Reducing mother-to-infant transmission of HIV -- the door remains open

Neonatal HIV infection

The purpose of this article is to describe the pertinent issues related to mother-to-child transmission of HIV infection. Significant succcss has been achieved in developed countries to reduce the incidence of this devastating disease in neonates through screening of pregnant women, maternal antiretroviral therapy to reduce transmission, and cesarean section for delivery. Prophylaxis continues for the first six weeks of the newborn's life with antiretroviral therapy and careful monitoring of clinical well-being. Antiretroviral therapy offers significant reduction in the rate of mother-to child transmission, and this is presently the cornerstone of therapy for the HIV-infected pregnant woman. Clinical studies of treatment modalities continue to offer new hope to prevent transmission of the virus to the fetus. Care for the HIV infected newborn is highly complex and constantly evolving. All neonatal nurses should be aware of these issues so that they can be partners in the identification of new cases and the ongoing treatment of babies who are infected.

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.

Perception of voluntary screening for paediatric HIV and response to post-test counselling by Nigerian parents

Nigeria may be taken to represent countries with an evolving HIV/AIDS epidemic. With particular reference to paediatric HIV, the voluntary testing of young children and their parents may provide an important entry point for the institution of control measures. However, there is a paucity of knowledge about how individuals perceive voluntary testing. This knowledge is important to the development of guidelines for counselling. To reduce this gap, 258 parents of hospitalized children (> 1 month to 15 years of age) were interviewed using a structured questionnaire. In addition, to complement the data, four examples of seropositive mother's responses during post-test counselling are presented and analyzed. In the survey, 223 (86%) parents were HIV/AIDS aware but only 88 (39%) of these parents could describe one or more route(s) of transmission and none described vertical transmission. Among the respondents, 153 (62%) of 248 would consent to the screening of self, and 195 (85%) of 230 to the screening of a hospitalized child if based on his/her clinical condition. Perceptions of good health and lack of exposure, and despair owing to lack of a specific treatment, were the common reasons for refusing consent. These represent some of the issues which would need to be addressed to increase the acceptance of voluntary testing. The fear of a break up of families with seropositive mothers but seronegative fathers was a major concern expressed during post-test counselling. HIV-discordance among couples may be frequent and should be considered in the formulation of policies on counselling and voluntary testing.

Impact of zidovudine use on risk and risk factors for perinatal transmission of HIV. Perinatal AIDS Collaborative Transmission Studies

OBJECTIVES

To evaluate the impact of perinatal zidovudine use on the risk of perinatal transmission of HIV and to determine risk factors for transmission among women using perinatal zidovudine.

DESIGN

Prospective cohort study of 1533 children born to HIV-infected women between 1985 and 1995 in four US cities.

METHODS

The association of potential risk factors with perinatal HIV transmission was assessed with univariate and multivariate statistics.

RESULTS

The overall transmission risk was 18% [95% confidence interval (CI), 16-21]. Factors associated with transmission included membrane rupture > 4 h before delivery [relative risk (RR), 2.1; 95% CI, 1.6-2.7], gestational age < 37 weeks (RR, 1.8; 95% CI, 1.4-2.2), maternal CD4+ lymphocyte count < 500 x 10(6) cells/l (RR, 1.7; 95% CI, 1.3-2.2), birthweight < 2500 g (RR, 1.7; 95% CI, 1.3-2.1), and antenatal and neonatal zidovudine use (RR, 0.6; 95% CI, 0.4-0.9). For infants exposed to zidovudine antenatally and neonatally, the transmission risk was 13% overall but was significantly lower following shorter duration of membrane rupture (7%) and term delivery (9%). The transmission risk declined from 22% before 1992 to 11% in 1995 (P < 0.001) in association with increasing zidovudine use and changes in other risk factors.

CONCLUSIONS

Perinatal HIV transmission risk has declined with increasing perinatal zidovudine use and changes in other factors. Further reduction in transmission for women taking zidovudine may be possible by reducing the incidence of other potentially modifiable risk factors, such as long duration of membrane rupture and prematurity.

HIV screening for pregnant women in south eastern France: evolution 1992-1994-1996

OBJECTIVES

To assess the evolution of the HIV screening practices towards pregnant women between 1992 and 1996, in relation with the 1993 French mandatory obligation to offer prenatal HIV testing and recent therapeutic possibilities to reduce HIV vertical transmission.

STUDY DESIGN

Three successive surveys (January 1992, May 1994 and May 1996) about HIV screening policies among medical chiefs of all prenatal care and abortion departments of South Eastern France. Sixty-seven of the 74 departments concerned agreed to participate in the three surveys.

RESULTS

The proportion of departments practising routine prenatal HIV screening had not increased since 1992 (89%) but systematic women's consent is more often requested (65.5 vs. 38.2%, P < 0.01). In the context of abortion, HIV testing is more often routinely offered (38.1 vs. 16.4%, P < 0.05) but selective screening remains a frequent practice (29.1%).

CONCLUSION

Mandatory proposal of HIV testing to women who terminate could improve access to test but is not sufficient to guarantee adequate preventive counselling.

Acceptability and impact of zidovudine for prevention of mother-to-child human immunodeficiency virus-1 transmission in France

We studied the propagation and the impact of zidovudine prevention on the human immunodeficiency virus-1 transmission rate from infected mothers to their infants in the French nationwide prospective cohort. Infection was diagnosed in the children on the basis of at least two positive human immunodeficiency virus-1 polymerase chain reaction tests, culture, or both. The transmission rate among treated women was compared with that among untreated women during the same period and with that among women enrolled in the cohort since 1986. The impact of zidovudine was analyzed according to the women's clinical and biologic characteristics, the mode of delivery, and use of zidovudine therapy before the pregnancy. Nearly 90% of women were treated as soon as the second half of 1994. In 1994 and 1995, 80% of mother-child pairs received at least one of the three phases of preventive treatment. Among the 663 mothers enrolled during these 2 years, only six refused the treatment. Zidovudine treatment was associated with a reduction in the transmission rate of nearly two-thirds, from 14% +/- 6% to 5% +/- 2% (p < 0.01). The degree of reduction was not influenced by the maternal CD4+ cell count or p24 antigenemia at delivery. Zidovudine treatment of the mother before the pregnancy considerably reduced the impact of preventive therapy; the transmission rate was significantly higher among pretreated mothers (20% versus 5%, p < 0.01) even after adjusting for maternal CD4+ cell count. Zidovudine prevention is now widely used in France and has had a major impact on the epidemiology of mother-child human immunodeficiency virus transmission. This justifies a policy of offering human immunodeficiency virus screening to all women before or shortly after the diagnosis of pregnancy.