Prenatal care and birth outcomes of a cohort of HIV-infected women

HIV, placental pathology and birth outcomes - a brief overview

The spectrum of placental pathology in human immunodeficiency virus (HIV) is vast. Features observed are not only limited to the effects of the virus itself but may include that of coinfections such as tuberculosis and syphilis. The presence of other comorbidities and changes as a result of antiretroviral therapy may further confound the histologic findings. There is a paucity of unbiased information of the effects of maternal HIV on the placenta and how these changes relate to birth outcomes. Antiretroviral therapy, now in widespread use, has altered the course of maternal HIV disease and it is unknown whether this has altered the pathophysiology of HIV on the placenta. HIV-associated placental findings that have been most well described include acute chorioamnionitis, low placental weight and maternal vascular malperfusion, with a tendency towards lower rates of chronic villitis.

Adequacy of prenatal care among women living with human immunodeficiency virus: a population-based study

Background

Prenatal care reduces perinatal morbidity. However, there are no population-based studies examining the adequacy of prenatal care among women living with HIV. Accordingly, we compared the prevalence of adequate prenatal care among women living with and without HIV infection in Ontario, Canada.

Methods

Using administrative data in a universal single-payer setting, we determined the proportions of women initiating care in the first trimester and receiving adequate prenatal care according to the Revised-Graduated Prenatal Care Utilization Index . We also determined the proportion of women with HIV receiving adequate prenatal care by immigration status. We used generalized estimating equations with a logit link function to derive adjusted odds ratios (aORs) and 95 % confidence intervals (CI) for all analyses.

Results

Between April 1, 2002 and March 31, 2011, a total of 1,132,135 pregnancies were available for analysis, of which 634 (0.06 %) were among women living with HIV. Following multivariable adjustment, women living with HIV were less likely to receive adequate prenatal care (36.1 % versus 43.3 %; aOR 0.74, 95 % CI 0.62 to 0.88) or initiate prenatal care in the first trimester (50.8 % versus 70.0 %; aOR 0.51, 95 % CI 0.43 to 0.60) than women without HIV. Among women with HIV, recent (i.e. ≤ 5 years) immigrants from Africa and the Caribbean were less likely to receive adequate prenatal care (25.5 % versus 38.5 %; adjusted odds ratio 0.51; 95 % CI, 0.32 to 0.81) than Canadian-born women.

Conclusion

Despite universal health care, disparities exist in the receipt of adequate prenatal care between women living with and without HIV. Interventions are required to ensure that women with HIV receive timely and adequate prenatal care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1842-y) contains supplementary material, which is available to authorized users.

Perinatal outcomes in HIV positive pregnant women with concomitant sexually transmitted infections

Objective. To evaluate whether HIV infected pregnant women with concomitant sexually transmitted infection (STIs) are at increased risk of adverse perinatal and neonatal outcomes. Methods. We conducted a cohort study of HIV positive women who delivered at an inner-city hospital in Atlanta, Georgia, from 2003 to 2013. Demographics, presence of concomitant STIs, prenatal care information, and maternal and neonatal outcomes were collected. The outcomes examined were the association of the presence of concomitant STIs on the risk of preterm birth (PTB), postpartum hemorrhage, chorioamnionitis, preeclampsia, intrauterine growth restriction, small for gestational age, low Apgar scores, and neonatal intensive care admission. Multiple logistic regression was performed to adjust for potential confounders. Results. HIV positive pregnant women with concomitant STIs had an increased risk of spontaneous PTB (odds ratio (OR) 2.11, 95% confidence interval [CI] 1.12–3.97). After adjusting for a history of preterm birth, maternal age, and low CD4+ count at prenatal care entry the association between concomitant STIs and spontaneous PTB persisted (adjusted OR 1.96, 95% CI 1.01–3.78). Conclusions. HIV infected pregnant women with concomitant STIs relative to HIV positive pregnant women without a concomitant STI are at increased risk of spontaneous PTB.

Rapid HIV testing and obstetrical characteristics of women with unknown HIV serostatus at time of labor and delivery

OBJECTIVE

To describe the obstetrical characteristics of women without prenatal care and/or undocumented human immunodeficiency virus (HIV) serostatus who presented for delivery and to assess the usefulness of rapid HIV screening in these women.

MATERIALS AND METHODS

The study design was a retrospective analysis. Demographics, labor, delivery characteristics, and pregnancy outcomes of women without prenatal care and/or unknown HIV serostatus were reviewed.

RESULTS

Three hundred fifty parturients met the inclusion criteria: 15.2% presented at complete cervical dilation, 48.6% with cervical dilation of at least 5 cm, and 43.1% with ruptured membranes. Twenty-two percent of parturients delivered within 1 hour of admission, 47.6% delivered within 4 hours of admission, and 5.5% delivered prior to arrival to the hospital. With the lengthy admission process and procurement of zidovudine from the pharmacy requiring at least 1 hour at best, 27.5% would not have the benefit of intrapartum zidovudine treatment. Single Use Diagnostic System HIV-1 rapid test was reactive and confirmed in 7 women (2.5%).

CONCLUSION

Rapid HIV screening is a useful tool for guiding immediate obstetrical management and coordinated care for the neonate. In some circumstances, the full benefit of rapid HIV detection will not be realized due to advanced labor, ruptured members, or delivery prior to arrival.

Pregnancy outcomes in HIV-infected and uninfected women in rural and urban South Africa

OBJECTIVE

To describe pregnancy outcomes among clade C HIV-infected and uninfected women in South Africa.

DESIGN

A longitudinal cohort study.

METHODS

Pregnant women attending 9 rural/urban antenatal clinics were prospectively recruited and followed up. Women were seen at the clinic or at home after delivery on 4 occasions after enrollment: 2 times within the first 2 weeks of the newborn's life at home, and every 2 weeks thereafter until their first health clinic visit when the infant was 6 weeks old.

RESULTS

A total of 3465 women were enrolled; 615 withdrew after delivery, moved away, or had a missing or indeterminate HIV status, leaving 2850 women (1449 HIV-infected women). Six women died after delivery and there were 17 spontaneous abortions and 104 stillbirths. An adverse pregnancy outcome was independently associated with HIV infection (adjusted odds ratio [AOR] = 1.63; P = 0.015), urban enrollment (AOR = 0.39; P = 0.020), and nonhospital delivery (AOR = 13.63; P < 0.001) as well as with a CD4 count <200 cells/mL among HIV-infected women (AOR = 1.86; P = 0.127). Among 2529 singleton liveborn babies, birth weight was inversely associated with maternal HIV (AOR = 1.45; P = 0.02) and maternal middle upper arm circumference (AOR = 0.93; P < 0.001). Early infant mortality was not significantly associated with maternal HIV (hazard ratio [HR] = 1.18; P = 0.52) but was with urban sites (HR = 0.34; P = 0.045). Low birth weight substantially increased mortality (AOR = 8.3; P < 0.001). HIV status of infants by 8 weeks of age (14.6%, 95% confidence interval: 12.5% to 17.0%) was inversely associated with maternal CD4 cell count and birth weight.

CONCLUSIONS

HIV-infected women are at a significantly increased risk of adverse pregnancy outcomes. Low-birth-weight infants of HIV-infected and uninfected women are at substantially increased risk of dying.

Declines in low birth weight and preterm birth among infants who were born to HIV-infected women during an era of increased use of maternal antiretroviral drugs: Pediatric Spectrum of HIV Disease, 1989-2004

OBJECTIVE

Our goal was to determine trends in low birth weight and preterm birth among US infants born to HIV-infected women.

METHODS

We used data from the longitudinal Pediatric Spectrum of HIV Disease, a large HIV cohort, to assess trends in low birth weight and preterm birth from 1989 to 2004 among 11,321 study infants. Among women with prenatal care, we also assessed risk factors, including maternal antiretroviral therapy during pregnancy, that were predictive of low birth weight and preterm birth using univariate and multivariate logistic regression models.

RESULTS

Overall, 11,231 of 14,464 infants who were enrolled in Pediatric Spectrum of HIV Disease were tested during the neonatal period. From 1989 to 2004, testing increased from 32% to 97%. The proportion of HIV-exposed infants who had low birth weight decreased from 35% to 21% and occurred in all racial/ethnic groups. Prevalence of preterm birth decreased from 35% to 22% and occurred in all groups. Any maternal antiretroviral therapy use increased from 2% to 84%. Among 8793 women who had prenatal care, low birth weight was associated with a history of illicit maternal drug use, unknown maternal HIV status before delivery, symptomatic maternal HIV disease, black race, Hispanic ethnicity, and infant HIV infection. Antiretroviral therapy or lack of it was not associated with low birth weight. Among women with prenatal care, preterm birth was associated with a history of illicit maternal drug use, symptomatic maternal HIV disease, no antiretroviral therapy, receipt of a 3-drug highly active antiretroviral therapy regimen with protease inhibitors, black race, and infant HIV infection.

CONCLUSIONS

The proportion of infants who had low birth weight or were born preterm declined during an era of increased maternal antiretroviral therapies. These Pediatric Spectrum of HIV Disease trends differ from the overall increases in both outcomes among the US population.

Why are children still being infected with HIV? Experiences in the prevention of mother-to-child transmission of HIV in south London

OBJECTIVES

To evaluate the effectiveness of interventions to prevent mother-to-child transmission of HIV at a large teaching hospital in South East London, and to assess reasons for the small numbers of transmissions that continue to occur.

DESIGN

A database of all pregnant women diagnosed as HIV positive between 1993 and 2005 was reviewed, with detailed (retrospective) case-note review of all mother-infant pairs where HIV transmission occurred.

SETTING

King's College Hospital, London, UK, a teaching hospital serving an ethnically diverse and socially deprived population.

RESULTS

296 pregnancies to 274 women were recorded. 9 of 296 (3.0%) women were lost to follow-up before the end of the pregnancy. Of 287 pregnancies followed up until after delivery, 6 (2.1%) resulted in HIV infection in the infant. More recently, between 2000 and 2004, this transmission rate was even lower, at 3 in 231 (1.3%). Each of these six women had complications, including late presentation to services and defaulting follow-up appointments, which were likely to increase the risk of HIV transmission. Four of the six transmissions occurred in utero.

CONCLUSION

The overall transmission rate of 2% attests to the efforts of the multidisciplinary care team in managing this population which is often hard to reach. Clearly, good systems are needed to trace those women who default. Further data are needed regarding in utero transmissions.

A comparison of HIV positive and negative pregnant women at a public sector hospital in South Africa

AIM

The aim of the study was to compare HIV positive and negative pregnant women with respect to maternal and neonatal outcome to inform the development of clinical practice guidelines.

BACKGROUND

HIV infection in pregnancy places an added burden on the physical ability of the woman's body to cope with pregnancy. As a result HIV causes an exaggeration of the problems related to pregnancy.

METHOD

Data were collected by means of a retrospective record review conducted on 212 stratified randomly selected HIV positive and 101 matched HIV negative pregnant women. The two sample t-test and Fisher exact test were used to compare the maternal and neonatal outcomes of HIV positive and negative pregnant women.

RESULTS

HIV positive pregnant women had a significantly lower haemoglobin (10.85 vs. 11.48 g/dl; P = 0.001), attended significantly fewer antenatal clinic appointments (4.03 vs. 4.63; P = 0.04), weighed significantly less (72.07 vs. 76.69 kg; P = 0.02) and were significantly more likely to present with an abnormal vaginal discharge (32.55 vs. 24.75%; P = 0.02) than HIV negative pregnant women. The difference in the prevalence in HIV positive pregnant women of pregnancy induced hypertension (16.98 vs. 9.90%; P = 0.06), syphilis infection (5.95 vs. 0.99%; P = 0.062) and urinary tract infection (15.53 vs. 7.92%; P = 0.06) approached significance when compared with HIV negative pregnant women. HIV positive pregnant women were significantly more likely to present with intrauterine growth retardation (4.72 vs. 0%; P = 0.03), significantly more likely to deliver earlier (37.92 vs. 38.51 weeks; P = 0.03) and significantly more likely to deliver neonates weighing less (2969.98 vs. 3138.43 g; P = 0.01) than HIV negative pregnant women.

CONCLUSION

The Department of Health attributes the high rate of HIV and AIDS related maternal morbidity and mortality in South Africa to the absence of accepted and practical guidelines for midwives' antenatal assessment and management of HIV positive pregnant women. Relevance to clinical practice. This study identifies maternal and neonatal outcomes related to HIV infection in pregnancy and provides evidence required to inform the development of clinical practice guidelines.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Adequação do pré-natal e peso ao nascer: uma revisão sistemática

Esta foi uma revisão sistemática da literatura de publicações em que o pré-natal foi investigado com uma das variáveis preditoras do peso ao nascer. Os bancos de dados MEDLINE, Cochrane Library e SciELO foram rastreados usando-se a combinação dos seguintes descritores: "prenatal care", "antenatal care", "quality", "adequacy", "birthweight", e "low birthweight". Foram localizados 25 estudos: 17 transversais, quatro coortes, três caso-controle e um ensaio randomizado. Os indicadores de adequação empregados foram os de utilização (quantitativos) e os de conteúdo do cuidado (de processo ou qualitativos). A maioria dos autores aplicou indicadores de utilização, principalmente o Índice de Kessner e o Adequacy of Prenatal Care Utilization Index. Somente dois estudos usaram critérios qualitativos. De modo geral, os estudos transversais detectaram efeito protetor do pré-natal sobre o baixo peso ao nascer, enquanto que os resultados de investigações com outros desenhos foram conflitantes. Os achados desta revisão evidenciam que o impacto do pré-natal sobre o peso ao nascer não é inequívoco, principalmente devido ao efeito do viés de auto-seleção. Há a necessidade de realização de ensaios randomizados para esclarecer essa relação.

Sensitivity of an AIDS case-finding algorithm: who are we missing?

OBJECTIVE

The objective of this study was to determine the sensitivity of an AIDS case-finding algorithm.

METHOD

This study applied the AIDS case-finding algorithm to paid Medicaid claims linked to New Jersey AIDS surveillance data and assesses its sensitivity across subgroups of patients.

FINDINGS

Of the 7183 cases with confirmed AIDS, based on the state's registry information, 95% (n = 6818) were correctly detected using all Medicaid claims, including pharmacy. For patients in a community-based waiver program, covered by Medicare, diagnosed with a severe mental illness, or continuously enrolled in Medicaid, with regular contact with the medical system, the algorithm identified almost all patients. To further evaluate algorithm performance, it was used with 2 groups of interest to researchers. For AIDS patients in the last 6 months of life, 88% were correctly detected without use of pharmacy claims and 95% when pharmacy claims were included. For pregnant women, data from the 6 months before the latest delivery date identify 27% of pregnant women without pharmacy claims and 41% when pharmacy claims were included. Using claims made after the latest delivery date, 81% of pregnant women were detected without pharmacy claims and 93% when pharmacy claims were included

CONCLUSION

Results demonstrate that a multilevel screen can be used with Medicaid claims to effectively to detect most patients with AIDS. Detection is lower for some subgroups, and the absence of pharmacy claims can compromise detection.

Effects of long-term, medically supervised, drug-free treatment and methadone maintenance treatment on drug users' emergency department use and hospitalization

We examined the effect of drug treatment in 1996 on repeated (> or =2) emergency department visits and hospitalization in 1997 in a cohort of New York State Medicaid-enrolled human immunodeficiency virus (HIV)-positive and HIV-negative drug users. In HIV-positive drug users, the adjusted odds of repeated emergency department visits were increased for those receiving no long-term treatment (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.04-2.75), whereas the adjusted odds for those receiving methadone treatment and those receiving drug-free treatment for > or =6 months did not differ. The adjusted odds of hospitalization in the HIV-positive group were higher for those receiving long-term methadone treatment (OR, 1.69; 95% CI, 1.14-2.55) and for those receiving no long-term treatment (OR, 1.91; 95% CI, 1.29-2.88), compared with those receiving drug-free treatment. In the HIV-negative group, these associations were similar but weaker. For both HIV-positive and HIV-negative drug users, long-term drug-free treatment was at least as effective as long-term methadone treatment in reducing use of services indicative of poorer access to care and/or poorer health.

Effect of medical, drug abuse, and mental health care on receipt of dental care by drug users

We examined the association of patterns of health care in 1996 with subsequent dental care in 1997 or 1998 for 47,260 drug users enrolled in New York State Medicaid. From Medicaid files, we identified psychiatric care, prescribed antidepressants, a regular source of medical care, regular drug treatment (6+ contiguous months), and clinical conditions. Of this cohort, 58% received dental care. The adjusted odds ratios (AOR) of dental care were increased for drug users receiving psychiatric care and antidepressants (1.66 [1.55, 1.77]), psychiatric care alone (1.48 [1.41, 1.56]), or only antidepressants (1.18 [1.10, 1.27]), vs. neither. AORs of dental care were also higher for those with a regular source of medical care alone (1.27 [1.23, 1.35]) or with regular drug treatment (1.33 [CI 1.25, 1.41]) vs. neither. Mental health care and, to a lesser extent, a regular source of medical care and regular drug treatment may promote dental care in this vulnerable population.

Outpatient patterns of care and longitudinal intensity of antiretroviral therapy for HIV-infected drug users

OBJECTIVE

To examine the association of drug users' outpatient patterns of care with subsequent intensity of antiretroviral therapy (ART).

MATERIALS AND METHODS

Annual types of ART in 8897 New York State Medicaid drug users who were prescribed ART for > or =6 months in 1996 or 1997 were determined. From pharmacy claims, intensity was classified from changes in annual type of ART in 1996 to 97 and 1997 to 98 as: optimal (ie, on or starting highly active ART [HAART]), acceptable (ie, on or starting 2+ non-HAART drugs), or suboptimal (ie, none, <6 months, one drug, or change from HAART to non-HAART). In both 1996 and 1997, outpatient pattern of care was defined including regular medical care, regular drug treatment, both, and neither and categories of visits for HIV-focused care. Predictors of adequate ART intensity were examined among the group with suboptimal or adequate intensity (model 1) and predictors of optimal ART intensity among the group with adequate or optimal intensity (model 2).

RESULTS

The adjusted odds ratios (AOR) of acceptable ART intensity in model 1 were increased for those with HIV-focused care (AOR, 2.9; 95% CI, 2.6, 3.3 for 4+ visits 1.7; 95% CI, 1.5, 1.9 for 1-3 visits) or regular medical care (AOR, 1.2 [1.1, 1.4]. Adjusted odds ratios (AOR) of optimal intensity in model 2 were increased for those with regular substance abuse care with (AOR, 1.4 [1.2, 1.7]) or without (AOR, 1.2 [1.1, 1.4]) regular medical care whereas HIV-focused visits had no effect.

CONCLUSION

Care from an HIV-focused provider was predictive of a drug user receiving at least adequate intensity of ART for more than 2 years whereas regular drug abuse treatment, especially with regular medical care, was associated with optimal intensity of ART.

Zidovudine use during pregnancy among HIV-infected women on Medicaid

OBJECTIVES

This study estimates the rate of zidovudine (ZDV) use during pregnancy among HIV-infected women receiving Medicaid. The rates of ZDV use during pregnancy are compared before (preperiod) and after (postperiod) the 1994 publication of US Public Service Task Force guidelines, recommending use of ZDV during pregnancy. The authors also compare and contrast the correlates of ZDV use during pregnancy in each of the preguideline and postguideline periods.

METHODS

New Jersey AIDS/HIV surveillance data and paid Medicaid claims data between 1992 and 1996 were merged to examine ZDV use during pregnancy. Among ZDV users, the authors also examined persistence of ZDV use during the 3 months preceding delivery. In these analyses, the authors examined care received during pregnancy and differentiated routine medical care from pregnancy-specific care. Correlates of intrapregnancy ZDV use were examined using chi2 analysis and robust regression techniques that correct for correlation among repeated observations.

RESULTS

Use of ZDV during pregnancy steadily increased from 13% in 1992 to 70% in 1996, with the upward trend beginning before the release of the guidelines. Averaged over the full preperiod (1992-1994), the rate was 29%, increasing to 57% during the full postperiod (1995-1996). Women with no health care during pregnancy did not receive any ZDV prophylaxis. Women who had some health care contacts, but did not receive pregnancy-specific care, had low rates of ZDV use that did not increase after the promulgation of the guidelines (21% in preperiod and 27% in postperiod). Women who received pregnancy-specific care, whether from obstetrician-gynecologists (OB-GYNs) or other providers, substantially increased their use of ZDV in the postguideline period (from 37% to 63% for those who saw OB-GYNS, and from 20% to 59% for those who received pregnancy-specific care from other providers). However, among users of ZDV, only a minority (24%) used ZDV persistently during the 3 months preceding delivery. African American women were less likely to be persistent ZDV users, even after controlling for other factors.

CONCLUSIONS

The study highlights the underutilization of ZDV by women who did not receive pregnancy-related care, even after the publication of guidelines. Lack of pregnancy-specific medical care during pregnancy is an important barrier to ZDV prophylaxis. This study confirms that the receipt of prenatal care during pregnancy is a key intervening variable in the real world application of the PHS guidelines and underscores the importance of proactive efforts to provide prenatal care to pregnant women with HIV.

Human immunodeficiency virus infection is a risk factor for adverse perinatal outcome

OBJECTIVE

The purpose of this study was to examine the relationship between maternal human immunodeficiency virus infection and adverse perinatal outcomes.

STUDY DESIGN

A retrospective cohort study was conducted in a population of pregnant women who were delivered in a large inner-city hospital between January 1, 1988, and December 31, 1995. The study population consisted of 563 women who were human immunodeficiency virus seropositive and 2252 control subjects who were human immunodeficiency virus seronegative. Results were analyzed with descriptive statistics, chi2 tests, and logistic regression to adjust for potential confounders.

RESULTS

Women who were seropositive were more likely than control subjects to deliver low birth weight infants (29.3% vs 16.3%; odds ratio, 2.11; 95% CI, 1.68-2.64), preterm infants (28.9% vs 18.2%; odds ratio, 1.83; 95% CI, 1.45-2.38), and intrauterine growth-restricted infants (16.5% vs 10.6%; odds ratio, 1.66; 95% CI, 1.26-2.19). They were also more likely to have perinatal deaths (11.5% vs 8.3% odds ratio, 1.41; 95% CI, 1.03-1.95). The risk of fetal malformations, fetal distress, and route of delivery were similar between the groups. After race, parity, alcohol use, prenatal care, diabetes mellitus, hypertension, percent ideal body weight, and sexually transmitted diseases were controlled with logistic regression, the increased risk of low birth weight (adjusted odds ratio, 1.45; 95% CI, 1.14-1.86) and preterm delivery (adjusted odds ratio, 1.32; 95% CI, 1.04-1.70) persisted.

CONCLUSION

Parturients in our inner-city hospital who were infected with human immunodeficiency virus are at increased risk for delivery of low-birth-weight and premature infants.

HIV-1 RNA viral load monitoring in HIV-infected drug users on antiretroviral therapy: relationship with outpatient care patterns

HIV-1 viral load (VL) testing is a standard component of HIV care. We examined the use and predictors of VL testing in drug users, a group at risk for problematic care. Using 1996 to 1998 New York State (NYS) Medicaid files, we studied drug users who had been enrolled >10 months, had been prescribed antiretroviral agents in 1997 and 1998, and who had undergone any VL testing in 1997. Our outcome was regular VL testing shown by two or more paid claims for this test in 1998. Patterns of care in 1997 were defined as: regular source of medical care (>35% of visits to one provider), and/or regular drug treatment of >6 months, or neither. We counted visits in 1997 to a provider offering HIV-focused care. Adjusted odds ratios (AORs) of VL testing were assessed. Of 3131 drug users, 73.9% had at least one VL test, whereas 56.2% had two or more VL tests in 1998. The AORs of two or more VL tests were increased for those with regular drug abuse care alone (AOR, 1.50; 95% confidence interval [CI], 1.21-1.84) or with regular medical care (AOR, 1.27; 95% CI, 1.03-1.57) versus those with neither. HIV-focused care was positively associated with two or more VL tests (AOR, 1.38; 95% CI, 1.05-1.81 for 1-3 visits; AOR, 1.94; 95% CI, 1.50-2.51 for four or more visits). We found that nearly half this cohort of drug users did not have regular VL testing. Drug users with HIV-focused care or with regular drug treatment are more likely to have regular VL testing.

Clinical care issues for women living with HIV and AIDS in the United States

As the number of women infected with HIV in the United States continues to increase, the medical community is faced with the challenge of providing adequate and appropriate care to them. This paper reviews key questions concerning the state of knowledge on the epidemiology, biology, and clinical care of women living with HIV and AIDS in the United States. Because heterosexual transmission accounts for a growing number of cases among women, biological factors and cofactors that may enhance women's susceptibility to HIV infection are also reviewed. HIV-related gynecological issues are presented separately to evaluate whether gynecological complications are distinct in HIV-uninfected and HIV-infected women. Questions of whether there are sex-specific differences in the efficacy and adverse effects of new antiviral agents are discussed. In addition, significant gaps are highlighted that still exist in our understanding of both the effects of HIV and HIV-related drugs upon pregnancy. Finally, the psychiatric stresses and complications that affect women living with HIV and AIDS are also discussed. In each section of this review, gaps in our knowledge of these issues are identified. To properly address these disparities in knowledge, not only do efforts to gather sex-specific biomedical data need to be more exacting, but there is a distinct need to conduct more sex-specific research concerning HIV.

Infant birth weight among women with or at high risk for HIV infection: the impact of clinical, behavioral, psychosocial, and demographic factors

The purpose of these analyses was to provide a prospective examination of the impact of HIV on birth weight using clinical, behavioral, psychosocial, and demographic correlates. HIV-positive (n = 319) and HIV-negative (n = 220) pregnant women matched for HIV risk factors (i.e., drug use and sexual risk behaviors) were interviewed during the 3rd trimester of pregnancy and 6 weeks postpartum. Medical chart reviews were also conducted for the HIV-seropositive pregnant women to verify pregnancy-related and birth outcome data. In a logistic regression analysis, model chi2(9, N = 518) = 124.8, p < .001, controlling for parity and gestational age, women who were HIV seropositive were 2.6 times more likely to have an infant with low birth weight. In addition, Black women and those who did not live with their partners were more than 2 times as likely to have infants with low birth weight, and those who smoked were 3.2 times more likely to have infants with low birth weight. Knowing that women with HIV, those who are Black, and those not living with a partner are at highest risk for adverse birth outcomes can help those in prenatal clinics and HIV specialty clinics to target resources and develop prevention interventions. This is particularly important for women with HIV because birth weight is associated with risk of HIV transmission from mother to child.

Risk factors for preterm birth, low birth weight, and intrauterine growth retardation in infants born to HIV-infected pregnant women receiving zidovudine. Pediatric AIDS Clinical Trials Group 185 Team

OBJECTIVE

To evaluate independent contributions of maternal factors to adverse pregnancy outcomes (APO) in HIV-infected women receiving antiretroviral therapy (ART).

DESIGN

Risk factors for preterm birth (< 37 weeks gestation), low birth weight (LBW) (< 2500 g), and intrauterine growth retardation (IUGR) (birth weight < 10th percentile for gestational age) examined in 497 HIV-infected pregnant women enrolled in PACTG 185, a perinatal clinical trial.

METHODS

HIV RNA copy number, culture titer, and CD4 lymphocyte counts were measured during pregnancy. Information collected included antenatal use of cigarettes, alcohol, illicit drugs; ART; obstetric history and complications.

RESULTS

Eighty-six percent were minority race/ethnicity; 86% received antenatal monotherapy, predominantly zidovudine (ZDV), and 14% received combination antiretrovirals. Preterm birth occurred in 17%, LBW in 13%, IUGR in 6%. Risk of preterm birth was independently associated with prior preterm birth [odds ratio (OR) 3.34; P < 0.001], multiple gestation (OR, 6.02; P = 0.011), antenatal alcohol use (OR, 1.91; P = 0.038), and antenatal diagnosis of genital herpes (OR, 0.24; P = 0.022) or pre-eclampsia (OR, 6.36; P = 0.025). LBW was associated with antenatal diagnosis of genital herpes (OR, 0.08; P = 0.014) and pre-eclampsia (OR, 5.25; P = 0.049), and baseline HIV culture titer (OR, 1.41; P = 0.037). IUGR was associated with multiple gestation (OR, 8.20; P = 0.010), antenatal cigarette use (OR, 3.60; P = 0.008), and pre-eclampsia (OR, 12.90; P = 0.007). Maternal immune status and HIV RNA copy number were not associated with APO.

CONCLUSIONS

Risk factors for APO in antiretroviral treated HIV-infected women are similar to those reported for uninfected women. These data suggest that provision of prenatal care and ART may reduce APO.

Improved birth outcomes among HIV-infected women with enhanced Medicaid prenatal care

OBJECTIVES

This study evaluated the impact of enhanced prenatal care on the birth outcomes of HIV-infected women.

METHODS

Medicaid claims files linked to vital statistics were analyzed for 1723 HIV-infected women delivering a live-born singleton from January 1993 to October 1995. Prenatal care program visits were indicated by rate codes. Logistic models controlling for demographic, substance use, and health care variables were used to assess the program's effect on preterm birth (less than 37 weeks) and low birthweight (less than 2500 g).

RESULTS

Of the women included in the study, 75.3% participated in the prenatal care program. Adjusted program care odds were 0.58 (95% confidence interval [CI] = 0.42, 0.81) for preterm birth and 0.37 (95% CI = 0.24, 0.58) for low-birthweight deliveries in women without a usual source of prenatal care. Women with a usual source had lower odds of low-birthweight deliveries if they had more than 9 program visits. The effect of program participation persisted in sensitivity analyses that adjusted for an unmeasured confounder.

CONCLUSIONS

A statewide prenatal care Medicaid program demonstrates significant reductions in the risk of adverse birth outcomes for HIV-infected women.

The cost-effectiveness of voluntary intrapartum rapid human immunodeficiency virus testing for women without adequate prenatal care

OBJECTIVES

We sought to determine the health and economic consequences of voluntary rapid human immunodeficiency testing during labor for women who have not received adequate prenatal care.

STUDY DESIGN

A decision-tree model was used to assess the number of pediatric human immunodeficiency virus cases that would be averted if women who were unable to determine their human immunodeficiency virus serostatus antenatally were offered an intrapartum rapid human immunodeficiency virus test. Medical costs associated with the introduction of this policy were also determined. Probability and cost estimates entered into the model are based on data in the published literature.

RESULTS

Under the base-case assumptions, a policy of intrapartum voluntary rapid human immunodeficiency virus testing decreases the number of cases of perinatal human immunodeficiency virus from 407 to 339 per 100,000 women without adequate prenatal care per year, with a corresponding cost savings of $6 million. Sensitivity analysis demonstrates that these cost savings are maintained across a wide range of assumptions and that even conservative scenarios still result in a cost-effective policy.

CONCLUSIONS

In the absence of adequate prenatal care, a voluntary rapid human immunodeficiency virus test not only allows patients to fully explore their options with regard to testing and treatment but also has the potential to provide significant health benefits to women and children and economic benefits to the medical system.

Frequency and predictors of medically attended injuries in HIV-infected children

The extent to which medically attended injuries complicate the clinical course of HIV-infected (HIV+) children is unknown. In a cohort of HIV+ children delivered from 1985 to 1990 and aged less than 60 months, we determined medically attended injuries per 100 child-years, Injury Severity Scores (ISS), and predictors of medically attended injuries by using New York State Medicaid claims from 1986 to 1992 linked to birth certificates. Injury rates and ISS were compared to those of a population of black, inner city children aged less than 60 months from emergency room records. HIV+ children had slightly more injuries (19.3 vs. 16.8/100 child-years) but similar ISS (2.4 vs. 2.3). Predictors of injuries in HIV+ children included younger maternal age (24/100 child-years, p = 0.008) and delivery outside of New York City (29/100 child-years, p = 0.02). Illicit drug use and alcohol use were associated with greater ISS while cocaine use was associated with a higher rate of possibly intentional injuries. Medically attended injuries affected one in five HIV+ children in our cohort annually, slightly more than the comparison population. Specific maternal and birth characteristics such as substance abuse and younger age at delivery may help target at-risk children.

Obstetric and newborn outcomes in a cohort of HIV-infected pregnant women: a report of the women and infants transmission study

OBJECTIVE

To determine obstetric and neonatal outcomes in a cohort of HIV-infected pregnant women and to assess whether HIV-related immunosuppression increases the risk of adverse outcomes of pregnancy.

METHODS

Between 1989 and 1994, interview, physical examination, laboratory, and medical record data were prospectively collected from HIV-infected pregnant women and on their newborns. Factors associated with adverse pregnancy outcome and HIV disease status were correlated with pregnancy outcome using logistic regression analysis.

RESULTS

634 women delivered after 24 weeks of gestation. Preterm birth, low birth weight, and small-for-gestational-age neonates occurred in 20.5%, 18.9%, and 24.0% of pregnancies, respectively. Factors associated with low birth weight were CD4 percentage <14%, history of adverse pregnancy outcome, pediatric HIV infection, bleeding during pregnancy, and Trichomonas infection. Preterm birth was associated with CD4 percentage <14%, a history of adverse pregnancy outcome, and bleeding during pregnancy. Being small for gestational age was associated with maternal hard drug use during pregnancy, Trichomonas infection, history of adverse pregnancy outcome, and hypertension.

CONCLUSIONS

Adverse pregnancy outcomes are common for HIV-infected women and are associated with low maternal CD4 percentage and pediatric HIV infection. Preterm birth, low birth weight, and small-for-gestational-age ranking, however, are also associated with previously recognized sociodemographic and obstetric factors that are not unique to HIV infection.

Safety of the maternal-infant zidovudine regimen utilized in the Pediatric AIDS Clinical Trial Group 076 Study

OBJECTIVE

To determine the safety of the zidovudine (ZDV) regimen utilized in the Pediatric AIDS Clinical Trial Group (ACTG) 076 study.

DESIGN

ACTG 076 was a randomized, double-blind, placebo-controlled trial which demonstrated that a ZDV regimen could prevent mother-to-child HIV-1 transmission. Infants were followed through 18 months of age and women were followed through 6 months postpartum.

METHODS

Maternal complications, pregnancy outcomes, growth and development of the uninfected infants, and HIV-1 disease progression in the women were monitored prospectively.

RESULTS

Maternal therapy was well tolerated. There was no serious pattern of adverse pregnancy outcomes associated with ZDV use. Amongst the ZDV-exposed infants, the only recognized toxicity was anemia within the first 6 weeks of life; the risk for anemia was not associated with premature delivery, duration of maternal treatment, degree of maternal immunosuppression, or maternal anemia. ZDV treatment was not associated with an increased incidence of newborn structural abnormalities. At 18 months of age, uninfected infants did not differ in growth parameters or immune function. No childhood neoplasias were reported in either group. In the women, at 6 months postpartum, there were no differences in clinical, immunologic, or virologic disease progression.

CONCLUSION

There were no identified problems that would alter current recommendations for the routine use of ZDV for the prevention of mother-child HIV-1 transmission.

The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis

OBJECTIVE

To investigate the association between maternal HIV infection and perinatal outcome by a systematic review of the literature and meta-analysis.

METHODS

Appropriate publications were identified using electronic and hand searching of relevant journals from 1983 to 1996. Studies were included in the review if they were prospective cohorts with pregnant women identified as being HIV-infected with a control group of pregnant women who were not infected with HIV. Methodological quality was assessed for each study. Data were extracted for pre-determined outcome measures. Sensitivity analyses were performed to explore the association between HIV infection and an adverse perinatal outcome for the following study characteristics: clinical setting (developed or developing countries), methodological quality (high or poor) and whether studies controlled for potential confounding.

RESULTS

Thirty-one studies were eligible to be included in the review. The summary odds ratio of the risk of pre-defined adverse perinatal outcomes related to maternal HIV infection were as follows: spontaneous abortion 4.05 (95% CI 2.75-5.96); stillbirth 3.91 (95% CI 2.65-5.77); fetal abnormality 1.08 (95% CI 0.7-1.66); perinatal mortality 1.79 (95% CI 1.14-2.81); neonatal mortality 1.10 (95% CI 0.63-1.93); infant mortality 3.69 (95% CI 3.03-4.49); intrauterine growth retardation 1.7 (95% CI 1.43-2.02); low birthweight 2.09 (95% CI 1.86-2.35) and pre-term delivery 1 83 (95% CI 1.63-2.06). Sensitivity analyses showed that the association between infant mortality and maternal HIV infection was stronger in studies conducted in developing countries when compared with developed countries [odds ratios (OR) 3.72 (95% CI 3.05-4.54) and 8.6 (95% CI 0.53-141.05), respectively]; studies of higher methodological quality compared with those of poorer quality [odds ratios 14.57 (95% CI 6.93-30.65) and 3.37 (95% CI 2.74-4.14), respectively] and studies which had used restriction or matching to control for potential confounding factors compared with those that had not [OR 11.60 (95% CI 5.71-23.58) and 3.35 (95% CI 2.73-4.12), respectively].

CONCLUSIONS

The findings of this review have implications for women infected with HIV who are planning a pregnancy or who find themselves pregnant. There appears to be an association, although not strong, between maternal HIV infection and an adverse perinatal outcome. This relationship may be due to bias including uncontrolled or residual confounding. There does, however, appear to be a real and large increase in the risk of infant death in developing countries associated with maternal HIV infection, especially so when there has been an attempt to control for confounding.

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.

Cigarette smoking and maternal-child HIV transmission

We investigated the association of cigarette smoking with maternal-child HIV transmission, adjusting for illicit drug use, maternal clinical status, and delivery factors. Vital statistics birth data were linked to the New York State Medicaid HIV/AIDS Research Database for HIV-infected women delivering a liveborn singleton from 1988 through 1990. Follow-up of these children was accomplished by Medicaid data > or = 2 years after birth, and their HIV status was ascertained by a clinically based classification. The adjusted relative risk or hazard (RH) of transmission for maternal factors was determined from Cox models. The overall transmission was 24.5% for the 901 maternal-child pairs. Smokers comprised 40% of women with data on smoking (n = 768); their transmission rate was 31% versus 22% for nonsmokers (p = 0.02). In the entire cohort, the adjusted RH of transmission for smokers was 1.45 (95% confidence interval [CI] 1.07-1.96); among women with advanced HIV, the adjusted RH was even higher (RH = 1.71; 95% CI 1.14-2.58). Users of cocaine (15% of the cohort) or of mixed or unspecified illicit drugs (28%) had higher transmission rates in unadjusted analysis (33%, p = 0.06 and 31%, p = 0.06 respectively); after adjustment for smoking and other maternal factors, neither cocaine (RH = 1.04 (95% CI 0.66-1.63)) nor mixed nor unspecified drug use (RH = 1.13 (95% CI = 0.75-1.70)) was significantly associated with transmission. Our data document an association of cigarette smoking during pregnancy with an increased risk of maternal-child HIV transmission that can be added to the growing list of complications caused by cigarette smoking.