Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission

Metabolites profiling and pharmacokinetics of troxipide and its pharmacodynamics in rats with gastric ulcer

Troxipide is widely used to treat gastric ulcer (GU) in the clinic. However, a lack of systematic metabolic, pharmacokinetic and pharmacological studies limits its clinical use. This study aimed to firstly explore the metabolic, pharmacokinetic and pharmacological mechanisms of troxipide in rats with GU compared to normal control (NC) rats. First, metabolic study was perormed by a highly selective, high-resolution mass spectrometry method. A total of 45 metabolites, including 9 phase I metabolites and 36 phase II metabolites, were identified based on MS/MS spectra. Subsequently, the pharmacokinetics results suggested that the Cmax, Ka, t1/2, AUC(0-t) and AUC(0-∞) of troxipide were significantly increased in rats with GU compared with NC rats. The Vz, K10 and absolute bioavailability of troxipide were obviously decreased in rats with GU compared with NC rats, and its tissue distribution (in the liver, lung and kidney) was significantly different between the two groups of rats. Additionally, the pharmacodynamic results suggested that the levels of biochemical factors (IL-17, IL-6, TNF-α, IFN-γ, AP-1, MTL, GAS, and PG-II) were significantly increased, the PG-Ӏ level was obviously decreased, and the protein expression levels of HSP-90, C-Cas-3 and C-PARP-1 were markedly increased in rats with GU compared with NC rats. The above results suggested that the therapeutic mechanisms underlying the metabolic, pharmacokinetic and pharmacological properties of troxipide in vivo in rats deserve further attention based on the importance of troxipide in the treatment of GU in this study, and these mechanisms could be targets for future studies.

UNICEF's contribution to the adoption and implementation of option B+ for preventing mother-to-child transmission of HIV: a policy analysis

BACKGROUND

Between 2011 and 2013, global and national guidelines for preventing mother-to-child transmission (PMTCT) of HIV shifted to recommend Option B+, the provision of lifelong antiretroviral treatment for all HIV-infected pregnant women.

METHODS

We aimed to analyse how Option B+ reached the policy agenda, and unpack the processes, actors and politics that explain its adoption, with a focus on examining UNICEF's contribution to these events. Analysis drew on published articles and other documentation, 30 key informants interviews with staff at UNICEF, partner organisations and government officials, and country case studies. Cameroon, India, South Africa and Zimbabwe were each visited for 5-8 days. Interview transcripts were analysed using Dedoose software, reviewed several times and then coded thematically.

RESULTS

A national policy initiative in Malawi in 2011, in which the country adopted Option B+, rather than existing WHO recommended regimens, irrevocably placed the policy on the global agenda. UNICEF and other organisations recognised the policy's potential impact and strategically crafted arguments to support it, framing these around operational considerations, cost-effectiveness and values. As 'policy entrepreneurs', these organisations vigorously promoted the policy through a variety of channels and means, overcoming concerted opposition. WHO, on the basis of scanty evidence, released a series of documents towards the policy's endorsement, paving the way for its widespread adoption. National-level policy transformation was rapid and definitive, distinct from previous incremental policy processes. Many organisations, including UNICEF, facilitated these changes in country, acting individually, or in concert.

CONCLUSIONS

The adoption of the Option B+ policy marked a departure from established processes for PMTCT policy formulation which had been led by WHO with the support of technical experts, and in which recommendations were developed following shifts in evidence. Rather, changes were spurred by a country-level initiative, and a set of strategically framed arguments that resonated with funders and country-level actors. This bottom-up approach, supported by normative agencies, was transformative. For UNICEF, alignment between the organisation's country focus and the policy's underpinning values, enabled it to work with partners and accelerate widespread policy change.

Testing HIV positive in pregnancy: A phenomenological study of women's experiences

OBJECTIVE

globally women receive HIV testing in pregnancy; however, limited information is available on their experiences of this potentially life-changing event. This study aims to explore women's experiences of receiving a positive HIV test result following antenatal screening.

DESIGN

a qualitative, phenomenological approach.

SETTING

two public National Health Service (NHS) hospitals and HIV support organisations.

PARTICIPANTS

a purposive sampling strategy was used. Thirteen black African women with a positive HIV result, in England, participated.

METHODS

data were collected using in-depth semi-structured interviews. An interpretive phenomenological approach to data analysis was used.

FINDINGS

the emergent phenomenon was transition and transformation of 'being,' as women accepted HIV as part of their lives. Paired themes support the phenomenon: shock and disbelief; anger and turmoil; stigma and confidentiality issues; acceptance and resilience. Women had extreme reactions to their positive HIV diagnosis, compounded by the cultural belief that they would die. Initial disbelief of the unexpected result developed into sadness at the loss of their old self. Turmoil was evident, as women considered termination of pregnancy, self-harm and suicide. Women felt isolated from others and relationship breakdowns often occurred. Most reported the pervasiveness of stigma, and how this was managed alongside living with HIV. Coping strategies included keeping HIV 'secret' and making their child(ren) the prime focus of life. Growing resilience was apparent with time.

KEY CONCLUSIONS

this study gives midwives unique understanding of the complexities and major implications for women who tested positive for HIV. Women's experiences resonated with processes of bereavement, providing useful insight into a transitional and transformational period, during which appropriate support can be targeted.

IMPLICATIONS

midwives are crucial in improving the experience of women when they test HIV positive and to do this they need to be appropriately trained. Midwives need to acknowledge the social and psychological impact of HIV and pathways should be developed to support early referral for appropriate support.

Adrenal enzyme impairment in neonates and adolescents treated with ritonavir and protease inhibitors for HIV exposure or infection

BACKGROUND

Human deficiency virus (HIV) protease inhibitors (PIs) are widely used drugs whose effects are pharmacologically enhanced by ritonavir, a potent cytochrome P450 inhibitor. We reported previously that prophylactic postnatal ritonavir-PI therapy in HIV-exposed neonates was associated with increases in plasma 17-hydroxyprogesterone (17-OHP) and dehydroepiandrosterone sulfate (DHEA-S).

AIMS

To further investigate adrenal function in neonates and adolescents given ritonavir-PI.

METHODS

Adrenal function was assessed prospectively in 3 HIV-exposed neonates given short-term prophylactic treatment and 3 HIV-infected adolescents given long-term treatment. Plasma cortisol, 17-OHP, 17-OH-pregnenolone, DHEA-S, and androstenedione were measured before and after ACTH administration.

RESULTS

None of the patients had clinical signs of adrenal dysfunction. The only neonate exposed to ritonavir-PI in utero had up to 3-fold increases in plasma 17-OHP. Increases in 17-OH-pregnenolone of up to 3.1-fold were noted in 4 of the 6 patients, and all 6 patients had elevations in DHEA-S (up to 20.4-fold increase) and/or DHEA (up to 4.7-fold) and/or androstenedione (up to 5.2-fold). All these parameters improved after treatment completion.

CONCLUSION

Neonates and adolescents given ritonavir-PI exhibit a similar adrenal dysfunction profile consistent with an impact on multiple adrenal enzymes. These abnormalities require evaluation, given the potentially long exposure times.

Pregnancy outcomes of HIV-positive women in a tertiary centre in the UK

With the advent of highly active antiretroviral therapy (HAART), the mother-to-child HIV transmission rate in the UK has reduced to less than 2%. A review of delivery outcomes of 106 HIV-positive pregnant women in a tertiary centre between January 2005 and December 2010 was conducted. A total of 20 women had detectable plasma viral load at 36 weeks, or before in the two women who delivered preterm. Various peripartum management measures were undertaken in women with detectable viral load close to delivery, to accelerate reduction in plasma viral load and to reduce the risk of HIV transmission to the fetus. In our review, the overall mother-to-child transmission rate was less than 1% and in women with undetectable viral load at 36 weeks, it was 0% (zero), which signifies the importance of strict virological control and a multidisciplinary approach, which plays an important role in the successful achievement of this.

The potential for elimination of racial-ethnic disparities in HIV treatment initiation in the Medicaid population among 14 southern states

OBJECTIVES

The purpose of this study was to explore the racial and ethnic disparities in initiation of antiretroviral treatment (ARV treatment or ART) among HIV-infected Medicaid enrollees 18-64 years of age in 14 southern states which have high prevalence of HIV/AIDS and high racial disparities in HIV treatment access and mortality.

METHODS

We used Medicaid claims data from 2005 to 2007 for a retrospective cohort study. We compared frequency variances of HIV treatment uptake among persons of different racial- ethnic groups using univariate and multivariate methods. The unadjusted odds ratio was estimated through multinomial logistic regression. The multinomial logistic regression model was repeated with adjustment for multiple covariates.

RESULTS

Of the 23,801 Medicaid enrollees who met criteria for initiation of ARV treatment, only one third (34.6%) received ART consistent with national guideline treatment protocols, and 21.5% received some ARV medication, but with sub-optimal treatment profiles. There was no significant difference in the proportion of people who received ARV treatment between black (35.8%) and non-Hispanic whites (35.7%), but Hispanic/Latino persons (26%) were significantly less likely to receive ARV treatment.

CONCLUSIONS

Overall ARV treatment levels for all segments of the population are less than optimal. Among the Medicaid population there are no racial HIV treatment disparities between Black and White persons living with HIV, which suggests the potential relevance of Medicaid to currently uninsured populations, and the potential to achieve similar levels of equality within Medicaid for Hispanic/Latino enrollees and other segments of the Medicaid population.

Pre-eclampsia and gestational hypertension are less common in HIV infected women

OBJECTIVE

To determine whether pre-eclampsia and gestational hypertension are less common in HIV infected women.

METHODS

This prospective cohort study was performed in the Western Cape province of South Africa. HIV negative and positive pregnant women without chronic renal or chronic hypertensive disease were continuously recruited. During the study period HIV positive patients received either mono- or triple (HAART) antiretroviral therapy for prevention of vertical transmission or maternal care. Only routine clinical management was performed. The development of hypertensive disease during pregnancy was recorded.

RESULTS

1093 HIV positive and 1173 HIV negative cases were identified during pregnancy and evaluated again after delivery. Significantly fewer cases of pre-eclampsia n=35 (3.2%) were recorded in the HIV positive group than in the HIV negative group, n=57 (4.9%) (p=0.045; OR 0.65 95% CI 0.42-0.99). There were also significantly fewer cases of gestational hypertension recorded in the HIV positive group compared to the HIV negative group (p=0.026; OR 0.53 95% CI 0.30-0.94). Multiple logistic regression analysis confirmed the reductive effect of HIV on pre-eclampsia and gestational hypertension.

CONCLUSION

Pre-eclampsia and gestational hypertension are less common in HIV infected women being managed with mono- or triple anti-retroviral therapy.

When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery?

BACKGROUND

HAART dramatically reduces mother-to-child transmission of HIV allowing vaginal delivery if the viral load is low. This study provides data for the optimum timing of short-term HAART in pregnancy.

METHODS

Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, UK. Demographics, gestation, drug class, CD4 cell count, and viral load results were collated. Survival curves for reaching a viral load less than 50  copies/ml were stratified by initial HIV viral load. Cox's proportional hazards regression model was adjusted for demographics and immunovirological parameters.

RESULTS

Viral load was less than 50  copies/ml in 292 of 378 pregnancies (77.2%) by delivery. Pretreatment viral load was associated with the time taken, and the proportion achieving a viral load less than 50  copies/ml at (P≤0.001). When baseline viral load was less than 10 ,000  copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was more than 10 ,000  copies/ml, deferring HAART past 20.4 weeks reduced the probability of reaching less than 50  copies/ml by delivery (P=0.011). When baseline viral load was more than 100, 000  copies/ml the likelihood of reaching a viral load of less than 50  copies/ml was low (37%: hazard ratio 0.31), and dependent on the length of time on HAART. The hazard ratio for a nonnucleoside reverse transcriptase inhibitor regimen achieving a viral load less than 50  copies/ml compared with a protease inhibitor was 0.7 (95% confidence interval 0.52-0.94).

CONCLUSION

With a viral load more than 10, 000  copies/ml and especially with a viral load more than 100 ,000  copies/ml, the probability of achieving either less than 50 copies/ml by the time of delivery is compromised by delaying initiation of short-term highly active antiretroviral therapy beyond 20.4 weeks gestation. Current UK and other guidelines for when to commence START may therefore limit the chance of vaginal delivery.

A Paradigm Shift in the Epidemiology of HIV in Pregnancy at ICTC of a Medical College

OBJECTIVES

To study the present status and effect of paradigm shift in the epidemiology of HIV amongst pregnant women in urban set up.

AIMS

The purpose of the study is to evaluate the paradigm shift in overall screening and management strategy of HIV in antenatal women for last four and half years in an urban medical college.

METHODS

The study was conducted from 1st January 2004 to 30th June 2008 and all registered and unregistered pregnant women who attended ICTC clinic and also for emergency admission (unregistered) were counseled and blood samples were tested as per NACO guidelines with cafeteria choice of opt in and opt out strategy. Reactive women in antenatal period were counseled and discussed about anti-retroviral therapy (ART) and universal treatment regime. Seroprevalent women were counseled about their spouse, personal habits and demographic status. Marked improvement was seen in the use of contraceptive and drug abuse. During labor mother and baby were given nevirapine as per NACO guidelines.

RESULTS

The seroprevalence of HIV reactive women in our Centre was 0.23, 0.19, 0.14 and 0.12% in the year 2004, 2005, 2006, 2007 and zero prevalence in 2008 till date. Spouse positivity was noted in 80, 58.33, 72.72 and 70% in the set period from 2004 to 2008.

CONCLUSION

Marked improvement was noticed in all the strategic points from registration, counseling, screening and availability of improved diagnostic kits for screening HIV 1 and HIV 2.

Use of neonatal post-exposure prophylaxis for prevention of mother-to-child HIV transmission in the UK and Ireland, 2001-2008

OBJECTIVES

To investigate changing clinical practice with regard to antiretroviral post-exposure prophylaxis (PEP) and factors associated with the use of combination prophylaxis in infants born to HIV-infected women in the UK and Ireland.

METHODS

Surveillance of obstetric and paediatric HIV infection in the UK and Ireland is conducted through the National Study of HIV in Pregnancy and Childhood. Infants born to HIV-infected women between 2001 and 2008 were included in the study.

RESULTS

Ninety-nine per cent of infants (8155 of 8205) received antiretroviral prophylaxis; 86% of those with information on type of prophylaxis (n=8050) received single, 3% dual and 11% triple drug prophylaxis. Among those who received prophylaxis, use of triple prophylaxis increased significantly between 2001-2004 and 2005-2008, from 9% (297 of 3243) to 13% (624 of 4807) overall (P<0.001); from 43% (41 of 95) to 71% (45 of 63) in infants born to untreated women; and from 13% (114 of 883) to 32% (344 of 1088) where mothers were viraemic despite highly active antiretroviral therapy (HAART) in pregnancy. In multivariable analysis, factors associated with receipt of triple prophylaxis included later time period, shorter duration or lack of antenatal antiretroviral therapy, receipt of antiretroviral drugs during labour, detectable maternal viral load, CD4 count<200 cells/μL in pregnancy, preterm delivery (<37 weeks) and unplanned (emergency caesarean or vaginal) delivery.

CONCLUSION

Between 2001 and 2008, almost all infants born to HIV-infected women in the UK and Ireland received antiretroviral PEP, mostly with one drug. Use of triple PEP increased over time, particularly for infants whose mothers were untreated or viraemic despite HAART, in line with current guidelines.

Urologic aspects of HIV infection

Although lifespan has dramatically improved in the human immunodeficiency virus-positive (HIV+) population, HIV and its treatment continue to be a source of substantial morbidity in many organ systems, including the genitourinary tract. As the number of long-term survivors increases with advances in antiretroviral therapy, age-associated urologic symptoms are also becoming increasingly relevant considerations for people living with HIV. Primary care physicians have a major role to play in maintaining the genitourinary health of their HIV+ patients. This role is of great importance not just for the well-being of the individual patient but for the public health, as the genitourinary tract is a common vector for HIV transmission. In this article the authors review the management of the genitourinary system in patients with HIV infection. Particular consideration is given to urinary tract infections, lower urinary tract symptoms, renal insufficiency, sexual and fertility problems, and cancers of the genitourinary tract. Management algorithms are outlined and indications for referral to a urologist are emphasized.

Effects of gender on the health and development of medically at-risk infants

OBJECTIVES

To examine gender-differentiated health and cognitive/motor/language developmental outcomes among medically at-risk infants.

DESIGN

Longitudinal descriptive and comparative secondary analysis.

SETTING

Neonatal Intensive Care Unit, intermediate care unit, and infectious disease clinic of tertiary medical centers in the southeast and east United States.

PARTICIPANTS

One hundred eight (108) premature infants, 67 medically fragile infants, and 83 infants seropositive for HIV.

METHODS

Neonatal and later health variables were obtained from the medical record to determine the technology dependence scores and frequency of common health problems. Data for physical growth and cognitive/motor/language development were obtained through the physical measurement, including the Bayley Scales of Infant Development-Second Edition, the Vineland Adaptive Behavior Scale, the Toll Control Developmental Checklist, and the Preschool Language Scale-3 during home visits between 6 and 27 months corrected ages.

RESULTS

Fewer effects on health and developmental outcomes related to gender were observed with medically fragile infants than the other two groups of infants. The cognitive/motor/language scores were decreased with increasing age of the infants in all groups.

CONCLUSION

Male gender can be considered a significant biological risk factor for infants' cognitive and motor development, especially for premature infants. Because of their increased risk, it is recommended that male infants who are born prematurely or seropositive for HIV have early and advanced developmental screening tests by trained personnel through periodic pediatric clinic.

Short-term antiretroviral therapy to prevent mother-to-child transmission is safe and results in a sustained increase in CD4 T-cell counts in HIV-1-infected mothers

BACKGROUND

Short-term antiretroviral therapy (START) to prevent mother-to-child transmission (MTCT) is currently recommended for all HIV-1-infected pregnant women. The objective of this study was to assess the effect on CD4 cell counts and viral load dynamics the withdrawal of START after birth could generate.

METHODS

This was a 5-year cohort study involving HIV-1-infected pregnant women who presented with CD4 counts >300 cells/microL and had received START to prevent MTCT.

RESULTS

Seventy-five pregnancies were assessed. In 24 cases, there was a history of antiretroviral therapy prior to prophylaxis. The median baseline CD4 count was 573 cells/microL. In 75% of cases, prophylaxis was started after 26.6 weeks of gestation. The median CD4 cell count increase over baseline during prophylaxis was 24.5%. In only five cases did HIV-1 viral load remain detectable during prophylaxis. After START, CD4 cell counts did not drop significantly, and the HIV-1 viral load plateau was near the baseline level. The estimated mean time for CD4 count to fall below 300 cells/microL was 3.5 years and was directly associated with high baseline CD4 cell count, as well as with CD4 increase after prophylaxis, whereas it was negatively correlated with previous use of antiretroviral (ARV) drugs and persistence of detectable HIV-1 viral load during prophylaxis.

CONCLUSIONS

A potent, well-tolerated prophylactic ARV regimen can improve CD4 cell counts during and after START. In women receiving such prophylaxis, there is a remarkable time interval for CD4 cell counts to drop to levels that indicate treatment.

Is pre-eclampsia less common in patients with HIV/AIDS?

HIV/AIDS and pre-eclampsia are very important diseases in developing countries. There is uncertainty as to whether HIV lowers the rate of pre-eclampsia. As existing studies are either small or retrospective, there exists the need for a prospective study of sufficient size to bring clarity to this matter.

Pregnant women with HIV infection can expect healthy survival: three-year follow-up

OBJECTIVES

To document postpartum disease-free survival of HIV-infected women taking antiretroviral therapy (ART) during pregnancy.

METHODS

Laboratory and clinical data were collected on all HIV-infected pregnant women delivering from 1998 to 2002 and followed up until September 2004 at 6 hospitals in London. Mothers were grouped according to receipt of zidovudine monotherapy (ZDVm), highly active antiretroviral therapy (HAART) given during and continued after pregnancy (cHAART), and short-term HAART given during pregnancy and discontinued on delivery (START).

RESULTS

Eight-five women took ZDVm, 155 took cHAART, and 71 took START. The mean follow-up for all mothers was 33 months, with a total of 847 person-years. At the first antenatal clinic (ANC) visit, 72% of women were in Centers for Disease Control and Prevention (CDC) stage A, 85% were treatment naive, and the ZDVm group had a median HIV viral load (VL) 10-fold less than those mothers who started HAART during pregnancy. At last follow-up, 1 patient had died and 6 (1.9%) had progressed to CDC stage C; 62% of all women, including a quarter of the ZDVm group, were receiving HAART for their own health; and 83% of all mothers had a VL <50 HIV RNA copies/mL of plasma regardless of whether they were on treatment or not.

CONCLUSIONS

The median-term postpartum prognosis of HIV-infected pregnant women with access to HAART is good. Exposure to short-course ZDVm or START during pregnancy did not jeopardize their response to subsequent therapy.

Prevention of mother-to-child transmission of HIV: treatment options

Mother-to-child transmission of HIV-1 is responsible for 1800 new infections in children daily. The use of antiretroviral therapy can significantly reduce the risk of transmission. In settings where highly active antiretroviral therapy is available, mother-to-child transmission rates have been reduced to less than 2%, in the absence of breastfeeding. Women who require ongoing highly active antiretroviral therapy for their own health should receive this in pregnancy, which is also very effective in preventing transmission. Where resources allow, combination highly active antiretroviral therapy can also be used for preventing mother-to-child transmission in those women who do not yet need to receive ongoing treatment. The potential side effects of highly active antiretroviral therapy must be considered in pregnant women and their infants. Where highly active antiretroviral therapy is not possible, a dual combination regimen of antepartum zidovudine with single-dose nevirapine to mother and baby can reduce transmission to below 5%. In many places, the only available option is single-dose nevirapine to mother and baby, which is effective in halving transmission risk, although the effectiveness in practice will be influenced by continued infection through breastfeeding, and by program factors such as the uptake of HIV testing. Exposure to nevirapine for mother-to-child transmission prevention can select for resistant virus in the majority of women. While the long-term implications of this are not completely clear, this selection can be reduced by the addition of short courses of postpartum zidovudine and lamivudine.

National review of maternity care for women with HIV infection

OBJECTIVE

To assess adherence to the British HIV Association (BHIVA) 2001 guidelines for the management of HIV-infected pregnant women.

METHODS

A survey and a case note review were carried out using structured questionnaires sent to providers of adult HIV care in the UK and Ireland. Participants were women with HIV infection who delivered a live or stillborn infant between October 2002 and September 2003. The main outcome measures were the appropriate use of antiretroviral therapy, the use and timing of elective Caesarean section, and support for the avoidance of breast-feeding.

RESULTS

Of 186 centres, 100 (54%) responded with data on 501 eligible pregnancies.

CONCLUSIONS

In general, practice was in accordance with the BHIVA 2001 guidelines. However, in a number of cases Caesarean sections were planned later than the recommended 38 weeks.

Human immunodeficiency virus infection and fertility care in the United Kingdom: demand and supply

OBJECTIVE

To collect data on the demand and provision of fertility care in HIV-infected couples in the United Kingdom and data on the etiology of subfertility in this population.

DESIGN

A postal questionnaire survey and audit of causes of infertility in HIV-infected women.

SETTING

Seventy-four Human Embryology and Fertilisation Authority-registered assisted conception units (ACUs) and 294 genitourinary medicine (GUM) clinics in the United Kingdom were sent questionnaires.

PATIENT(S)

Sixty-five HIV-infected women attending the Research Clinic at the Chelsea and Westminster ACU.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Number of ACUs treating HIV-infected patients and number of GUM clinics receiving requests for referral, as well as the etiology of subfertility in HIV-infected women attending our clinic.

RESULT(S)

Response rates from ACUs and GUM clinics were 93% and 63%, respectively. Fourteen ACUs (20%) were treating HIV-infected men; of these, seven (10%) performed sperm washing, but only two (3%) tested sperm for HIV after processing, before use. Nine units (13%) treated HIV-infected women, but only three ACUs (4%) had separate laboratories for handling potentially infected gametes or embryos. Of the 15,211 patients registered in 81 GUM clinics, 4% of the men and 16% of the women had requested advice on conceiving. An audit of the Chelsea and Westminster HIV fertility clinic demonstrated a 40% prevalence of tubal factor infertility in HIV-infected women.

CONCLUSION(S)

Demand is high, and set to increase, but current suboptimal practice in some centers is placing unaffected partners and the unborn child at risk of seroconversion.

Progress and Emerging Challenges in Preventing Mother-to-Child Transmission

There is a widening gulf between the effectiveness of interventions for preventing mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa and other regions of the world. Compared with long-course, triple antiretroviral regimens used in Brazil, Europe, and the United States, most countries in sub-Saharan Africa use a less effective regimen consisting of single-dose nevirapine (NVP). Furthermore, the documentation of unacceptable levels of resistance following this regimen makes it prudent to review current PMTCT strategies. Not only is it necessary to review the use of single-dose NVP for PMTCT, but efforts to minimize breast milk transmission of HIV should be enhanced. This review summarizes the programmatic and evidence-based reasons for adopting a standardized approach to long-course, triple-drug MTCT prophylaxis in sub-Saharan Africa. Antiretroviral treatment programs in resource-constrained settings have achieved similar levels of effectiveness as high-income countries, despite adopting standardized approaches to antiretroviral treatment. Similarly, in resource-constrained settings with adequate infrastructure and programmatic capacity, use of standardized, long-course, triple-drug regimens for MTCT prevention are likely to achieve levels of effectiveness seen in Brazil, Europe, and the United States.

Diagnoses of HIV-1 and HIV-2 in England, Wales, and Northern Ireland associated with west Africa

OBJECTIVES

To describe HIV diagnoses, including those of HIV-2 infection, made in England, Wales, and Northern Ireland (E,W&NI) among those probably infected in west Africa, and to consider whether there is evidence for ongoing heterosexual transmission within the United Kingdom.

METHODS

Reports of new HIV diagnoses received at the Communicable Disease Surveillance Centre were analysed. Individuals probably infected in west Africa and those infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa were included.

RESULTS

Between 1985 and 2003 inclusive, 1324 individuals diagnosed and reported with HIV had probably been infected in west Africa, with 222 diagnoses made in 2003. 917 (69%) were HIV-1 infected and 52 (6%) HIV-2 or HIV-1/HIV-2 co-infected. For 355 (27%) the HIV type was not reported. The proportion of HIV-2 and HIV-1/HIV-2 infections varied by country of infection (p<0.001): ranging from the Gambia (11.7%-15.2%) to Nigeria (0.7%-1.0%). A further 130 individuals were probably infected through heterosexual intercourse within the United Kingdom by a heterosexual partner infected in west Africa. 89 (68%) were HIV-1 infected and three (2%) HIV-2 infected or HIV-1/HIV-2 co-infected. For 38 (29%) HIV type was not reported.

CONCLUSION

The number of people infected with HIV in west Africa and diagnosed in E,W&NI has increased in recent years, and there is evidence of heterosexual transmission within the United Kingdom from people infected in west Africa. While numbers of HIV-2 diagnoses remain relatively low, an appreciable proportion of people infected in some west African countries and diagnosed in the United Kingdom may be HIV-2 positive, with implications for prognosis and treatment.

REVIEW: Preventing mother-to-child transmission of HIV: successes and challenges

Mother-to-child transmission of HIV continues to be a major cause of infant morbidity and mortality in resource-poor settings. Intrapartum and postpartum nevirapine-based regimens have been introduced in many settings. New research has shown that better efficacy can be achieved with the addition of single-dose nevirapine to short course zidovudine regimens, and that selection of nevirapine-resistant virus can be reduced with a short postpartum combination antiretroviral cover. Women who need antiretroviral therapy for their own health should receive it in pregnancy, and access for pregnant women needs to be expanded urgently. The reduction of transmission through breastfeeding remains a challenge.

Laboratory safety during assisted reproduction in patients with blood-borne viruses

For couples where one or both partners are infected with human immunodeficiency virus or hepatitis C, the doors to receiving fertility care are opening as a result of better antiviral medication, better long-term prognosis and consequent changes in attitude. In line with this, fertility centres electing to treat couples with blood-borne viral (BBV) infection need to re-examine their policies and procedures to ensure the safety of their staff and both non-infected and infected patients during assisted reproduction treatments. At a time when the European Tissue Directive aims to introduce quality standards for assisted reproduction throughout Europe, we highlight the risks involved when treating patients with known BBV infections and argue that safety cannot be met with any certainty unless samples from such patients are handled within a separate high security laboratory or laboratory area, technically adapted to ensure minimal cross-contamination risk to uninfected gametes and embryos.

Failure of serial human immunodeficiency virus type 1 DNA polymerase chain reactions to identify human immunodeficiency virus type 1 clade A/G

The most commonly used test to screen for human immunodeficiency virus type 1 (HIV-1) infection in HIV-exposed infants in the United States is HIV-1 qualitative DNA polymerase chain reaction (PCR). However, the commercially available HIV-1 DNA PCR lack optimal sensitivity to detect non-subtype B subtypes of HIV-1. We report here HIV-1 infection in a West African infant that went undetected by serial HIV-1 DNA PCR tests.

Assessment of welfare of the child in HIV positive couples

BACKGROUND

Demand for assisted conception amongst HIV-infected couples is rising in parallel with increased efficacy of antiretroviral medication which has improved life expectancy and reduced vertical transmission risk. There are no published data on welfare of the child assessment in HIV positive couples undergoing assisted conception.

METHODS

We assessed welfare of the child in 131 (i.e. total number seen, not treated) couples, where one or both partners were infected with HIV and referred to the infertility clinic at Chelsea and Westminster Hospital since 1999. In total, 59 couples received sperm washing treatment (male partner infected) resulting in 17 healthy babies, and 14 couples were treated in the female positive programme (5 concordant and 9 discordant for HIV) resulting in three healthy babies.

RESULTS

Issues surrounding welfare of the child were commonly encountered in this series and were significant enough to withhold treatment in five cases. Many were relationship issues surrounding acquisition of infection, fear of infection in the negative partner or child (n = 1), poor prognosis (multiple drug resistance) (n=3) or disability related to infection (n = 1).

CONCLUSIONS

Welfare of the child in HIV infected couples must be carefully considered in specialist centres with experienced counsellors. Issues surrounding treatment are complex and require close liaison with HIV specialists and involvement of the couple.

Eligibility of overseas visitors and people of uncertain residential status for NHS treatment

Current UK regulations deny free treatment for HIV to illegal immigrants and failed asylum seekers. Is this policy resulting in unjustifiable harm to infants who are born to infected mothers?

A pilot study to evaluate the safety and feasibility of the administration of AZT/3TC fixed dose combination to HIV infected pregnant women and their infants in Rio de Janeiro, Brazil

OBJECTIVES

To evaluate the safety and feasibility of zidovudine and lamivudine (AZT/3TC) given to HIV infected pregnant women and their infants in Rio de Janeiro, Brazil.

METHODS

This open label phase II study enrolled 40 HIV infected antiretroviral naive women >or=20 weeks gestation, CD4 <500 cells x10(6)/l, from two public hospitals.

TREATMENT

fixed dose AZT 300 mg/3TC 150 mg by mouth every 12 hours until labour; AZT 300 mg by mouth every 3 hours until delivery; infants: AZT 4 mg/kg every 12 hours plus 3TC 2 mg/kg every 12 hours for 6 weeks. Blood haematology and chemistry were monitored; adherence evaluated by pills count; efficacy measured by changes in lymphocyte (CD4) and viral load, and by HIV RNA-PCR tests performed at birth, 6 and 12 weeks, to diagnose infant infection. No women breast fed.

RESULTS

PATIENT CHARACTERISTICS

mean age 24.48 (SD 3.5) years; gestational age 24.5 (4.5) weeks; AZT/3TC duration 14.4 (4.4) weeks; vaginal delivery: 11/39; caesarean section: 28/39. Entry and pre-labour CD4: 310/486 cells x10(6)/l (p<0.001); entry and pre-labour viral load: 53 818/2616 copies/ml (p<0.001). Thirty nine women tolerated treatment with >80% adherence; one was lost to follow up. Five newborns were excluded from 3TC receipt. All 39 babies were uninfected. Haematological toxicity in newborns was common: anaemia in 27; neutropenia in five (two severe); platelets counts <100000 in two. All values recovered on study completion.

CONCLUSIONS

Fixed dose AZT/3TC is well accepted, gives improvements in CD4 and viral load; no infants were HIV infected. Haematological toxicity in infants needs careful monitoring.

Drug resistance is uncommon in pregnant women with low viral loads taking zidovudine monotherapy to prevent perinatal HIV transmission

Zidovudine monotherapy is used to reduce perinatal HIV transmission in women with low viral loads. There are few data on the risk of drug resistance in this select cohort of women. We determined the prevalence of newly acquired mutations conferring reduced sensitivity to zidovudine after exposure during pregnancy, and found that the development of mutations was uncommon and was restricted to women treated before 1998 who had higher baseline viral loads than those currently recommended monotherapy.

Characteristics of HIV-infected women who do not receive preventive antiretroviral therapy in the French Perinatal Cohort

OBJECTIVE

To determine the percentage and the profile of women with known HIV-1 seropositivity who do not receive the prepartum phase of preventive treatment for maternofetal transmission.

METHODS

An observational study was conducted as part of the French Perinatal Cohort, an ongoing nationwide cohort of HIV-infected women and their children (followed from birth). This analysis was restricted to women who were delivered between 1996 and 1999.

RESULTS

Among the 2167 women studied, 92 (4.3%) did not receive the prepartum phase of preventive treatment. This proportion fell below 10% in 1996 and subsequently stabilized at 3% to 4%. The reasons for nontreatment were the woman's refusal (34%), premature delivery (8%, before initiation of planned treatment), late diagnosis of maternal HIV infection (3%, at the time of delivery), or unmonitored pregnancy (54%). One third of the women in this latter category were aware of their seropositivity before becoming pregnant. Treated and untreated women did not differ in terms of the usual parameters of HIV infection, geographic origin (sub-Saharan Africa vs. Europe), or HIV transmission category (sexual vs. intravenous [IV] drug use). Untreated women were also less likely than treated women to receive other preventive measures such as intrapartum IV zidovudine infusion, treatment of the newborn, and formula feeding. Indirect evidence strongly suggested that the untreated women were socially marginalized.

CONCLUSIONS

The prepartum phase of preventive treatment for maternofetal transmission is well accepted by HIV-seropositive women in France. The proportion of women who do not receive this treatment could be further reduced by earlier screening (before or at the beginning of pregnancy) and by focusing on a small subgroup of socially marginalized women.

Low Rate of Mother-to-Child Transmission of HIV-1 After Nevirapine Intervention in a Pilot Public Health Program in Yaound??, Cameroon

OBJECTIVE

To determine the percentage of infected children for whom nevirapine (NVP) was used to prevent peripartum mother-to-child transmission (MTCT) of HIV in Yaoundé, Cameroon.

DESIGN

The study was a prospective Public Health Pilot Program covering a 3-year period (January 2000-December 2002).

METHODS

Counseled and consenting HIV-1-positive pregnant women were given a single dose of NVP at the onset of labor. Babies were given 2 mg/kg NVP syrup within the first 72 hours of life. NVP-treated children were regularly followed up and examined for HIV-1 infection at 6-8 weeks and 5-6 months through plasma viral load (VL) quantification with the bDNA system.

RESULTS

One hundred twenty-three children were diagnosed with perinatal HIV-1 infection at 6-8 weeks and 5-6 months. Thirteen children (10.6% [13/123]; 95% confidence interval, 5.1-16) were infected and presented with high VLs, in general >500,000 copies/mL. Two children had intermediate VLs (between 50 and 3500 copies/mL) at both time points. One hundred seven children (87%) were considered not infected at 6-8 weeks of age.

CONCLUSIONS

Our results indicate that the HIV-1 MTCT rate 6-8 weeks after NVP administration was not >13% (16/123), thus demonstrating the effectiveness of NVP for lowering the risk of HIV-1 MTCT in real-life settings.

[The HIV infection in pregnant women in French Guiana]

OBJECTIVE

The aim of this study is to analyse the characteristics of HIV pregnant women in French Guiana then to evaluate the HIV mother to child transmission rate (MTCT) and determine the pronostic factors associated with MTCT.

PATIENTS AND METHOD

An epidemiological study has been led including all deliveries in French Guiana from January 1998 to December 2000. For each case a standardized questionnaire has been gathered including epidemiological, clinical and biological data and an univariate analysis has been realized. A hundred and forty-eight women have been included in the study among 135 women came for delivery.

RESULTS

The factors associated with increased MTCT in our study were no antiretroviral therapy before delivery, the lack of follow-up during pregnancy and no antiretroviral therapy in children. The HIV mother to child transmission rate was 6,5% despite the availability of antiretroviral therapies.

DISCUSSION AND CONCLUSION

This rate may be explained by the difficulties of follow-up in HIV infected women. Much more needs to be done to improve access to care for women coming from foreign countries. This may be indispensable to reduce the HIV mother to child transmission rate in French Guiana.

Zidovudine: a review of its use in the management of vertically-acquired pediatric HIV infection

Zidovudine is a thymidine analog that, after intracellular phosphorylation to zidovudine triphosphate metabolite, inhibits HIV-specific reverse transcriptase and terminates proviral DNA. Zidovudine administered to mildly symptomatic women with HIV infection in the antepartum (100mg orally 5 times/day), intrapartum (2 mg/kg intravenously over 1 hour then 1 mg/kg/h) and then to the neonate for 6 weeks (2 mg/kg), significantly reduced the rate of vertical HIV transmission by about two thirds, in the absence of breast-feeding (The Pediatric AIDS Clinical Trials Group 076 trial, standard protocol). Shorter zidovudine regimens, reduced the risk of transmission of HIV by 50% in a non-breast-feeding population and by about 37% in breast-feeding populations. Zidovudine (standard protocol) in combination with lamivudine was superior to zidovudine alone. A short oral zidovudine regimen was not as effective as a two-dose oral nevirapine regime, although the combination of short-course zidovudine plus lamivudine was as effective. Suppression of viral replication in neonates, infants and children has been achieved with zidovudine when used in triple-therapy regimens that include other antiviral drugs. Results from a trial of treatment-naive children indicate that the antiviral efficacy of combinations of zidovudine and lamivudine or abacavir, given with the protease inhibitor nelfinavir, is superior to treatment with this combination minus nelfinavir. When zidovudine was used in other highly active antiretroviral therapy regimens significant improvements in surrogate markers were consistently seen. Changing to ritonavir-containing regimens was superior to changing to treatment with two new nucleoside reverse transcriptase inhibitors. Short- and long-term (up to 5.6 years) outcomes from clinical trials showed that prenatal and neonatal exposure to zidovudine was generally well tolerated with the exception of mild anemia that resolved spontaneously after treatment cessation. Zidovudine was generally well tolerated as monotherapy in clinical trials of pediatric patients with HIV infection, and adverse events were similar to those reported in adults, with anemia and neutropenia being the most common.

CONCLUSION

Zidovudine, as monotherapy or in combination with other antiretroviral agents, remains a first-choice therapy for the prophylaxis of mother-to-child HIV transmission as shown by substantial reductions in transmission rates. Where feasible, the optimal strategy to prevent vertical transmission is to combine drug therapy with Cesarean section delivery and no breast-feeding. In addition, zidovudine in combination with another nucleoside analogue and a protease inhibitor is a first- or second-choice therapy for the treatment of pediatric HIV infection as significant and sustained reductions in viral load have been shown in both plasma and cerebrospinal fluid.

The evolving art of caring for pregnant women with HIV infection

Care for the pregnant woman who has human immunodeficiency virus (HIV) is highly complex and constantly evolving. The purpose of this article is to describe the pertinent issues regarding women and HIV during pregnancy, including epidemiology of mother-to-child transmission, the effect of the disease on pregnancy, care issues in the perinatal period, and the issues in women's lives that place them at risk for HIV infection. Antiretroviral therapy offers significant reduction in the rate of mother-to-child transmission, and this is presently the cornerstone of therapy for the pregnant woman with HIV. Careful intrapartum management may also reduce the risk of transmission. Clinical studies of treatment modalities continue to offer new hope to prevent transmission of the virus to the fetus.

Pre-eclampsia, antiretroviral therapy, and immune reconstitution

Antiretrovirals are standard treatment for HIV-1-positive women during pregnancy in the UK, but little is known about maternal or fetal safety. In our cohort study of 214 pregnant women with HIV-1 infection, those who received no antiretroviral therapy had a rate of pre-eclampsia significantly lower (none of 61) than those on triple antiretroviral therapy (8 of 76; odds ratio 15.3, 95% CI 0.9-270, p=0.0087). However, the rate of pre-eclampsia in HIV-1-positive women on treatment did not differ from that in uninfected controls (12 of 214; p=0.2). The association of HIV-1-related immune deficiency with a low rate of pre-eclampsia, and the restoration of this rate in women treated with triple antiretroviral therapy to the expected rate indicates a pivotal role of the immune system in the pathogenesis of pre-eclampsia. The clinical presentation of pre-eclampsia and toxic effects of antiretroviral therapy could overlap and complicate diagnosis and management in these patients.