons with AIDS, hospitals had to assume the major burden for providing basic medical care and developing the needed range of services required. This expansion of responsibilities strained hospitals and other health care agencies beyond their capabilities. Some hospitals have faced economic and allocation dilemmas because of high occupancy rates by AIDS patients since there are no specialized reimbursement rates for the intensive resource utilization required for their care. These substantial burdens underscored the need for coordinated long-term planning for a continuum of in-patient, out-patient and community support services. A major response to the epidemic has been a restructuring of the health and social service delivery systems. Hospitals have had to maintain patients beyond their need for an acute level of care, develop infrastructures to manage the increasing numbers of patients, alter physical facilities, provide educational programs and support groups to increase staff's knowledge and decrease fears of AIDS, consider alternatives to in-patient medical management, and lobby with local, state and federal governments to obtain increased public monies for AIDS treatment and care. In the past year, there has been a discernible shift to widening the network of ambulatory medical services and community-based social and health care supports. A major focus of this paper is the social and organizational impact of this epidemic on the hospital and health care system and the systems' responses. Alternatives to an acute care treatment locus for persons with AIDS are explored. Recommendations for future directions for a comprehensive, coordinated health and social services delivery network are presented.

Does gastric acid protect the preterm infant from bacteria in unheated human milk?

Although preterm mother's milk has greater nutritional and anti-infective properties than donor milk, it may be highly contaminated with bacteria. We therefore asked three questions: what is the fate of these bacteria in the preterm infant's stomach, is gastric pH important, and what factors affect gastric pH? pH, colony count and bacterial identification were performed on the milk and on serial gastric aspirates in 20 preterm infants on 25 occasions. Seventeen milk samples grew bacteria, five potentially pathogenic and 12 non-pathogenic. Twelve of 25 prefeeding gastric samples were sterile, but following the feeding all the samples grew non-pathogenic bacteria and 70% grew potential pathogens. With time pH decreased and by 2-h samples with pH less than 3.5 had no bacterial growth; Candida albicans still flourished in a low pH (mean 2.8). We concluded that a low gastric pH may be more important than the bacterial count of the milk. In a second study, 91 serial gastric pH measurements were made on 12 preterm infants. pH tended to decrease with increasing age and was significantly lower in infants fed exclusively human milk (2.7 vs. 3.6; human milk versus formula P less than 0.02) We speculate that human milk may influence gastric acid production and thus protect the preterm infant from bacteria in the milk.

No evidence for vertical transmission in children born to HIV seropositive male haemophiliacs

In order to evaluate the risk of HIV transmission during conception or pregnancy from seropositive male haemophiliacs to their children, we have investigated the families of 8 HIV antibody positive haemophilia A patients. HIV antibodies could be demonstrated in 1/9 mothers after delivery of her second child, whereas all the other mothers tested were seronegative. Of the 14 children studied at least 7 must have been conceived when the father was already seropositive. HIV antibodies were tested for in 6 of these 7 children; all were negative. All 14 children are healthy and free from clinical signs of HIV infection. We conclude that the overall risk of perinatal HIV transmission in haemophilic families should be low and this knowledge may be invaluable in family counselling.

AIDS-related psychiatric disorder

The background to HIV infection, its mode of transmission, and its neurological and psychiatric complications are described. The management of AIDS-related psychiatric disorder and problems encountered among staff involved in the management of patients suffering from AIDS are considered. There is a need for appropriate educational programmes. Although the incidence of AIDS in the UK has been appreciably lower than in many other countries, there are no grounds for complacency; psychiatric disorder associated with HIV infection will be encountered much more frequently in the future. Psychiatric staff are urged to inform and prepare themselves in anticipation of this development.

HIV infection in children: sizing up the paediatric problem

Cases of paediatric AIDS have increased each year in the USA, as the disease has spread to the heterosexual community. In the USA the geographic distribution of perinatal AIDS cases mirrors the distribution of cases in women. To date, 503 HIV antibody positive women have been reported in the UK. It is likely that the increasing number of seropositive women will be reflected in an increase in the number of reports of perinatal HIV infection and AIDS. Although screening of blood donors and blood products has stopped further increase in infections from this route, as transfusion-infected children become symptomatic the burden on paediatric services will increase.

Isolation of acquired immunodeficiency syndrome virus from the placenta

The etiologic agent of the acquired immunodeficiency syndrome is human immunodeficiency virus. We report here a case of the culturing of this agent from the placenta and suggest the clinical implications.

AIDS in an infant causing severe failure to thrive

A nine-month-old female Jamaican infant presented with a history of severe failure to thrive, recurrent pneumonia and developmental delay. She was found to have hepatosplenomegaly, generalised lymphadenopathy and hypotonia. Investigations revealed polyclonal hypergammaglobulinaemia, cytomegalovirus in her urine, and patchy lung infiltrates on her chest radiographs. Three separate tests were positive for human immunodeficiency virus in both the infant and her mother, suggesting vertical transmission, and confirming AIDS as the cause of the severe failure to thrive.

Transfusion-associated viral infections

Viral infections are a frequent occurrence following transfusion of blood products. While generally benign, these infections are capable of causing significant morbidity and mortality. Therefore, it is prudent to follow several general approaches diligently to reduce the risks of these infections in patients undergoing transfusions of blood products. These suggested measures include the following: 1. Prescribe and administer blood and blood products only when absolutely needed. 2. Use volunteer blood donors only. 3. Avoid use of pooled blood products when possible. 4. Use only blood and blood products that have been appropriately tested for HBsAg and HIV. 5. Use ALT determinations to screen blood products and eliminate those with high level. 6. Avoid the use of clotting-factor concentrates but, if necessary, use only those which have been heat-treated. 7. Limit use of leukocyte transfusion. 8. Use only CMV seronegative blood and blood products or frozen deglycerolized red cells in patients at high risk for posttransfusion CMV infection.

Transmission of human immunodeficiency virus from parents to only one dizygotic twin

The acquired immunodeficiency syndrome-related complex was identified in a mother and one of her nonidentical twins. Generalized lymphadenopathy was first noted in the infant at age 17 months, and that of the mother was incidentally discovered 6 months later. The father, who had had homosexual contacts before the conception of the twins, appeared to be in good health. No one in the family had constitutional symptoms or showed signs of opportunistic infection. Both parents and the patient had hypergammaglobulinemia, low T-helper-to-suppressor-cell ratio, and positive serum antibody to human immunodeficiency virus. Attempts to isolate the virus from all family members were unsuccessful. The twin brother was in good health with a normal immunologic profile and negative antibody to human immunodeficiency virus.