Infant HIV infection despite "universal" antenatal testing

Percentage and determinants of missed HIV testing in pregnancy: a survey of women delivering in the Lazio region, Italy

HIV testing is recommended as part of routine preconception and prenatal care but some cases of vertical transmission still occur because of missed HIV testing in pregnancy. We estimated the percentage of women missing HIV testing before delivery, and we evaluated factors related with it. An anonymous survey was distributed to women giving birth during a two-week period in the maternity units of hospitals in the Lazio region of Italy in 2011. Among the 1568 women who filled out the questionnaire, only 33.6% had an HIV test prior to conception, while 88.2% were tested during pregnancy; main reasons reported for missed testing were: not requested by the gynaecologist (57.0%), performed previously (20.7%), requested by the gynaecologist but not done (13.3%) and structural/organisational barriers (4.4%). The percentage of women who missed the HIV test as part of preconception care or during pregnancy was 9.1% (95% confidence interval, CI: 7.7-10.6). Multivariate analysis showed that those with missed test were younger (p = 0.05), of lower education level (p < 0.01), with a lower HIV-knowledge score (p < 0.01) and with fewer visits during pregnancy (p < 0.01). Around 10% of delivering women were not tested for HIV during pregnancy or as part of preconception care. Absence of a specific request by the gynaecologist was the most frequent reason given. The association of missed HIV testing with poor sociocultural level and limited maternal HIV knowledge emphasise the importance of promoting HIV information among women and prenatal care providers. Strategies to increase routine testing may include the adoption of an opt-out approach. Finally, availability of rapid HIV testing in the delivery room should be encouraged.

HIV testing of male partners of pregnant women in Porto Alegre, Brazil: a potential strategy for reduction of HIV seroconversion during pregnancy

Pregnant women have a significantly higher risk of HIV acquisition during gestation than their non-pregnant counterparts due to behavioral and biological factors. Acute seroconversion during gestation results in increased HIV mother-to-child transmission rates and has been identified as a major public health challenge. In order to address potential HIV seroconversion in our pregnant patients, we conducted a prospective cohort study to evaluate the acceptability of offering HIV testing to sexual partners of HIV-negative pregnant women receiving antenatal care at two hospitals in Porto Alegre, Brazil. Over a 14-month study period, HIV-negative pregnant women at two hospital-based clinic sites were encouraged to bring their stable sexual partner for HIV voluntary counseling and testing during prenatal care. Women were re-interviewed following delivery to measure success of the intervention. Of the 1223 HIV-negative pregnant women enrolled in the study, 663 (54%) of their male sexual partners received HIV testing during antenatal care and 4 (0.6%) were diagnosed with HIV infection. A total of 645 women were interviewed at the time of delivery, with 620 (97%) confirming that HIV testing was suggested to their partner. The most common reason provided by women as to why partners did not come for testing was work (69%) and lack of perceived risk (14%). Independent predictors of successful partner testing included being white (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.18-2.12), married (OR 1.78, 95% CI 1.08-2.94), having an older age of sexual debut (OR 0.94, 95% CI 0.9-0.98), and being recruited at Hospital Conceiçao (OR 2.1, 95% CI 1.52-2.88). We conclude that HIV partner testing during prenatal care is acceptable, rendering this intervention attractive to public health programs targeting prevention of sexually transmitted infections.

Audio computer-assisted survey instrument versus face-to-face interviews: optimal method for detecting high-risk behaviour in pregnant women and their sexual partners in the south of Brazil

Audio computer-assisted survey instrument (ACASI) has been shown to decrease under-reporting of socially undesirable behaviours, but has not been evaluated in pregnant women at risk of HIV acquisition in Brazil. We assigned HIV-negative pregnant women receiving routine antenatal care at in Porto Alegre, Brazil and their partners to receive a survey regarding high-risk sexual behaviours and drug use via ACASI (n = 372) or face-to-face (FTF) (n = 283) interviews. Logistic regression showed that compared with FTF, pregnant women interviewed via ACASI were significantly more likely to self-report themselves as single (14% versus 6%), having >5 sexual partners (35% versus 29%), having oral sex (42% versus 35%), using intravenous drugs (5% versus 0), smoking cigarettes (23% versus 16%), drinking alcohol (13% versus 8%) and using condoms during pregnancy (32% versus 17%). Therefore, ACASI may be a useful method in assessing risk behaviours in pregnant women, especially in relation to drug and alcohol use.

Risk-taking behavior for HIV acquisition during pregnancy in Porto Alegre, Brazil

Recent studies suggest that acquisition of HIV-1 infection during pregnancy and breastfeeding is associated with a high risk of HIV mother-to-child transmission. This study evaluates risk factors associated with HIV acquisition during pregnancy in women delivering at a large metropolitan medical facility located in the south of Brazil. From February to August 2009, our group conducted a cross-sectional study assessing women's risk for HIV acquisition by administering an oral survey to peripartum women. Of 2465 participants, 42% (n = 1046) knew that partner had been tested for HIV. During pregnancy, 82% (n = 2022) of participants never used condoms; yet 97% (n = 2399) practiced vaginal sex. Multivariate logistic regression analysis showed that patients with more years of education, in a relationship for more than 1 year, and who knew their own HIV status were more likely to know their partners' HIV status (P < 0.05). Those who were in relationship for more than 1 year and were married/living together were more likely to be comfortable discussing HIV testing with partners (P < 0.05). In conclusion, women in Brazil are at risk of HIV-infection during pregnancy as they remain sexually active, often do not know their sexual partner's HIV status, and have minimal condom use.

The association between ethnicity and late presentation to antenatal care among pregnant women living with HIV in the UK and Ireland

UK and Ireland guidelines state that all pregnant women should have their first antenatal care appointment by 13 weeks of pregnancy (antenatal booking). We present the results of an analysis looking at the association between maternal ethnicity and late antenatal booking in HIV-positive women in the UK and Ireland. We analysed data from the National Study of HIV in Pregnancy and Childhood (NSHPC). We included all pregnancies in women who were diagnosed with HIV before delivery and had an estimated delivery date between 1 January 2008 and 31 December 2009. Late booking was defined as antenatal booking at 13 weeks or later. The baseline reference group for all analyses comprised women of "white" ethnicity. Logistic regression models were fitted to estimate adjusted odds ratios (AOR). There were 2721 eligible reported pregnancies; 63% (1709) had data available on antenatal care booking date. In just over 50% of pregnancies (871/1709), the antenatal booking date was ≥13 weeks of pregnancy (i.e., late booking). Women diagnosed with HIV during the current pregnancy were more likely to present for antenatal care late than those previously diagnosed (59.1% vs. 47.5%, p<0.001). Where women knew their HIV status prior to becoming pregnant, the risk of late booking was raised for those of African ethnicity (AOR 1.80; 95% confidence interval (CI) 1.14, 2.82; p=0.011). In women diagnosed with HIV during pregnancy, the risk of late booking was also higher for women of African ethnicity (AOR 2.98: 95% CI 1.45, 6.11; p=0.003) and for women of other black ethnicity (AOR 3.74: 95% CI 1.28, 10.94; p=0.016). Overall, women of African or other black ethnicity were more likely to book late for antenatal care compared with white women, regardless of timing of diagnosis. This may have an adverse effect on maternal and infant outcomes, including mother-to-child transmission of HIV.

Management of suspected viral encephalitis in children - Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines

In the 1980s the outcome of patients with herpes simplex encephalitis was shown to be dramatically improved with aciclovir treatment. Delays in starting treatment, particularly beyond 48 h after hospital admission, are associated with a worse prognosis. Several comprehensive reviews of the investigation and management of encephalitis have been published. However, their impact on day-to-day clinical practice appears to be limited. The emergency management of meningitis in children and adults was revolutionised by the introduction of a simple algorithm as part of management guidelines. In February 2008 a group of clinicians met in Liverpool to begin the development process for clinical care guidelines based around a similar simple algorithm, supported by an evidence base, whose implementation is hoped would improve the management of patients with suspected encephalitis.

Infections related to pregnancy

Infections in pregnancy and in the postpartum period represent an important knowledge base that emergency physicians should have. Being able to understand the risk that pregnancy-related infections have on maternal and fetal health in addition to the initiation of appropriate treatment for these infections is crucial. In the postpartum period, most infections (94%) are likely to manifest after hospital discharge; therefore, patients frequently present to the emergency department.