The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1--a meta-analysis of 15 prospective cohort studies

Preventing perinatal HIV acquisition; current gaps and future perspectives

PURPOSE OF REVIEW

Although current treatment could eradicate vertical transmission, in 2022, 130 000 infants acquired HIV globally. HIV suppression with antiretroviral therapy (ART) transforms survival for people living with HIV (PLWH), and prevents transmission, including vertical. International guidelines recommend lifelong ART for PLWH, consequently perinatal HIV acquisition reflects implementation gaps in the HIV care cascade. We summarize these gaps, exploring potential novel approaches and therapeutic innovations towards eliminating vertical HIV transmission.

RECENT FINDINGS

Multifactorial challenges continue to underpin gaps in the HIV care cascade, including accessibility, availability and sustainability of HIV testing, prevention and treatment, alongside stigma, gender-based violence and poverty. Long-acting ART may be important in preventing perinatal HIV acquisition, with early data demonstrating tolerability and efficacy of injectable ART throughout pregnancy, both as HIV treatment and prevention. Carefully selected long-acting broadly neutralizing antibodies (bNAbs) matching circulating, exposing viral envelope sequences have demonstrated safety, clinical trials are ongoing to demonstrate efficacy.

SUMMARY

Emerging clinical studies should prioritize pregnant/lactating people and infants to ensure such therapies are well tolerated and efficacious. Alongside therapeutic innovation, programmatic strategies must address social and economic challenges, ensuring sustainable HIV treatment/prevention programmes and facilitating global elimination of blood-borne viruses.

Cohort profile: the Swiss Mother and Child HIV Cohort Study (MoCHiV)

PURPOSE

Prospective, multicentric observational cohort study in Switzerland investigating measures to prevent mother-to-child transmission in pregnant women with HIV (WWH) and assessing health and development of their exposed children as well as of children with HIV (CWH) in general.

PARTICIPANTS

Between January 1986 and December 2022, a total of 1446 mother-child pairs were enrolled. During the same period, the study also registered 187 CWH and 521 HIV-exposed but uninfected children (HEU), for whom detailed maternal information was not available. Consequently, the cohort comprises a total of 2154 children.

FINDINGS TO DATE

During these 37 years, research by the Swiss Mother and Child HIV Cohort Study (MoCHiV) and its international collaborators has strongly influenced the prevention of vertical transmission of HIV (eg, introduction and discontinuation of elective caesarean section, neonatal postexposure prophylaxis and breastfeeding). Contributions have also been made to the management of diagnostics (eg, p24 antigen assay) and the effects of antiretroviral treatment (eg, prematurity, growth) in HEU and CWH.

FUTURE PLANS

Most children present within the cohort are now HEU, highlighting the need to investigate other vertically transmitted pathogens such as hepatitis B and C viruses, cytomegalovirus or Treponema pallidum. In addition, analyses are planned on the longitudinal health status of CWH (eg, resistance and prolonged exposure to antiretroviral therapy), on social aspects including stigma in CWH and HEU, and on interventions to further optimise antenatal and postpartum care in WWH.

Updates in the Management of HIV During Pregnancy

Human immunodeficiency virus in pregnant people remains a significant public health issue worldwide. The rate of perinatal transmission is 15% to 40% but can be decreased to less than 1% with appropriate antenatal management. Previous recommendations included a protease inhibitor-based antiretroviral therapy, infant prophylaxis, performance of cesarean section for uncontrolled viremia, and the use of formula for infant feeding. However, recent updates include first line of integrase inhibitor-based regimens and supporting parental choices for safe lactation. In this review, we summarize and provide updated recommendations for the care of people living with human immunodeficiency virus during pregnancy.

Prophylaxis and treatment of HIV infection in pregnancy, Swedish guidelines 2024

In May 2024, the Swedish Reference Group on Antiviral Therapy updated the guidelines on management of HIV infection in pregnancy. The most important recommendations and revisions were: (i) ART during pregnancy should be started as early as possible and continue after delivery; (ii) Suppressive ART should normally not be modified; (iii) The treatment target of HIV RNA <20 copies/ml remains; (iv) Dolutegravir/emtricitabine/tenofovir DF is the first-line drug combination also in pregnant women and women planning pregnancy; (v) There is no evidence of an increased risk of neural tube defects associated with dolutegravir; (vi) Mode of delivery for women with effective ART and HIV RNA <200 copies/ml should follow standard obstetric procedures; (vii) Caesarean section is recommended if HIV RNA ≥200 copies/ml; (viii) Scalp electrode, foetal blood sampling and/or vacuum delivery should be used on strict indications, but does not necessitate intensified infant prophylaxis; (ix) Management and mode of delivery in case of premature or full-term rupture of membranes should follow standard obstetric procedures; (x) Recommended infant antiretroviral prophylaxis has been updated; (xi) The duration of infant antiretroviral prophylaxis (gestational age ≥35 weeks and mother on effective ART and HIV RNA <200 copies/ml) has been changed from 4 to 2 weeks; (xii) Infants born to women with HIV RNA ≥200 copies/ml should receive 4 weeks of combination prophylaxis; (xiii) Fertility evaluation and assisted reproduction should be offered to women on suppressive ART according to the same principles as for other women; (xiv) Women living with HIV should still be advised against breastfeeding; (xv) Women who nevertheless opt to breastfeed should be offered intensified support and follow-up.

Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission

OBJECTIVE

This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations.

TARGET POPULATION

Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant.

OUTCOMES

Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV.

BENEFITS, HARMS, AND COSTS

The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission.

EVIDENCE

Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).

INTENDED AUDIENCE

The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV.

SOCIAL MEDIA SUMMARY

Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV

Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.

FIGO good practice recommendations for cesarean delivery: Prep-for-Labor triage to minimize risks and maximize favorable outcomes

Cesarean delivery is an abdominal surgical procedure performed for child delivery when the vaginal route is not feasible or desired due to maternal/fetal indications. All childbirth facilities should be able to safely perform a cesarean, which is not the current reality. For planned cesarean delivery, the facility must be prepared for the patient. In contrast, for unplanned arrivals at the facility, FIGO's Prep-for-Labor triage method allows rapid decision-making on whether cesarean delivery can be safely performed on site or whether transfer to an advanced care center is needed. A checklist of staff/tools for safe on-site cesarean delivery is provided to enable timely decision-making. Maternal complications following cesarean are three-fold higher than vaginal delivery. To prevent nonmedically indicated cesarean by favoring vaginal delivery, up-to-date safe and effective guidance is provided, defining labor, second stage length, and status before an arrested labor is confirmed. Whether cesarean delivery is planned or emergency, the Misgav Ladach simplified procedure is proposed as it is suitable for both low- and high-risk cases, including twins, thereby reducing both operative morbidity and postoperative recovery. A trial of labor after first cesarean (TOLAC) should be pursued when feasible, for which the indications, contraindications, safeguards, and steps of safe labor induction are delineated. Implementation of these good practice recommendations will improve childbirth by reducing excessive nonindicated cesareans, while precisely defining the resources and postoperative care required for safe performance on site. Enabling safe childbirth by cesarean and TOLAC, even at sites with low rates currently, will significantly improve maternal and fetal outcomes.

HIV/Tuberculosis Coinfection in Pregnancy and the Postpartum Period

The convergence of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) represents a considerable global public health challenge. The concurrent infection of HIV and TB in pregnant women not only intensifies the transmission of HIV from mother to fetus but also engenders adverse outcomes for maternal health, pregnancy, and infant well-being, necessitating the implementation of integrated strategies to effectively address and manage both diseases. In this article, we review the pathophysiology, clinical presentation, treatment, and management of HIV/TB coinfection during pregnancy, the postpartum period, and lactation and highlight the differences compared to the general population.

Pregnancy incidence, outcomes and associated factors in a cohort of women living with HIV/AIDS in Rio de Janeiro, Brazil, 1996-2016

The aim of this research was to analyze pregnancy incidence and associated factors in a cohort of 753 women living with HIV/AIDS (WLWHA) in Rio de Janeiro, Brazil, from 1996 to 2016. Women aged 18-49 years who were not on menopause (surgical or natural) and did not have a tubal ligation were eligible for the study. Data were collected by medical professionals during initial and follow-up visits. Person-time pregnancy incidence rates were calculated throughout the follow-up period. Pregnancy incidence-associated factors were investigated by univariate and multiple analyzes, using an extension of the Cox survival model. Follow-up visits recorded 194 pregnancies, with an incidence rate of 4.01/100 person-years (95% CI: 3.47; 4.60). A higher pregnancy incidence was associated with CD4 nadir ≥ 350 cells/mm³, use of an antiretroviral regimen not containing Efavirenz, and prior teenage pregnancy. In turn, women with a viral load ≥ 50 copies/mL, age ≥ 35 years old, with two or more children and using a highly effective contraceptive method showed a lower incidence. Results showed a significant reduction in pregnancy incidence after 2006, a significant reduction in female sterilization from 1996 to 2016, and a high rate of cesarean sections. The association found between pregnancy incidence and the use of contraceptive methods and virological control markers suggests a good integration between HIV/AIDS and reproductive health services. The high rate of cesarean section delivery indicates the need to improve childbirth care.

Cesarean delivery and risk of HIV vertical transmission in Southern Brazil, 2008-2018

BACKGROUND

Childbirth via cesarean delivery can prevent intrapartum vertical transmission for women who are not virally suppressed at the time of delivery. Few studies have compared cesarean delivery trends between women living with HIV and women without HIV and have examined the role of cesarean delivery in the prevention of vertical transmission in the era of potent combination antiretroviral therapy.

OBJECTIVE

We hypothesized that the cesarean delivery rate is high in women living with HIV compared with women without HIV and that cesarean delivery usage decreases over time among women living with HIV with advances in combined antiretroviral therapy in a country with a high national cesarean delivery rate. This study aimed (1) to evaluate cesarean delivery trends in women with and without HIV and (2) to examine its role in preventing vertical transmission among women living with HIV in a setting of free, universal combined antiretroviral therapy coverage in a retrospective cohort of nearly 56,000 deliveries at a major referral institution in a city with the highest prevalence of maternal HIV in Brazil.

STUDY DESIGN

Data from maternal-infant pairs from January 1, 2008, to December 31, 2018, were extracted. Cesarean delivery rates were compared using the Pearson chi-square test. Cesarean delivery predictors were evaluated by multivariate log-linear Poisson regression using a generalized estimating equations approach. HIV viral suppression was defined as a viral load of <1000 copies/ml at delivery. HIV vertical transmission was determined following national guidelines.

RESULTS

Over 11 years, 48,688 pregnancies occurred in 40,375 women; HIV seroprevalence was 2.7%; 18,886 cesarean deliveries (38.8%) were performed; 47.7% of women living with HIV and 38.6% of women without HIV underwent cesarean delivery (P<.001). Although HIV was associated with cesarean delivery (adjusted relative risk, 1.17 [95% confidence interval, 1.05-1.29]), women living with HIV with vertical transmission achieved similar cesarean delivery rates (36.7%) as women without HIV (39.8%) in 2018. Cesarean delivery in women living with HIV with an unknown viral load at delivery (42.6%) did not increase over time. HIV vertical transmission rate was 2.2%, the highest in women living with HIV with an unknown viral load (8.4%) vs women living with HIV without vertical transmission (4.1%) and women living with HIV with vertical transmission (0.5%) (P<.001).

CONCLUSION

In the HIV epicenter of Brazil, women living with HIV with vertical transmission had fewer surgical deliveries, likely because of the use of potent combination antiretroviral therapy. Nearly half of the women living with HIV with an unknown viral load did not undergo cesarean delivery, a potential missed opportunity for the prevention of HIV vertical transmission.

The End Is in Sight: Current Strategies for the Elimination of HIV Vertical Transmission

PURPOSE OF REVIEW

The goal of this review is to highlight and interpret recent trends and developments in the diagnosis, treatment, and prevention of HIV vertical transmission from a clinical perspective.

RECENT FINDINGS

Universal third-trimester retesting and partner testing may better identify incident HIV among pregnant patients and result in early initiation of antiretroviral therapy to prevent vertical transmission. The proven safety and efficacy of integrase inhibitors such as dolutegravir may be particularly useful in suppressing viremia in pregnant persons who present late for ART treatment. Pre-exposure prophylaxis (PrEP) during pregnancy may play a role in preventing HIV acquisition; however, its role in preventing vertical transmission is difficult to elucidate. Substantial progress has been made in recent years to eliminate HIV perinatal transmission. Future research hinges upon a multipronged approach to improving HIV detection, risk-stratified treatment strategies, and prevention of primary HIV infection among pregnant persons.

Prevention of the Vertical Transmission of HIV; A Recap of the Journey so Far

In 1989, one in four (25%) infants born to women living with HIV were infected; by the age of 2 years, there was 25% mortality among them due to HIV. These and other pieces of data prompted the development of interventions to offset vertical transmission, including the landmark Pediatric AIDS Clinical Trial Group Study (PACTG 076) in 1994. This study reported a 67.5% reduction in perinatal HIV transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine. Numerous studies since then have provided compelling evidence to further optimize interventions, such that annual transmission rates of 0% are now reported by many health departments in the US and elimination has been validated in several countries around the world. Despite this success, the elimination of HIV's vertical transmission on the global scale remains a work in progress, limited by socioeconomic factors such as the prohibitive cost of antiretrovirals. Here, we review some of the key trials underpinning the development of guidelines in the US as well as globally, and discuss the evidence through a historic lens.

Antiretroviral Options and Treatment Decisions During Pregnancy

The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.

Understanding Viral and Immune Interplay During Vertical Transmission of HIV: Implications for Cure

Despite the significant progress that has been made to eliminate vertical HIV infection, more than 150,000 children were infected with HIV in 2019, emphasizing the continued need for sustainable HIV treatment strategies and ideally a cure for children. Mother-to-child-transmission (MTCT) remains the most important route of pediatric HIV acquisition and, in absence of prevention measures, transmission rates range from 15% to 45% via three distinct routes: in utero, intrapartum, and in the postnatal period through breastfeeding. The exact mechanisms and biological basis of these different routes of transmission are not yet fully understood. Some infants escape infection despite significant virus exposure, while others do not, suggesting possible maternal or fetal immune protective factors including the presence of HIV-specific antibodies. Here we summarize the unique aspects of HIV MTCT including the immunopathogenesis of the different routes of transmission, and how transmission in the antenatal or postnatal periods may affect early life immune responses and HIV persistence. A more refined understanding of the complex interaction between viral, maternal, and fetal/infant factors may enhance the pursuit of strategies to achieve an HIV cure for pediatric populations.

Pre-existing infant antibody-dependent cellular cytotoxicity associates with reduced HIV-1 acquisition and lower morbidity

In humans, pre-existing anti-HIV-1 neutralizing antibodies (nAbs) have not been associated with decreased HIV-1 acquisition. Here, we evaluate antibody-dependent cellular cytotoxicity (ADCC) present in pre-transmission infant and maternal plasma and breast milk (BM) against the contemporaneous maternal HIV-1 variants. HIV-1-exposed uninfected compared with HIV-1-exposed infected infants have higher ADCC and a combination of ADCC and nAb responses against their corresponding mother's strains. ADCC does not correlate with nAbs, suggesting they are independent activities. The infected infants with high ADCC compared with low ADCC, but not those with higher ADCC plus nAbs, have lower morbidity up to 1 year after birth. A higher IgA to IgG ratio, observed in BM supernatants and in a higher proportion of the infected compared with the uninfected infants, associates with lower ADCC. Against the exposure strains, ADCC, more than nAbs, associates with both lower mother-to-child transmission and decreased post-infection infant morbidity.

Maternal natural killer cells at the intersection between reproduction and mucosal immunity

Many maternal immune cells populate the decidua, which is the mucosal lining of the uterus transformed during pregnancy. Here, abundant natural killer (NK) cells and macrophages help the uterine vasculature adapt to fetal demands for gas and nutrients, thereby supporting fetal growth. Fetal trophoblast cells budding off the forming placenta and invading deep into maternal tissues come into contact with these and other immune cells. Besides their homeostatic functions, decidual NK cells can respond to pathogens during infection, but in doing so, they may become conflicted between destroying the invader and sustaining fetoplacental growth. We review how maternal NK cells balance their double duty both in the local microenvironment of the uterus and systemically, during toxoplasmosis, influenza, cytomegalovirus, malaria and other infections that threat pregnancy. We also discuss recent developments in the understanding of NK-cell responses to SARS-Cov-2 infection and the possible dangers of COVID-19 during pregnancy.

Human immunodeficiency virus and infertility treatment: an Ethics Committee opinion

Human Immunodeficiency Virus is a serious but manageable chronic disease that affects persons of reproductive age, many of whom express a desire for biological parenthood. This document is a revision of the original document of the same name, last published in 2015 (Fertil Steril 2015;104:e1-8).

Considerations and Recommendations for Pregnancy and Postpartum Care for People Living With Human Immunodeficiency Virus

Considerable strides have been made in reducing the rate of perinatal human immunodeficiency virus (HIV) transmission within the United States and around the globe. Despite this progress, preventable perinatal HIV transmission continues to occur. Adherence to HIV screening and treatment recommendations preconception and during pregnancy can greatly reduce the risk of perinatal HIV transmission. Early and consistent usage of highly active antiretroviral therapy (ART) can greatly lower the HIV viral load, thus minimizing HIV transmission risk. Additional intrapartum interventions can further reduce the risk of HIV transmission. Although the current standard is to recommend abstinence from breastfeeding for individuals living with HIV in settings where there is safe access to breast milk alternatives (such as in the United States), there is guidance available on counseling and risk-reduction strategies for individuals on ART with an undetectable viral load who elect to breastfeed.

Premature Rupture of Membranes with Concurrent Viral Infection

Treatment of viral infections is geared toward ameliorating maternal symptoms and minimizing perinatal transmission. Multidisciplinary teams often are required to manage sequelae due to viral diseases in patients with preterm premature rupture of membranes (PPROM). although data are scarce regarding the antepartum management of common viruses in PPROM, essential principles may be extrapolated from national guidelines and studies in gravid patients. The well-established risks of prematurity are weighed against the often unclear risks of vertical transmission.

Prevention of Perinatal HIV Transmission in an Area of High HIV Prevalence in the United States

OBJECTIVE

To evaluate the uptake of perinatal HIV preventive interventions by the risk of perinatal HIV transmission in mother-infant pairs in a high-HIV prevalence area in the US.

STUDY DESIGN

This was a retrospective cohort study of mother-infant pairs with perinatal HIV exposure during 2013-2017 managed at a subspecialty pediatric HIV program in Washington, DC. We collected demographic data, maternal HIV history, delivery mode, maternal and infant antiretroviral drug (ARV) use, and infant HIV test results. We compared the uptake of recommended preventive interventions in low-risk (ie, mothers on antiretroviral therapy [ART] with viral suppression) and high-risk (mothers without ART or viral suppression) mother-infant pairs using the Pearson chi-square, Fisher exact, and Wilcoxon rank-sum tests and logistic regression.

RESULTS

We analyzed 551 HIV-exposed infants (HEIs) and 542 mothers living with HIV. The majority of mothers received ARVs (95.5%), had HIV RNA ≤1000 copies/mL before delivery (81.9%), and received intrapartum zidovudine (ZDV; 65.5%). The majority of all HEIs were low risk (82.6%) and received postpartum ARVs (98.9%). Among the low-risk infants, 53.2% were delivered via cesarean delivery (CD), and 62.9% and 96.5% were administered intrapartum and postpartum ZDV, respectively. Among high-risk infants, 84.4% were delivered via CD, 78.1% received intrapartum ZDV, and 62.5% received combination ART. Nine high-risk infants acquired HIV perinatally.

CONCLUSION

In an area of high HIV prevalence in the US, a large proportion of low-risk HEIs received intrapartum ZDV and were delivered via CD. We also observed missed opportunities for the prevention of perinatal HIV transmission.

Risk Factors for Maternal Chagas Disease and Vertical Transmission in a Bolivian Hospital

BACKGROUND

Vertical transmission of Trypanosoma cruzi infection accounts for a growing proportion of new cases of Chagas disease. Better risk stratification is needed to predict which women are more likely to transmit the infection.

METHODS

This study enrolled women and their infants at the Percy Boland Women's Hospital in Santa Cruz, Bolivia. Pregnant women were screened for Chagas disease by rapid test and received confirmatory serology. Infants of seropositive mothers underwent diagnostic testing with quantitative polymerase chain reaction (qPCR).

RESULTS

Among 5,828 enrolled women, 1,271 (21.8%) screened positive for Chagas disease. Older maternal age, family history of Chagas disease, home conditions, lower education level, and history of living in a rural area were significantly associated with higher adjusted odds of maternal infection. Of the 1,325 infants of seropositive mothers, 65 infants (4.9%) were diagnosed with congenital Chagas disease. Protective factors against transmission included Cesarean delivery (adjusted OR [aOR]: 0.60, 95% CI: 0.36-0.99) and family history of Chagas disease (aOR: 0.58, 95% CI: 0.34-0.99). Twins were significantly more likely to be congenitally infected than singleton births (OR: 3.32, 95% CI: 1.60-6.90). Among congenitally infected infants, 32.3% had low birth weight, and 30.8% required hospitalization after birth.

CONCLUSIONS

Although improved access to screening and qPCR increased the number of infants diagnosed with congenital Chagas disease, many infants remain undiagnosed. A better understanding of risk factors and improved access to highly sensitive and specific diagnostic techniques for congenital Chagas disease may help improve regional initiatives to reduce disease burden.

HIV in pregnancy - An update

Human immunodeficiency virus (HIV) is an infection with a global prevalence and currently no cure or vaccine. Women living with HIV who become pregnant or who acquire the virus during pregnancy are at risk of both maternal and perinatal morbidity and mortality mainly if the virus is poorly controlled. Furthermore, there is a risk of vertical transmission to the fetus during pregnancy labour and postpartum through breastfeeding.

Appropriate management must be instituted to reduce the consequences of HIV in pregnancy, ideally starting with preconception counselling and planning pregnancies when the viral load is minimum. During pregnancy, an appropriate combined anti-retroviral (cART) medication is mandatory with very close monitoring of the viral load, cluster of differentiation 4 (CD4) cell counts, blood counts, liver and kidney function tests.

Planning delivery should not be different in women on cART and suppressed viral loads. However, special care must be taken to limit vertical transmission in those who present late and in whom viral load is unknown or not controlled at the time of delivery.

Breastfeeding remains a potential source of infection for the baby and is being discouraged in high-income countries for women living with HIV; however, in low-income countries, the recommendation is exclusive breastfeeding. If breastfeeding must happen, it is best when viral load is suppressed, and cART continued until weaning.

Serodiscordant couples present unique problems, and their management should begin with the planning of pregnancy. Emphasis should be on taking steps to prevent HIV transmission to the negative partner and vertical transmission to the new-born.

Perceptions of obstetricians and pediatricians about the risk of COVID-19 for pregnant women and newborns

Objective

To assess the perception of obstetricians and pediatricians about risks of COVID‐19 to pregnant women and possible complications in newborns.

Methods

A structured 27‐item online survey was sent via social media messaging to obstetricians and pediatricians from public, academic, and private sectors in Jordan between March 23–30, 2020. Descriptive statistics were used to represent numbers and percentages of participants’ responses to survey items.

Results

A total of 147 physicians participated (107 obstetricians, 40 pediatricians). Participants were well informed about the symptoms, diagnosis, modes of transmission, and methods of prevention. Participants had variable perceptions about COVID‐19 risk during pregnancy, including potential vertical transmission, preferred route of delivery, and safety of breastfeeding. Most participants felt that pregnant women should be prioritized for testing and medical care provision.

Conclusion

While evidence‐based strategies to reduce the risks of COVID‐19 in pregnant women and newborns are evolving, healthcare providers showed excellent knowledge of the infection and were vigilant regarding its complications for mothers and newborns. To ensure safe pregnancy, physicians must keep informed of developing guidance on best and safest prenatal and perinatal health services. Implementing local hospital policies and adequate training in infection control measures is strongly encouraged.

Physicians are well informed about COVID‐19 transmission and preventive measures. Physicians should follow the developing guidance about the safest prenatal and perinatal health services.

Preventing vertical HIV virus transmission: hospital care assessment

OBJECTIVES

assess the implementation of actions to prevent vertical transmission of HIV.

METHODS

a retrospective cohort study conducted in two maternity hospitals in the city of Montes Claros, State of Minas Gerais. All women admitted for childbirth diagnosed with HIV and their respective newborns were included from 2014 to 2017. Data were collected from medical records and analyzed descriptively.

RESULTS

population consisted of 46 pairs of mothers and newborns. Management was considered inadequate in 30 cases of parturient/postpartum women (65.2%) and 14 cases of newborns (30.4%). The main reasons for inadequate maternal management were lack of pharmacological inhibition of lactation (53.3%) and counseling/consent for HIV testing (43.3%). For newborns, late onsetoffirst dose ofZidovudine (50.0%) and no prescriptionofNevirapine (28.6%).

CONCLUSIONS

important prevention opportunities were missed, pointing to the need for improved care.

Impact of human immunodeficiency virus, malaria, and tuberculosis on adverse pregnancy outcomes in the United States

OBJECTIVE

To compare rates of adverse pregnancy outcomes for HIV, tuberculosis, and malaria-infected patients in the United States with those of uninfected patients.

STUDY DESIGN

A nationally representative sample of 24,149,664 singleton live births were identified using pregnancy hospitalizations that resulted in delivery between 1998-2000 and 2009-2011 in this retrospective cohort study. Maternal and fetal outcomes were evaluated.

RESULTS

There were 7204 HIV cases, 1450 TB cases, and 296 malaria cases over the two time periods, and the average age of infected subjects was 28.3. The HIV group was more likely to have almost all adverse pregnancy outcomes than the control group in both time periods. The 2009-2011 HIV group was more likely to undergo cesarean delivery than the 1998-2000 HIV group [1959 versus 1649, p < 0.0001].

CONCLUSION

Out of pregnant women infected with HIV, malaria, or tuberculosis, those infected with HIV are more likely to experience several adverse pregnancy outcomes than uninfected women.

Comparison of two combined antiretroviral treatment regimens in the management of HIV in pregnancy: an observational study

Objective: Combined antiretroviral therapy (cART) in pregnancy traditionally included two nucleoside reverse transcriptase inhibitors plus 1 protease inhibitor (PI). Recently, integrase strand transfer inhibitors (INSTI) have been approved for use in pregnancy. We sought to compare the rate of undetectable VL near delivery in pregnant HIV-infected women receiving INSTI-based versus PI-based cART.Material and methods: Prospective cohort study (January 2010-March 2017) of pregnant HIV-infected pregnancies receiving care in a single obstetric infectious disease clinic. Included pregnancies (total = 171; INSTI - group = 111, PI - group = 60) had at least 2 VL (before and after intervention) during pregnancy. The primary outcome was the rate of undetectable VL near delivery.Results: We found comparable rates of undetectable HIV VL near delivery in pregnancies treated with INSTI-cART (74/111, 66.7%) compared to PI-cART (34/60, 56.7%; [adjusted p = .116, RR 1.26, 95% CI 0.92-2.59]). Compared to the PI-group, pregnancies in the INSTI-group showed lower median HIV VL near delivery (20 versus 50 copies/mL; adjusted p = .0454) and greater VL reduction (adjusted p = .0185). There were 3/171 (1.75%) infants diagnosed with HIV, 1 in the INSTI-group and 2 in the PI-group (p = .5635, RR 0.51, 95% CI 0.10-2.53).Conclusion: Pregnant HIV-infected women receiving either INSTI- or PI-based cART achieved comparable rates of undetectable HIV VL near delivery with similar perinatal transmission.

Attrition Across the HIV Cascade of Care Among a Diverse Cohort of Women Living With HIV in Canada

BACKGROUND

In North America, women have lower engagement across the HIV cascade of care compared with men. Among women living with HIV (WLWH) in Canada, we measured the prevalence and correlates of attrition across cascade stages overall, and by key subpopulations.

METHODS

We analyzed baseline survey data regarding 6 nested stages of the HIV cascade among 1424 WLWH enrolled in the Canadian HIV Sexual and Reproductive Health Cohort Study (CHIWOS), including: linked to care, retained in care, initiated antiretroviral therapy (ART), current ART use, ART adherence (≥90%), and viral suppression (<50 copies/mL). Logistic regression identified factors associated with attrition at each stage.

RESULTS

Overall, 98% of WLWH were linked to care; 96% retained; 88% initiated ART; 83% were currently on ART; and, among those on ART, 68% were adherent and 72% were virally suppressed, with substantial variability by subpopulation (49%-84%).The largest attrition occurred between current ART use and adherence (-17%), with the greatest losses among indigenous women (-25%), women who use illicit drugs (-32%), and women incarcerated in the past year (-45%). Substantial attrition also occurred between linkage to care and ART initiation (-11%), with the greatest losses among women 16-29 years (-20%) and with unstable housing (-27%). Factors independently associated with attrition at viral suppression included household annual income, racial discrimination, incarceration history, age, and resilience.

CONCLUSIONS

Overall, 28% of WLWH were lost across the HIV care cascade, with significant differences by stage, subpopulation, and social inequities. Targeted interventions are needed to improve women's retention across the cascade.

ACOG Committee Opinion No. 751: Labor and Delivery Management of Women With Human Immunodeficiency Virus Infection

This Committee Opinion is being revised to provide updated guidance on the management of pregnant women during pregnancy and delivery to prevent mother-to-child transmission of the human immunodeficiency virus (HIV). Prevention of transmission of HIV from the woman to her fetus or newborn is a major goal in the care of pregnant women infected with HIV. Continuing research into mother-to-child transmission of HIV has suggested that a substantial number of cases of perinatal HIV transmission occur as the result of fetal exposure to the virus during labor and delivery. The precise mechanisms are not known. Established and ongoing research has shown that treatment of HIV-infected pregnant women with combined antiretroviral therapy can achieve a 1-2% or lower risk of mother-to-child transmission if maternal viral loads of 1,000 copies/mL or less can be sustained, independent of the route of delivery or duration of ruptured membranes before delivery. Vaginal delivery is appropriate for HIV-infected pregnant women who have been maintained on combined antiretroviral therapy and who have viral loads of 1,000 copies/mL or less at or near delivery. The risk of mother-to-child transmission in HIV-infected women with high viral loads can be reduced by performing cesarean deliveries before the onset of labor and before rupture of membranes (termed scheduled cesarean delivery in this document), in conjunction with the use of peripartum maternal antiretroviral therapy. Discussion of the option of scheduled cesarean delivery and its advantages in the situation of suboptimal viral suppression should begin as early as possible in pregnancy with every pregnant woman with HIV infection to give her an adequate opportunity to ask questions and consider her decision-making concerning the delivery plan. The patient's decision regarding her route of delivery should be respected after maternal and neonatal risks have been discussed.

Point-of-care HIV viral load in pregnant women without prenatal care: a cost-effectiveness analysis

BACKGROUND

Routine cesarean delivery has been shown to decrease mother-to-child-transmission of HIV in women with high viral load greater than 1000 copies/mL; however, women presenting late in pregnancy may not have viral load results before delivery.

OBJECTIVE

Our study investigated the costs and outcomes of using a point-of-care HIV RNA viral load test to guide delivery compared with routine cesarean delivery for all in the setting of unknown viral load.

STUDY DESIGN

A decision-analytic model was constructed using TreeAge software to compare HIV RNA viral load testing vs routine cesarean delivery for all in a theoretical cohort of 1275 HIV-positive women without prenatal care who presented at term for delivery, the estimated population of HIV-positive women without prenatal care in the United States annually. TreeAge Pro software is used to build decision trees modeling clinical problems and perform cost-effectiveness, sensitivity, and simulation analysis to identify the optimal outcome. The average cost per test was $15.22. To examine the downstream impact of a cesarean delivery and because most childbearing women in the United States will deliver 2 children, we incorporated a second pregnancy and delivery in the model. Primary outcomes were mother-to-child transmission, delivery mode, cesarean delivery-related complications, cost, and quality-adjusted life years. Model inputs were derived from the literature and varied in sensitivity analyses. The cost-effectiveness threshold was $100,000/quality-adjusted life year.

RESULTS

Measuring viral load resulted in more HIV-infected neonates than routine cesarean delivery for all due to viral exposure during more frequent vaginal births in this strategy. There were no observed maternal deaths or differences in cesarean delivery-related complications. Quantifying viral load increased cost by $3,883,371 and decreased quality-adjusted life years by 63 compared with routine cesarean delivery for all. With the threshold set at $100,000/quality-adjusted life year, the viral load test is cost-effective only when the vertical transmission rate in women with high viral load was below 0.68% (baseline: 16.8%) and when the odds ratio of vertical transmission with routine cesarean delivery for all compared with vaginal delivery was above 0.885 (baseline: 0.3).

CONCLUSIONS

For HIV-infected pregnant women without prenatal care, quantifying viral load to guide mode of delivery using a point-of-care test resulted in increased costs and decreased effectiveness when compared with routine cesarean delivery for all, even after including downstream complications of cesarean delivery.

Missed opportunities to prevent mother-to-child transmission of HIV in Italy

OBJECTIVES

Vertical transmission of HIV can be effectively controlled through antenatal screening, antiretroviral treatment and the services provided during and after childbirth for mother and newborn. In Italy, the National Health Service guarantees universal access to prenatal care for all women, including women with HIV infection. Despite this, children are diagnosed with HIV infection every year. The aim of the study was to identify missed opportunities for prevention of mother-to-child transmission of HIV.

METHODS

The Italian Register for HIV Infection in Children, which was started in 1985 and involves 106 hospitals throughout the country, collects data on all new cases of HIV infection in children. For this analysis, we reviewed the database for the period 2005 to 2015.

RESULTS

We found 79 HIV-1-infected children newly diagnosed after birth in Italy. Thirty-two of the mothers were Italian. During the pregnancy, only 15 of 19 women with a known HIV diagnosis were treated with antiretroviral treatment, while, of 34 women who had received an HIV diagnosis before labour began, only 23 delivered by caesarean section and 17 received intrapartum prophylaxis. In 25 mothers, HIV infection was diagnosed during pregnancy or in the peripartum period. Thirty-one newborns received antiretroviral prophylaxis and 39 received infant formula.

CONCLUSIONS

We found an unacceptable number of missed opportunities to prevent mother-to-child transmission (MCTC). Eliminating HIV MTCT is a universal World Health Organization goal. Elucidating organization failures in Italy over the past decade should help to improve early diagnosis and to reach the zero transmission target in newborns.

Minimizing the Risk of Perinatal Human Immunodeficiency Virus Transmission

Importance

There are approximately 284,500 adolescent and adult women living with human immunodeficiency virus (HIV) in the United States. It is estimated that approximately 8500 of these women give birth annually. While the rate of perinatal transmission in the United States has decreased by more than 90% since the early 1990s, potentially preventable HIV transmission events still occur and cause significant morbidity and mortality.

Objective

The aim of this review was to summarize the current data regarding perinatal HIV transmission timing and risk factors, current management recommendations, and implications of timing of transmission on patient management.

Evidence Acquisition

Literature review.

Results

This review reiterates that the risk of perinatal HIV transmission can be reduced to very low levels by following current recommendations for screening for HIV in all pregnant women and properly treating HIV-infected mothers, as well as using evidence-based labor management practices.

Conclusions and Relevance

Familiarity with the pathogenesis of HIV transmission is important for obstetric care providers to appropriately manage HIV-infected women in pregnancy, intrapartum, and the postpartum period.

Congenital HIV: Prevention of Maternal to Child Transmission

BACKGROUND

Human immunodeficiency virus (HIV) is caused by a cytopathic lentivirus. HIV without adequate treatment during pregnancy can result in maternal to child transmission (MCT) of the virus. Sequelae can include severe lifelong morbidities, shorter life expectancies, and high mortality rates without antiretroviral therapy.

PURPOSE

To discuss epidemiological trends, pathophysiology, and clinical care guidelines including those for diagnosis, treatment, and management of MCT of HIV in the United States. To emphasize the importance of prompt identification, prophylaxis, and treatment of at-risk infants.

METHODS

PubMed, CINAHL, MEDLINE, and Google Scholar were used to search key words-maternal to child transmission, HIV, HIV in pregnancy, and neonatal HIV-for articles that were relevant and current. The World Health Organization, Centers for Disease Control and Prevention, and UNICEF were also utilized for up-to-date information on the topic.

FINDINGS

Timely identification, intervention, and treatment are necessary to prevent MCT of HIV. Membrane rupture duration is not associated with higher transmission rates with adequate viral suppression.

IMPLICATIONS FOR PRACTICE

An evidence-based maternal/neonatal collaborative approach to care for the prevention and management of MCT of HIV including adherence to combined antiretroviral therapy (cART) should be emphasized. Early testing, prophylaxis, and treatment for neonates at risk, as well as education on current clinical care guidelines for caregivers.

IMPLICATIONS FOR RESEARCH

Pregnancy complications of cART. MCT rates in conjunction with birthing practices and restrictions among women living with HIV with low to undetectable viral loads.

Changing Patterns and Factors Associated With Mode of Delivery Among Pregnant Women With Human Immunodeficiency Virus Infection in the United States

OBJECTIVE

To describe patterns and factors associated with mode of delivery among pregnant women with human immunodeficiency virus (HIV) infection in the United States in relation to evolving HIV-in-pregnancy guidelines.

METHODS

We conducted an analysis of two observational studies, Pediatric AIDS Clinical Trials Group and International Maternal Pediatric Adolescent AIDS Clinical Trials Network Protocol P1025, which enrolled pregnant women with HIV infection from 1998 to 2013 at more than 60 U.S. acquired immunodeficiency syndrome clinical research sites. Multivariable analyses of factors associated with an HIV-indicated cesarean delivery (ie, for prevention of mother-to-child transmission) compared with other indications were conducted and compared according to prespecified time periods of evolving HIV-in-pregnancy guidelines: 1998-1999, 2000-2008, and 2009-2013.

RESULTS

Among 6,444 pregnant women with HIV infection, 21% delivered in 1998-1999, 58% in 2000-2008, and 21% in 2009-2013; 3,025 (47%) delivered by cesarean. Cesarean delivery increased from 30% in 1998 to 48% in 2013. Of all cesarean deliveries, repeat cesarean deliveries increased from 16% in 1998 to 42% in 2013; HIV-indicated cesarean deliveries peaked at 48% in 2004 and then dropped to 12% by 2013. In multivariable analyses, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, a plasma viral load 500 copies/mL or greater, and delivery between 37 and 40 weeks of gestation increased the likelihood of an HIV-indicated cesarean delivery. In analyses by time period, an HIV diagnosis during pregnancy, initiation of antiretroviral therapy in the third trimester, and a plasma viral load of 500 copies/mL or greater were progressively more likely to be associated with an HIV-indicated cesarean delivery over time.

CONCLUSION

Almost 50% of pregnant women with HIV infection underwent cesarean delivery. Over time, the rate of repeat cesarean deliveries increased, whereas the rate of HIV-indicated cesarean deliveries decreased; cesarean deliveries were more likely to be performed in women at high risk of mother-to-child transmission. These findings reinforce the need for both early diagnosis and treatment of HIV infection in pregnancy and the option of vaginal delivery after cesarean among pregnant women with HIV infection.

Most women living with HIV can deliver vaginally-National data from Finland 1993-2013

Introduction

Vaginal delivery has been recommended for more than ten years for women living with HIV (WLWH) with good virological control. However, in Europe most WLWH still deliver by cesarean section (CS). Our aim was to assess the rate of vaginal delivery and the indications for CS in WLWH over 20 years in a setting of low overall CS rate.

Materials and methods

This was a retrospective study of all WLWH delivering in Finland 1993–2013. We identified the women by combining national health registers and extracted data from patient files.

Results

The study comprised 212 women with 290 deliveries. Over 35% of the women delivered several children during the study years. During 2000–2013, with consistent viral load monitoring, 80.0% showed HIV viral loads <50 copies/mL in the last measurement preceding the delivery. Altogether 74.5% of all WLWH delivered vaginally and the rate of both elective CS and emergency CS was 12.8% each. For most CSs (63.5%) the indication was obstetrical, for 28.4% it was avoiding HIV transmission and for 0.7% it was mother’s request. In hospitals with less than ten HIV-related deliveries during the study period, the rate of elective CS was higher than in more experienced hospitals (22.7% versus 10.6% [p = 0.024]). No perinatal HIV transmissions occurred.

Conclusions

Most WLWH can achieve good virological control and deliver vaginally. This will help them to maintain their future child bearing potential and reduce CS-related morbidity.

Universal Rapid Human Immunodeficiency Virus Screening at Delivery: A Cost-Effectiveness Analysis

Objective

To determine the cost-effectiveness of universal maternal HIV screening at time of delivery to decrease mother-to-child transmission (MTCT), by comparing the cost and quality-adjusted life years (QALYs) of universal rapid HIV screening at time of delivery to two current standards of care for prenatal HIV screening in the United States.

Study Design

We conducted a cost-effectiveness analysis to compare the cost and QALY of universal intrapartum rapid HIV screening with two current standards of care: (I) opt-out rapid HIV testing limited to patients without previous third-trimester screening and (II) opt-out rapid HIV testing limited to patients without any prenatal screening. We developed a decision-tree model and performed sensitivity analyses to estimate the impact of variances in QALY, estimated lifetime medical costs, HIV prevalence, and cumulative incidence.

Results

The incremental cost-effectiveness ratio for universal screening was $7,973.45/QALY. The results remained robust to sensitivity analysis, except for annual cumulative incidence. In areas with an annual cumulative incidence rate of <0.02% for reproductive-age women, the incremental cost-effectiveness ratio for the expanded program would exceed $89,926.94/QALY, approaching the commonly applied cost-effectiveness thresholds ($100,000/QALY).

Conclusions

Intrapartum universal rapid HIV screening to decrease MTCT appears cost-effective in populations with high HIV incidence in the United States.

Implementation of universal rapid human immunodeficiency virus screening on labor and delivery

Background

A case of mother to child transmission (MTCT) of HIV at a medical center in Washington, DC, resulted in the implementation of universal opt-out rapid testing of patients admitted for delivery. This article evaluates the policy's efficacy and implementation.

Methods

We evaluated the implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Results

We could not evaluate decrease in MTCT rate secondary to low sample size (n = 3324) and no true-positive results. Patients not tested (n = 458) were predominately secondary to physician omission (93.7%) and were more likely to be White (p < 0.01) and older (p < 0.01). There was a negative relationship with physician omission over time.

Conclusion

The policy was successfully implemented with decreasing proportions of patients not tested. Earlier inclusion of testing into standard admission orders and nurse-based approach may have expedited adoption. Given the low incidence of new HIV diagnosis in labor, we were unable to assess decrease in MTCT.

Prophylaxis and treatment of HIV-1 infection in pregnancy - Swedish Recommendations 2017

Prophylaxis and treatment with antiretroviral drugs have resulted in a very low rate of mother-to-child transmission (MTCT) of HIV during recent years. Registration of new antiretroviral drugs, modification of clinical praxis, updated general treatment guidelines and increasing knowledge about MTCT have necessitated regular revisions of the recommendations for 'Prophylaxis and treatment of HIV-1 infection in pregnancy'. The Swedish Reference Group for Antiviral Therapy (RAV) has updated the recommendations from 2013 at an expert meeting 19 September 2017. In the new text, current treatment guidelines for non-pregnant are considered. The most important revisions are that: (1) Caesarean section and infant prophylaxis with three drugs are recommended when maternal HIV RNA >150 copies/mL (previously >50 copies/mL). The treatment target of undetectable HIV RNA remains unchanged <50 copies/mL; (2) Obstetric management and mode of delivery at premature rupture of the membranes and rupture of the membranes at full term follow the same procedures as in HIV negative women; (3) Vaginal delivery is recommended to a well-treated woman with HIV RNA <150 copies/mL regardless of gestational age, if no obstetric contraindications are present; (4) Treatment during pregnancy should begin as soon as possible and should continue after delivery; (5) Ongoing well-functioning HIV treatment at pregnancy start should usually be retained; (6) Recommended drugs and drug combinations have been updated.

Brief Report: Estimated Incidence of Perinatally Acquired HIV Infection in the United States, 1978-2013

BACKGROUND

An incidence of perinatally acquired HIV infection less than 1:100,000 live births is one of the Centers for Disease Control and Prevention (CDC) goals of the United States. Such an estimate has only been possible in recent years because regular nationwide data were lacking.

METHOD

Using previously published CDC estimates of the number of infants born with HIV infection in the United States (interpolating for years for which there was no published estimate), and census data on the annual number of live-born infants, estimated incidence was calculated for 1978-2013. Exact 95% confidence intervals (CIs) were calculated using the Poisson distribution.

RESULTS

Estimated incidence of perinatally acquired HIV infection peaked at 43.1 (95% CI: 41.1 to 45.1) in 1992 and declined rapidly after the use of zidovudine prophylaxis was recommended in 1994. In 2013, estimated incidence of perinatally acquired HIV infection in the United States was 1.8 (95% CI: 1.4 to 2.2), a 96% decline since the peak.

CONCLUSION

Estimated incidence of perinatally acquired HIV infection in the United States in 2013 was 1.8/100,000 live births.

Reproductive decision-making in women living with human immunodeficiency virus: A systematic review

OBJECTIVES

Analyze and synthesize the research evidence to understand the reproductive decisions made by women living with HIV from the beginning of the epidemic to the present. Evaluate the barriers and the facilitators for reproductive decision-making. Identify areas of strength, improvement, and those requiring further research.

DESIGN AND DATA SOURCES

Systematic review following the PRISMA guideline. PubMed, CINAHL, PsycINFO, Cochrane Library, SocINDEX, Embase, and Scopus databases were searched from 1985 to 2016 using the following Keywords: HIV, AIDS, pregnancy, reproduction, and decision-making.

STUDY SELECTION

A total of 42 research papers were included in this review. Initially, 1563 papers were identified for the review by database (n=1544) and hand (n=19) searches. With three review levels, 1521 papers were excluded (title review, n=1272; abstract review, n=136; and full paper review, n=113). Studies published in English in peer-reviewed journals using both quantitative and qualitative methods and addressing reproductive decisions in women living with HIV were included. Thirdly, inclusion eligibility was assessed by title, abstract, and full text.

REVIEW METHODS

Random allocation conducted by the primary researcher assigned an equal number of papers to each researcher for review, including detailed instructions with an abstraction form. Discrepancies were resolved by two researchers. Research quality was assessed using the NCHBL Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, the Critical Appraisal Skills Programme for the qualitative studies and its version for systematic reviews RESULTS: The review included 42 papers, both quantitative (n=24) and qualitative methods (n=14). Most studies were completed by physicians (n=16) or nurses (n=15). More than two-thirds of the studies were performed in urban settings with predominantly African-American women (n=27). Eight factors were identified as influencing the reproductive decision-making process in women living with HIV: 'Socio-demographic, Health status and Pregnancy', 'Religion and spirituality', 'Beliefs and Attitudes about Antiretroviral Therapy', 'Healthcare providers', 'Significant others', 'Motherhood and fulfillment', 'Fear of perinatal infection and infection of partner(s)', 'Birth control and pregnancy management'.

CONCLUSIONS

Health care providers are not providing patient-centered care by applying scientific evidence to their practice when advising women with HIV in making reproductive decisions. Despite the strong evidence indicating pregnancy for women with HIV results in a safe birthing trajectory, one not likely to jeopardize the health of the either the mother or fetus, providers continue to recommend the women with HIV avoid pregnancy and neglect to invite partners to participate in the discussion.

Elective cesarean section for women living with HIV: a systematic review of risks and benefits

Supplemental Digital Content is available in the text

Objective and design:

To inform WHO guidelines, we conducted a systematic review and meta-analysis to assess maternal and perinatal outcomes comparing cesarean section (c-section) before labor and rupture of membranes [elective c-section (ECS)] with other modes of delivery for women living with HIV.

Methods:

We searched PubMed, CINAHL, Embase, CENTRAL, and previous reviews to identify published trials and observational studies through October 2015. Results were synthesized using random-effects meta-analysis, stratifying for combination antiretroviral therapy (cART), CD4⁺/viral load (VL), delivery at term, and low-income/middle-income countries.

Results:

From 2567 citations identified, 36 articles met inclusion criteria. The single randomized trial, published in 1999, reported minimal maternal morbidity and significantly fewer infant HIV infections with ECS [odds ratio (OR) 0.2, 95% confidence interval (CI) 0.0–0.5]. Across observational studies, ECS was associated with increased maternal morbidity compared with vaginal delivery (OR 3.12, 95% CI 2.21–4.41). ECS was also associated with decreased infant HIV infection overall (OR 0.43, 95% CI 0.30–0.63) and in low-income/middle-income countries (OR 0.27, 95% CI 0.16–0.45), but not among women on cART (OR 0.82, 95% CI 0.47–1.43) or with CD4⁺ cell count more than 200/VL less than 400/term delivery (OR 0.59, 95% CI 0.21–1.63). Infant morbidity moderately increased with ECS.

Conclusion:

Although ECS may reduce infant HIV infection, this effect was not statistically significant in the context of cART and viral suppression. As ECS poses other risks, routine ECS for all women living with HIV may not be appropriate. Risks and benefits will differ across settings, depending on underlying risks of ECS complications and vertical transmission during delivery. Understanding individual client risks and benefits and respecting women's autonomy remain important.

Assessment of mode of delivery and predictors of emergency caesarean section among women living with HIV in a matched-pair setting with women from the general population in Denmark, 2002-2014

OBJECTIVES

We aimed to assess mode of delivery and predictors of emergency caesarean section (EmCS) in women living with HIV (WLWH) in a matched-pair setting with women from the general population (WGP) in Denmark. Further, we analysed birth plan in WLWH.

METHODS

All WLWH giving birth to live-born children from 2002 to 2014 were included in the study. Data were retrieved from medical records and national registries. WLWH were matched 1:5 by age, birth year, parity and ethnicity to WGP. Multivariate logistic regression was used to estimate predictors.

RESULTS

We included 389 WLWH and 1945 WGP in the study. At delivery, all WLWH were on antiretroviral therapy and 85.6% had HIV RNA <40 HIV-1 RNA copies/mL. Mean age was 32.7 years [95% confidence interval (CI) 32.1-33.2 years]. Mode of delivery differed significantly between WLWH and WGP [vaginal delivery, 33.4% versus 73.3%, respectively; elective caesarean section (ECS), 40.6% versus 9.7%, respectively; EmCS, 26% versus 17%, respectively; P < 0.0001]. Age > 40 years [adjusted odds ratio (aOR) 2.3; 95% CI 1.5-3.5], asphyxia (aOR 3.2; 95% CI 2.4-4.1), delivery during the evening and at night [aOR 2.3 (95% CI 1.7-3.0) and aOR 2.0 (95% CI 1.5-2.7), respectively], preterm delivery (aOR 3.8; 95% CI 2.6-5.6) and premature rupture of membranes (aOR 3.0; 95% CI 2.1-4.4) predicted EmCS. WLWH had a higher risk of EmCS compared with WGP [2002-2006, aOR 2.0 (95% CI 1.2-3.3); 2007-2008, aOR 2.9 (95% CI 1.4-5.9); 2009-2014, aOR 2.6 (95% CI 1.7-3.9)]. After 2007, more than half of WLWH planned to deliver vaginally. Prior caesarean section was associated with ECS (aOR 11.0; 95% CI 4.5-26.8). No mother-to-child transmission occurred.

CONCLUSIONS

Increasing numbers of WLWH deliver vaginally. Despite virological suppression, more WLWH plan and deliver by ECS than WGP. WLWH had a twofold higher risk of EmCS compared with WGP.

Estimated Perinatal HIV Infection Among Infants Born in the United States, 2002-2013

Importance

Perinatal transmission of human immunodeficiency virus (HIV) can be reduced through services including antiretroviral treatment and prophylaxis. Data on the national incidence of perinatal HIV transmission and missed prevention opportunities are needed to monitor progress toward elimination of mother-to-child HIV transmission.

Objective

To estimate the number of perinatal HIV cases among infants born in the United States.

Design, Setting, and Participants

Data were obtained from the National HIV Surveillance System on infants with HIV born in the United States (including the District of Columbia) and their mothers between 2002 and 2013 (reported through December 31, 2015). Estimates were adjusted for delay in diagnosis and reporting by weighting each reported case based on a model incorporating time from birth to diagnosis and report. Analysis was performed from April 1 to August 15, 2016.

Exposures

Maternal HIV infection and antiretroviral medication, including maternal receipt prenatally or during labor/delivery and infant receipt postnatally.

Main Outcomes and Measures

Diagnosis of perinatally acquired HIV infection in infants born in the United States. Infant and maternal characteristics, including receipt of perinatal HIV testing, treatment, and prophylaxis.

Results

The estimated annual number of perinatally infected infants born in the United States decreased from 216 (95% CI, 206-230) in 2002 to 69 (95% CI, 60-83) in 2013. Among perinatally HIV-infected children born in 2002-2013, 836 (63.0%) of the mothers identified as black or African American and 243 (18.3%) as Hispanic or Latino. A total of 236 (37.5%) of the mothers had HIV infection diagnosed before pregnancy in 2002-2005 compared with 120 (51.5%) in 2010-2013; the proportion of mother-infant pairs receiving all 3 recommended arms of antiretroviral prophylaxis or treatment (prenatal, intrapartum, and postnatal) was 22.4% in 2002-2005 and 31.8% in 2010-2013, with approximately 179 (28.4%) (2002-2005) and 94 (40.3%) (2010-2013) receiving antiretroviral prophylaxis or treatment during pregnancy. Five Southern states (Florida, Texas, Georgia, Louisiana, and Maryland) accounted for 687 (38.0%) of infants born with HIV infection in the United States during the overall period. According to national data for live births, the incidence of perinatal HIV infection among infants born in the United States in 2013 was 1.75 per 100 000 live births.

Conclusions and Relevance

Despite reduced perinatal HIV infection in the United States, missed opportunities for prevention were common among infected infants and their mothers in recent years. As of 2013, the incidence of perinatal HIV infection remained 1.75 times the proposed Centers for Disease Control and Prevention elimination of mother-to-child HIV transmission goal of 1 per 100 000 live births.

Missed Opportunities for Prevention of Mother-to-Child Transmission of Human Immunodeficiency Virus

OBJECTIVE

To identify missed opportunities for prevention of mother-to-child transmission of human immunodeficiency virus (HIV).

METHODS

Data regarding HIV-infected children born between 2002 and 2009 to HIV-infected women enrolled in the U.S. International Maternal Pediatric Adolescent AIDS Clinical Trials prospective cohort study (protocol P1025) were reviewed. The characteristics of the HIV-infected infants and their mothers and the mothers' clinical management are described.

RESULTS

Twelve cases of mother-to-child transmission of HIV occurred among 1,857 liveborn neonates, for a prevalence of 0.65 per 100 live births to HIV-infected women (95% confidence interval 0.33-1.13). Four transmissions occurred in utero, three were peripartum transmissions, and the timing of transmission for five neonates was unable to be determined. None were breastfed. Seven women had plasma viral loads greater than 400 copies/mL near delivery. Six women had less than 11 weeks of antiretroviral therapy during pregnancy; three of these women had premature deliveries. One woman received no antiretroviral therapy during pregnancy because she was diagnosed with HIV postpartum. Six had poor to moderate adherence to antiretroviral therapy. Four of the five mothers with viral loads greater than 1,000 copies/mL delivered preterm neonates. There were five women who delivered by cesarean; four were nonelective cesarean deliveries and only one was an elective cesarean delivery for HIV prevention.

CONCLUSION

Despite access to high-level care and follow-up, a small proportion of HIV-infected women transmitted the virus to their neonates. This case series provides insight into factors contributing to HIV perinatal transmission and can inform the development of new strategies for prevention of mother-to-child transmission of HIV.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT00028145.

Pregnancy and neonatal outcomes among a cohort of HIV-infected women in a large Italian teaching hospital: a 30-year retrospective study

The primary study objective was to investigate three decades from 1985 to 2014 of changes in pregnancies among HIV-infected women. The secondary objective was to assess risk factors associated with preterm delivery and severe small-for-gestational-age (SGA) infants in HIV-infected women. A retrospective review of deliveries among pregnant HIV-infected women at the University of Genoa and IRCCS San Martino-IST in Genoa between 1985 and 2014 was performed. Univariate and multivariable analyses were used to study the variables associated with neonatal outcomes. Overall, 262 deliveries were included in the study. An increase in median age (26 years in 1985-1994 vs. 34 years in 2005-2014), in the proportion of foreigners (none in 1985-1994 vs. 27/70 (38·6%) in 2005-2014), and a decrease in intravenous drug use (75·2% (91/121) in 1985-1994 vs. 12·9% (9/70) in 2005-2014) among pregnant HIV-infected women was observed. Progressively, HIV infections were diagnosed sooner (prior to pregnancy in 80% (56/70) of women in the last decade). An increase in combined antiretroviral therapy (cART) prescription during pregnancy (50% (27/54) in 1995-2004 vs. 92·2% (59/64) in 2005-2014) and in HIV-RNA <50 copies/ml at delivery (19·2% (5/26) in 1995-2004 vs. 82·3% (53/64) in 2005-2014) was observed. The rate of elective caesarean section from 1985 to 1994 was 9·1%, which increased to 92·3% from 2004 to 2015. Twelve (10·1%) mother-to-child transmissions (MTCT) occurred in the first decade, and six (8·3%) cases occurred in the second decade, the last of which was in 2000. Preterm delivery (<37 weeks gestation) was 5% (6/121) from 1985 to 1994 and increased to 17·1% (12/70) from 2005 to 2014. In univariate and multivariable logistic regression analyses, advancing maternal age and previous pregnancies were associated with preterm delivery (odds ratio (OR) 2·7; 95% confidence intervals (CI) 1-7·8 and OR 2·6; 95% CI 1·1-6·7, respectively). In the logistic regression analysis, use of heroin or methadone was found to be the only risk factor for severe SGA (OR 3·1; 95% CI 1·4-6·8). In conclusion, significant changes in demographic, clinical and therapeutic characteristics of HIV-infected pregnant women have occurred over the last 30 years. Since 2000, MTCT has decreased to zero. An increased risk of preterm delivery was found to be associated with advancing maternal age and previous pregnancies but not with cART. The use of heroin or methadone has been confirmed as a risk factor associated with severe SGA.

Pregnancy outcomes in HIV-positive women: a retrospective cohort study

PURPOSE

In the United States, an estimated 8500 HIV (human immunodeficiency virus) positive women gave birth in 2014. This rate appears to be increasing annually. Our objective is to examine obstetrical outcomes of pregnancy among HIV-positive women.

METHODS

A population-based cohort study was conducted using the Nationwide Inpatient Sample database (2003-2011) from the United States. Pregnant HIV-positive women were identified and compared to pregnant women without HIV. Multivariate logistic regression was used to estimate the adjusted effect of HIV status on obstetrical and neonatal outcomes.

RESULTS

Among 7,772,999 births over the study period, 1997 were in HIV-positive women (an incidence of 25.7/100,000 births). HIV-infected patients had greater frequency of pre-existing diabetes and chronic hypertension, and use of cigarettes, drugs, and alcohol during pregnancy (p < 0.001). Upon adjustment for baseline characteristics, HIV-infected women had greater likelihood of antenatal complications: preterm premature rupture of membranes (OR 1.35, 95% CI 1.14-1.60) and urinary tract infections (OR 3.02, 95% CI 2.40-3.81). Delivery and postpartum complications were also increased among HIV-infected women: cesarean delivery (OR 3.06, 95% CI 2.79-3.36), postpartum sepsis (OR 8.05, 95% CI 5.44-11.90), venous thromboembolism (OR 2.21, 95% CI 1.46-3.33), blood transfusions (OR 3.67, 95% CI 3.01-4.49), postpartum infection (OR 3.00, 95% CI 2.37-3.80), and maternal mortality (OR 21.52, 95% CI 12.96-35.72). Neonates born to these mothers were at higher risk of prematurity and intrauterine growth restriction.

CONCLUSION

Pregnancy in HIV-infected women is associated with adverse maternal and newborn complications. Pregnant HIV-positive women should be followed in high-risk healthcare centers.

The impact of highly active antiretroviral therapy on obstetric conditions: A review

HIV is the leading cause of maternal and neonatal morbidity and mortality in resource constrained countries. Highly active antiretroviral treatment (HAART) initiated in pregnancy has now almost eliminated mother to child transmission of the virus, and is beginning to show the desired effect of reducing HIV related maternal mortality. By modulating host immunological responses HAART has the potential to alter infections during pregnancy, in addition to modifying clinical conditions such as preeclampsia. There is increasing evidence of the benefits of HAART given to pregnant women, however there is paucity of data that distinguishes HIV or HAART as the cause or exacerbation of pre-existing medical conditions or conditions specific to pregnancy. Anaemia is the commonest haematological disorder seen in HIV infected women and is more pronounced during pregnancy. The use of HAART has the potential to reduce the incidence and severity of the disease. Tuberculosis (TB) is the commonest chest infection amongst HIV infected people, being more common amongst pregnant than non-pregnant women. It is the leading cause of death from infectious diseases amongst women of reproductive age, and accounts for at least a quarter of all cases of maternal deaths associated with non-pregnancy related infections (NPRI). TB can manifest at any stage of the HIV infection, including during treatment with HAART. The latter (ie TB manifestation during HAART treatment) is thought to be the commonest manifestation of what is now known as immune reconstitution inflammatory syndrome (IRIS). In a South African report on maternal deaths, 55% of women who died of TB were on HAART, and a further 35% of women in the NPRI category died from other pneumoniae, notably pneumocystis jorevicci, which is also related to HIV infection. With regards to puerperal sepsis, studies are yet to show the impact of HAART independent of antibiotics in reducing infectious morbidity in HIV infected women. Preeclampsia has been associated with HIV infection, where most studies point towards a reduced risk in HIV infected women. There is increasing evidence that this reduced risk is reversed in the presence of HAART, with women accessing HAART having almost the same risk as HIV uninfected women. HIV or its treatment may be associated with increased risk of obstetric haemorrhage, and an increasing trend of obstetric haemorrhage as a cause of maternal deaths has been recently reported, proportionally in line with the introduction and increasing availability of HAART for pregnant women The mechanism by which this may occur remains elusive since pregnancy is a pro-thrombotic state, however, HIV-related thrombocytopenia or vasculitis could account for the association, if found. HAART would then be expected to reverse this. HAART especially protease inhibitor containing combinations, have been associated with preterm deliveries and low birth weight, particularly when initiated prior to the index pregnancy. With these overall findings of the effect of HAART on obstetric conditions, this review is intended to encourage heightened surveillance of adverse events associated with HAART use in pregnant women.