Lessons from the President's Emergency Plan for AIDS Relief: from quick ramp-up to the role of strategic partnership

In its first five years, the President's Emergency Plan for AIDS Relief (PEPFAR)--the largest commitment ever by any nation to combat a single disease--succeeded in getting 2.1 million people on antiretroviral treatment and 10.1 million people in care; prevented an estimated 237,600 HIV infections in infants; and saved an estimated 3.28 million adult years of life. Much of the global program's success can be attributed to early decisions to implement new structures and approaches designed to meet its ambitious targets quickly, overcome bureaucratic inertia, and ensure continued progress. A unified US government program was created with a single coordinator. There was a focus on quick ramp-up, strategic partnerships, and sustainable local ownership. Accountability and performance were emphasized. These new approaches played critical roles in translating the unprecedented resources and political support for PEPFAR into improved health for millions of people. Successful aspects of the way in which PEPFAR was organized and implemented, along with less successful or deficient ones, offer lessons for any large, complex international health initiative.

Factors associated with non-disclosure of HIV infection status of new mothers in Bangkok

The objective of this study was to estimate HIV disclosure rates and identify factors that predict non-disclosure in Thai women who tested HIV positive during pregnancy or at delivery. This was a cohort study evaluating the implementation of prevention of mother-to-child HIV transmission programs at two Bangkok hospitals in 1999-2003. All HIV-infected women who delivered during the study period were enrollment eligible. Thai-language questionnaires were used to collect baseline data before discharge from the hospital. At the 1 and 4 month follow-up visits, women were asked if they had disclosed their HIV status. Of the 799 women who enrolled, 647 (81.0%) completed follow-up at 1 and 4 months. Four hundred fifty-three (70.0%) women disclosed their status by 1 month. Of the 194 women who had not disclosed by 1 month, 48 (24.7%) had disclosed their status by 4 months. An independent increased odds of non-disclosure by 1 month was associated with not having a partner tested for HIV (OR=5.83, 95% CI=3.19-9.08) or not knowing if the partner was ever tested for HIV (OR=1 3.02, 95% Cl=5.26-32.28), first learning of HIV positive status during delivery (OR=6.84, 95% CI=2.36-19.81) or after delivery (OR=3.14, 95% CI=1.57-6.26) and having >2 lifetime sexual partners (OR=1.71, 95% CI=1.04-2.82). Not living with a partner every day was associated with non-disclosure by 4 months in those women who had not disclosed by 1 month (OR=2.28, 95% CI=1.43-3.64). Despite high rates of disclosure by 1 month, 22.6% of women still had not disclosed their HIV status to their partners by 4 months. The benefits of disclosure warrant effective interventions targeted at women at risk for non-disclosure.

Evaluating Programs to Prevent Mother-to-Child HIV Transmission in Two Large Bangkok Hospitals, 1999-2001

The 2 largest maternity hospitals in Bangkok implemented comprehensive programs to prevent mother-to-child HIV transmission in 1998. We conducted a cross-sectional survey of post-partum HIV-infected women in 1999 through 2001 to evaluate these programs. Women were given structured interviews at 0 to 3 days, 1 month, and 2 months postpartum. Medical records of women and their newborns were reviewed. Of 488 enrolled women, 443 (91%) had antenatal care: 391 (88%) at study hospitals and 52 (12%) elsewhere. The HIV diagnosis was first known before pregnancy for 61 (13%) women, during pregnancy for 357 (73%) women, during labor for 22 (5%) women, and shortly after delivery for 48 (10%) women. Antenatal zidovudine (ZDV) was used by 347 (71%) women, and intrapartum ZDV was used by 372 (76%) women. Twelve (55%) of the 22 women who first learned of their HIV infection during labor took intrapartum ZDV. All 495 newborn infants started prophylactic ZDV; the first dose was given within 12 hours for 491 (99%) children. Ten (2%) children were breast-fed at least once by their mother, and 10 (2%) were breast-fed at least once by someone else. Although uptake of services was high, inconsistent antenatal care, fear of stigmatization, and difficulty in disclosing HIV status prevented some women from using services.

Survival, disease manifestations, and early predictors of disease progression among children with perinatal human immunodeficiency virus infection in Thailand

OBJECTIVE

To describe survival and signs of human immunodeficiency virus (HIV) infection in perinatally infected children in Thailand.

METHODS

At 2 large Bangkok hospitals, 295 infants born to HIV-infected mothers were enrolled at birth from November 1992 through September 1994 and followed up with clinical and laboratory evaluations every 1 to 3 months for 18 months. Infected children remained in follow-up thereafter. For the infected children, we used data collected through October 2000 to estimate survival times and compare characteristics among those whose disease progressed at rapid (died within 1 year), intermediate (died at 1-5 years), and slow (survived at least 5 years) rates.

RESULTS

None of the 213 uninfected children died during the follow-up period. Of the 68 infected children, 31 (46%) died; median survival was 60 months (95% confidence interval: 31-89 months). The most common cause of death was pneumonia (52% of deaths). Thirty-two children (47%) started antiretroviral therapy. Six children died in their first year before developing specific signs of HIV infection; all others developed signs of HIV infection between 1 and 42 months old (median: 4 months). Severe clinical (Centers for Disease Control and Prevention Class C) conditions were diagnosed in 23 children at a median age of 12 months, 15 (65%) of whom died a median of 3 months later. Compared with children whose disease progressed slowly, those whose disease progressed rapidly gained less weight by 4 months old (median 1.7 vs 2.6 kg), and their mothers had higher viral loads (median 5.1 vs 4.5 log(10) copies/mL) and lower CD4(+) counts (median 350 vs 470 cells/ micro L) at delivery.

CONCLUSIONS

Among HIV-infected Thai children, survival times are longer than among children in many African countries, but shorter than among children in the United States and Europe. Signs of HIV develop early in most children. Growth failure and advanced maternal disease can predict rapid HIV disease progression and may be useful markers for treatment decisions.

Preventing mother-to-child HIV transmission: the first year of Thailand's national program

CONTEXT

Each year in Thailand, about 10,000 children are born at risk for mother-to-child human immunodeficiency virus (HIV) transmission. In 2000, Thailand implemented a national program to prevent mother-to-child HIV transmission.

OBJECTIVE

To describe the results of implementation of the program.

DESIGN

Monthly collection of summary data from hospitals.

SETTING

Public health hospitals (n = 822) in all 12 regions of Thailand, representing 75 provinces, excluding Bangkok.

PARTICIPANTS

Women giving birth from October 2000 through September 2001, including HIV-seropositive women and their neonates.

MAIN OUTCOME MEASURES

Percentages of women giving birth who were tested for HIV, HIV-seropositive women giving birth who received antenatal prophylactic antiretroviral drugs, and HIV-exposed neonates who received prophylactic antiretroviral drugs and infant formula.

RESULTS

Among 573,655 women (range, 27,344-77,806 by region) giving birth, 554,912 (96.7%) received antenatal care (range, 91.9%-98.8% by region). Of 554,912 women giving birth who had antenatal care, 517,488 (93.3%) were tested for HIV (range, 87.7%-99.4% by region) before giving birth; of 18,743 women giving birth who did not have antenatal care, 13,314 (71.0%) were tested for HIV (range, 21.7%-92.9% by region). Of 6646 HIV-seropositive women giving birth, 4659 (70.1%) received prophylactic antiretroviral drugs before delivery (range, 55.3%-81.2% by region). Of 6475 neonates of HIV-seropositive women, 5741 (88.7%) received prophylactic antiretroviral drugs (range, 67.4%-96.9% by region) and 5386 (83.2%) received infant formula (range, 65.3%-100% by region).

CONCLUSIONS

Major program components of Thailand's national program for preventing mother-to-child HIV transmission were implemented. Thailand's experience may encourage other developing countries to implement or expand similar national programs.

National program for preventing mother-child HIV transmission in Thailand: successful implementation and lessons learned

OBJECTIVE

To describe the development, components, and initial uptake of Thailand's national program for preventing mother-child HIV transmission.

DESIGN

Historical review, interpretation of experience, national program monitoring.

SETTING

Public health system, Thailand.

PARTICIPANTS

Policymakers, clinicians, HIV-infected pregnant women.

INTERVENTION

Voluntary counseling and HIV testing of pregnant women; short-course zidovudine for HIV-infected women and their infants and formula feeding for infants.

MAIN OUTCOME MEASURES

Program components implemented and program uptake.

RESULTS

Research, monitoring and evaluation of pilot projects, training, and policy-making provided the information, experience, infrastructure, and guidance to develop a program for preventing mother-child HIV transmission that was implemented in all Ministry of Public Health hospitals in Thailand in 2000. A national system was established to monitor program implementation. Monitoring reports were received from 669 hospitals in 65 provinces for the period October 2000 through July 2001. During this period, 93% of 318 721 women who gave birth were tested for HIV; 69% of 3958 HIV-infected women giving birth received zidovudine; and 86% and 80% of the 3865 children born to HIV-infected women received zidovudine and infant formula, respectively, through the program.

CONCLUSIONS

A national program for preventing mother-child HIV transmission was successfully implemented in Thailand. Early monitoring indicates good program uptake. Lessons learned from implementing this program include the importance of paying attention to counseling, communication, and training in the program, and using pilot projects and focused monitoring and evaluation data to guide the program development, expansion, and improvement.

Maternal characteristics associated with antenatal, intrapartum, and neonatal zidovudine use in four US cities, 1994-1998

OBJECTIVES

To evaluate implementation of 1994 United States Public Health Service guidelines for zidovudine (ZDV) use in HIV-infected women and their newborns by describing the prevalence of use of perinatal ZDV and other antiretrovirals and by investigating determinants of not receiving perinatal ZDV.

DESIGN/METHODS

The Perinatal AIDS Collaborative Transmission Study is a prospective cohort study designed to collect information related to mother-to-child HIV transmission that was conducted in New York City (NY), Newark (NJ), Baltimore (MD), and Atlanta (GA), U.S.A. The current analysis was restricted to infants born between July 1994 and June 1998.

RESULTS

Utilization rates for antenatal, intrapartum, and neonatal ZDV increased from 41% to 70% during the 4-year period. Use of combination antiretrovirals increased from fewer than 2% of women in 1994 to 1995 to 35% in 1997 to 1998. Antenatal and neonatal ZDV use increased each year, but intrapartum ZDV use reached a plateau after 1996. Mother-infant pairs with the following characteristics were less likely to have received a complete 3-part ZDV regimen: older maternal age, CD4 count >500 cells/microl, preterm birth, cocaine or heroin use during pregnancy, positive newborn drug screen test result, and smoking or alcohol use during pregnancy. By multivariate logistic regression adjusted for hospital and year of birth, cocaine or heroin use during pregnancy (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.6-3.3), maternal CD4 count (OR, 0.4; 95% CI, 0.2-0.8; comparing <200 with >500 cells/microl), and preterm birth (OR, 1.6; 95% CI, 1.1-2.5) remained independently associated with not receiving the complete ZDV regimen.

CONCLUSIONS

ZDV use by pregnant HIV-infected women and their infants has increased dramatically since publication of the 1994 guidelines. Nevertheless, women who abuse substances, give birth preterm, or have less advanced immunosuppression, were at substantial risk of not receiving the complete ZDV regimen.

Barriers to universal prenatal HIV testing in 4 US locations in 1997

OBJECTIVES

We determined rates of prenatal HIV testing and investigated barriers to testing.

METHODS

We surveyed 1362 representative parturient women from 7 hospitals in 4 locations of the United States.

RESULTS

Overall, 89.9% of women reported being offered HIV testing and 69.6% reported being tested. Proportions of women not offered testing differed by location (range = 5.2%-16.3%), as did proportions not tested (range = 12.2%-54.4%). Among women who perceived that their clinicians had not recommended testing, 41.7% were tested, compared with 92.8% of women who perceived a strong recommendation (P < .05). Private insurance for prenatal care was also associated with not being tested. Women gave multiple reasons for not being tested, most commonly not being at risk, having been tested recently, and the test's not being offered or recommended, cited by 55.3%, 39.1% and 11.1% of women, respectively.

CONCLUSIONS

Although most parturient women were offered a prenatal HIV test and got tested, testing proportions did not reach national goals and differed significantly by location and payment status. Concern about testing consequences was not a major barrier. Perception of clinicians' recommendations strongly influenced testing. Changing provider practices will be essential to implementing universal prenatal HIV testing.

HIV seroconversion during pregnancy and risk for mother-to-infant transmission

Pregnant women infected with HIV-1 were enrolled in a prospective mother-to-infant transmission study from 1992 through 1994 in Bangkok. In participating hospitals, voluntary HIV testing was routinely offered at the beginning of antenatal care and again in the middle of the third trimester of pregnancy. Women who seroconverted to HIV during pregnancy were compared with women who had tested positive on their first antenatal test. Maternal HIV RNA levels were determined during pregnancy, at delivery, and postpartum using RNA polymerase chain reaction (PCR), and infection status in infants was determined by DNA PCR. No infants were breast-fed, but prophylactic antiretroviral therapy was not yet used in Thailand to prevent transmission from mother to infant. Among enrolled women, 16 who seroconverted during pregnancy and 279 who were HIV-1-seropositive at their first antenatal test gave birth. Median plasma RNA levels at delivery were similar for the two groups (17,505 and 20,845 copies/ml, respectively; p =.8). Two (13.3%) of 15 infants born to women who seroconverted and 66 (24.8%) of 266 infants born to previously HIV-seropositive women were infected with HIV (p =.5). There was no increased risk for mother-to-infant HIV transmission and no significant difference in viral load at delivery between HIV-infected women who seroconverted to HIV during pregnancy and those who were HIV-seropositive when first tested.

Safety of late in utero exposure to zidovudine in infants born to human immunodeficiency virus-infected mothers: Bangkok. Bangkok Collaborative Perinatal HIV Transmission Study Group

BACKGROUND

Short-course zidovudine (ZDV) given in the late antenatal period can reduce mother-infant human immunodeficiency virus (HIV) transmission by one half. Because this intervention is being implemented in developing countries, evidence of its safety is needed.

METHODS

In a randomized, double-blinded, placebo-controlled trial in Bangkok, HIV-infected pregnant women received either ZDV (300 mg twice daily from 36 weeks' gestation until labor, then every 3 hours until delivery) or an identical placebo regimen. Infants were evaluated at birth and at 1, 2, 4, 6, 9, 12, 15, and 18 months of age. Growth, clinical events, and hematologic and immunologic measurements were compared between treatment groups.

RESULTS

Of the 395 children born (196 in ZDV group and 199 in placebo group), 330 were uninfected, 55 were infected, and 10 had indeterminate infection status. Overall, 319 children (81%) completed 18 months of follow-up, and 14 (4%) died before 18 months of age. Among uninfected children, the mean hematocrit was lower in the ZDV group at birth (49.1% vs 51.5%) but not at later ages; mean weight, height, head circumference, and CD4(+) and CD8(+) T lymphocyte counts were similar in both groups at all ages. Five uninfected children in the ZDV group but only one in the placebo group had a febrile convulsion. No other signs suggestive of mitochondrial dysfunction and no tumors were observed. Among infected children, an estimated 62% in the ZDV group and 77% in the placebo group survived free of Centers for Disease Control and Prevention class C disease during the 18-month follow-up.

CONCLUSIONS

No significant adverse events were associated with short-course ZDV during 18 months of follow-up in this population.

Antiretroviral therapy and declining AIDS mortality in New York City

The objective was to evaluate the association between antiretroviral therapy and AIDS mortality in New York City (NYC). Design was a population-based case-control study. We randomly selected 150 case patients and 150 control patients whose AIDS diagnosis was made during 1994 to 1996 (male:female, 2:1) from among 19,238 persons reported to the NYC Health Department HIV/AIDS Reporting System (HARS). Case patients had died of AIDS-related causes in 1996. Control patients, category matched with case patients on gender, were not known to have died by the end of 1996. Analysis was performed on 279 patients (142 cases and 137 controls). Cases and controls were similar in age, gender, race, HIV transmission category, and health insurance coverage. The median baseline CD4 count was 30 cells/microL for those who died and 103 cells/microL for survivors (p < 0.001). The prescription of HAART (antiretroviral combination that includes at least one protease inhibitor) in 1996 was strongly associated with survival in univariate analysis (OR = 5.1, 95%CI = 2.5-10.2). This association remained in a logistic regression analysis after adjusting for sex, age, race, health insurance status, HIV transmission categories, year of AIDS diagnosis, baseline CD4 count, and other antiretroviral therapy (AOR = 8.6, 95%CI = 3.5-20.7). Prescription of combination therapy other than HAART in 1996 and baseline CD4 count were also associated with survival, but less strongly so. The survival benefit of HAART extends beyond the confines of a few highly selected patients into the "real world," reducing AIDS deaths at the population level. This population-based study supports the likelihood that the introduction of HAART in 1996 played a primary role in the decline in NYC AIDS mortality.

Early diagnosis of HIV-1-infected infants in Thailand using RNA and DNA PCR assays sensitive to non-B subtypes

OBJECTIVES

To evaluate the sensitivity and specificity of RNA and DNA polymerase chain reaction (PCR) for early diagnosis of perinatal HIV-1 infection and to investigate early viral dynamics in infected infants.

DESIGN

A cohort study of 395 non-breastfed infants born to HIV-infected mothers in a randomized clinical trial of short-course antenatal zidovudine.

METHODS

Infant venous blood specimens collected at birth, 2 months, and 6 months of age were tested by qualitative DNA and quantitative RNA PCR (Roche Amplicor). To determine sensitivity and specificity of DNA and RNA PCR, results were compared with later DNA PCR results and to antibody results at 18 months. The HIV-1 subtype of the mother's infection was determined by peptide serotyping.

RESULTS

In the study, 92% of mothers were infected with subtype E. DNA PCR sensitivity was 38% (20 of 53) at birth, and 100% at 2 months (53 of 53) and 6 months (47 of 47). RNA PCR sensitivity was 47% (25 of 53) at birth and 100% (53 of 53) at 2 months. All samples that tested DNA-positive tested RNA-positive. Specificity was 100% for both DNA and RNA testing at all timepoints. For infected infants, the median viral load of RNA-positive specimens was 407,000 copies/ml (5.6 log10) at birth, 3, 700,000 copies/ml (6.6 log10) at 2 months, and 1,700,000 copies/ml (6.2 log10) at 6 months. Infant RNA levels at 2 and 6 months did not differ by maternal zidovudine exposure, or RNA level at birth.

CONCLUSION

This RNA PCR assay performed well for diagnosing perinatal HIV subtype E infection, detecting nearly half of infected infants at birth, and 100% at 2 and 6 months, with 100% specificity. Infected infant viral RNA levels were very high at 2 and 6 months, and were unaffected by maternal zidovudine treatment.

Evaluating a new strategy for prophylaxis to prevent Pneumocystis carinii pneumonia in HIV-exposed infants in Thailand. Bangkok Collaborative Perinatal HIV Transmission Study Group

OBJECTIVE

To evaluate a strategy for prophylaxis against Pneumocystis carinii pneumonia (PCP) for infants in Thailand.

METHODS

HIV-infected women were offered trimethoprim-sulfamethoxazole for PCP prophylaxis for their children at 1-2 months of age. When the children reached 6 months of age, investigators simulated a decision to continue or stop prophylaxis on the basis of clinical criteria, and compared their decisions with results of polymerase chain reaction (PCR) testing for HIV. We calculated the proportions of children who received and completed prophylaxis, and compared the rates of pneumonia and death from pneumonia with rates from an earlier prospective cohort.

RESULTS

Of 395 eligible infants, 383 (97%) started prophylaxis. By 6 months of age, 10 (2.6%) were lost to follow-up, three (0.8%) were non-adherent, seven (2%) had stopped because of adverse events, four (1%) had died, and 359 (94%) still received prophylaxis. At 6 months of age, 30 (70%) of 43 HIV-infected children and 16 (5%) of 316 uninfected children met the clinical criteria to continue prophylaxis. The incidence of pneumonia at 1 to 6 months of age was 22% (15/68) in the earlier cohort, and 13% (6/46) in the recent cohort [relative risk (RR) 0.6, 95% confidence interval (CI) 0.3-1.4; P= 0.22]; mortality rates were 9% and 4%, respectively (RR 0.5; 95% CI 0.1-2.3; P = 0.47).

CONCLUSION

This PCP prophylaxis strategy appeared to be acceptable and safe, may have reduced morbidity and mortality from pneumonia, and should be considered in developing countries where early laboratory diagnosis of perinatal HIV infection is unavailable.

Implementing short-course zidovudine to reduce mother-infant HIV transmission in a large pilot program in Thailand

OBJECTIVES

To describe a pilot mother-infant HIV prevention program started by the Ministry of Public Health of Thailand in July 1998 and to report on the first year of its implementation.

DESIGN

Analysis of monthly summaries of data from project logbooks, simple data forms in antenatal clinics and delivery rooms, site visits and workshops, mail survey.

SETTING

All 89 public hospitals in seven north-eastern provinces of Thailand.

PARTICIPANTS

Childbearing women, program officials.

INTERVENTIONS

Counseling and HIV testing for pregnant women, short-course antenatal zidovudine for HIV-infected pregnant women, and infant formula for their children.

MAIN OUTCOME MEASURES

Proportion of women with HIV test, proportion of HIV-infected women receiving zidovudine.

RESULTS

Of 75,308 women who gave birth between July 1998 and June 1999, 74,511 (98.9%) had antenatal care, 51,492 (69.1%) in the same district and 23,019 (30.9%) outside the district where they gave birth. HIV test results were available at delivery for 46,648 (61.9%) women, 410 (0.9%) of whom tested positive. Of these HIV-infected women, 259 (63.2%) participated in the zidovudine program and 6 (1.5%) received zidovudine from other sources. The proportion of women whose HIV test results were known and proportion of HIV-infected women who received zidovudine increased significantly during the year.

CONCLUSIONS

A mother-infant HIV prevention program using short-course antenatal zidovudine was quickly implemented in a large region of Thailand with moderate HIV prevalence. This successful experience is leading to national implementation of a perinatal HIV prevention program in Thailand and may prompt other developing countries to start similar programs.

Interventions to prevent vertical transmission of HIV-1: effect on viral detection rate in early infant samples

OBJECTIVE

To determine whether mode of delivery or the use of maternal or neonatal antiretroviral prophylaxis influence the age when HIV-1 can first be detected in infected infants, particularly the probability of detection at birth.

METHODS

In a collaboration between four multicentre studies, data on 422 HIV-1 infected infants who were assessed by HIV-1 DNA PCR or cell culture before 14 days of age were analysed. Weibull mixture models were used to estimate the cumulative proportion of infants with detectable levels of HIV-1 according to use of maternal/neonatal antiretroviral therapy (mainly zidovudine monotherapy) and mode of delivery.

RESULTS

HIV-1 was detected in 162 infants (38%) when they were first tested, at a median age of 2 days. At birth, it was estimated that 36% [95% confidence interval (CI), 31-41%] of infants have levels of virus that can be detected by DNA PCR or cell culture. This percentage was not associated with either mode of delivery (35% for vaginal delivery versus 40% for cesarean section delivery; P = 0.4) or the use of maternal or neonatal antiretroviral prophylaxis. Among infants with undetectable levels of HIV-1 at birth, the median time to viral detectability was estimated to be 14.8 days (95% CI, 12.9-16.8 days). This time was increased by 15% (95% CI, -11 to 48%; P = 0.3) among infants who were exposed to antiretroviral therapy postnatally compared with infants who were not exposed. No effect was observed for mode of delivery.

CONCLUSIONS

The outcome of an early virological test for HIV-1 is thought to be related directly to the timing of transmission and cesarean section delivery primarily reduces the risk of intrapartum transmission. The absence of an association between mode of delivery and viral detectability at birth was therefore unexpected. There was no evidence that foetal or neonatal exposure to prophylactic zidovudine delays substantially the diagnosis of infection, although this cannot be inferred for combination antiretroviral therapy.

Oral zidovudine during labor to prevent perinatal HIV transmission, Bangkok: tolerance and zidovudine concentration in cord blood. Bangkok Collaborative Perinatal HIV Transmission Study Group

OBJECTIVES

To evaluate tolerance for the oral administration of zidovudine (ZDV) during labor and measure the resulting ZDV concentrations in umbilical cord blood.

DESIGN

A cross-sectional study of women in a placebo-controlled trial of short-course ZDV (twice a day from 36 weeks' gestation until labor and every 3 h during labor) to prevent perinatal HIV transmission in Bangkok.

METHODS

Umbilical cord blood was collected. Sixty control specimens and specimens from 372 women (182 in the ZDV group, 190 in the placebo group) were tested for ZDV by radioimmunoassay (lower detection limit < 1 ng/ml).

RESULTS

All women in the ZDV group took one or more labor dose, 170 (93%) took their last dose within 3 h of delivery, and only five (3%) experienced nausea or vomiting, a proportion similar to the placebo group. The median concentration of ZDV in the cord blood in the ZDV group was 252 ng/ml (range, < 1-1133 ng/ml); 31 (17%) specimens were less than 130 ng/ml (0.5 microM), the concentration thought to be active against HIV in vitro. Median concentrations were 189 ng/ml in specimens from women taking one or two labor doses, 290 ng/ml in those taking three or four doses, and 293 ng/ml in those taking more than four doses (P < 0.01). The ZDV concentration was not associated with time since the last dose, body weight, or perinatal transmission.

CONCLUSION

Oral intrapartum ZDV was feasible and well tolerated. Most ZDV concentrations in the cord blood after oral dosing during labor were at therapeutic concentrations but were lower than those reported after continuous intravenous administration. Although concentrations were not associated with perinatal transmission, these data do not exclude the possibility that intrapartum and neonatal chemoprophylaxis is effective.

Update on perinatal HIV transmission

Over the past decade, much progress has been made in understanding the risk factors and timing of perinatal HIV transmission. Even more impressive have been the successful clinical trials with antiretrovirals, such as ZDV, ZDV-3TC, and nevirapine, that demonstrated significant reductions in the risk for infant infection. Within the United States and Europe, these trial results have led to rapid implementation and dramatic decreases in new perinatal HIV cases since 1994. An immediate challenge is to rapidly translate the short-course antiretroviral trial results with ZDV and nevirapine into public health policy and practice in resource-poor settings, where almost 600,000 neonates continue to become infected by mother-infant HIV transmission each year. Physicians must also test strategies to further decrease the risk for infant HIV infection during the breast-feeding period.

Short-course antenatal zidovudine reduces both cervicovaginal human immunodeficiency virus type 1 RNA levels and risk of perinatal transmission. Bangkok Collaborative Perinatal HIV Transmission Study Group

Human immunodeficiency virus (HIV) levels in cervicovaginal lavage (CVL) and plasma samples were evaluated in relation to perinatal transmission in a randomized placebo-controlled trial of brief antenatal zidovudine treatment. Samples were collected at 38 weeks' gestation from 310 women and more frequently from a subset of 74 women. At 38 weeks, after a 2-week treatment period, CVL HIV-1 was quantifiable in 23% and 52% of samples in the zidovudine and placebo groups, respectively (P<.001). The perinatal transmission rate was 28.7% among women with quantifiable CVL HIV-1 and high plasma virus levels (>10,000 copies/mL) and 1% among women without quantifiable CVL HIV-1 and with low plasma virus levels (P<.001). A 1-log increase in plasma HIV-1 increased the transmission odds 1.8 and 6.1 times (95% confidence interval, 0.9-3.5 vs. 2.4-15.4) for women with and without quantifiable CVL HIV-1, respectively (P=.03). CVL HIV-1 is an independent risk factor for perinatal HIV-1 transmission.

Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok Collaborative Perinatal HIV Transmission Study Group

BACKGROUND

Many developing countries have not implemented the AIDS Clinical Trials Group 076 zidovudine regimen for prevention of perinatal HIV-1 transmission because of its complexity and cost. We investigated the safety and efficacy of short-course oral zidovudine administered during late pregnancy and labour.

METHODS

In a randomised, double-blind, placebo-controlled trial, HIV-1-infected pregnant women at two Bangkok hospitals were randomly assigned placebo or one zidovudine 300 mg tablet twice daily from 36 weeks' gestation and every 3 h from onset of labour until delivery. Mothers were given infant formula and asked not to breastfeed. The main endpoint was babies' HIV-1-infection status, tested with HIV-1-DNA PCR at birth, 2 months, and 6 months. We measured maternal plasma viral concentrations by RNA PCR.

FINDINGS

Between May, 1996, and December, 1997, 397 women were randomised; 393 gave birth to 395 live-born babies. Median duration of antenatal treatment was 25 days, and median number of doses during labour was three. 99% of women took at least 90% of scheduled antenatal doses. Adverse events were similar in the study groups. Of 392 babies with at least one PCR test, 55 tested positive: 18 in the zidovudine group and 37 in the placebo group. The estimated transmission risks were 9.4% (95% CI 5.2-13.5) on zidovudine and 18.9% (13.2-24.2) on placebo (p=0.006; efficacy 50.1% [15.4-70.6]). Between enrolment and delivery, women in the zidovudine group had a mean decrease in viral load of 0.56 log. About 80% of the treatment effect was explained by lowered maternal viral concentrations at delivery.

INTERPRETATION

A short course of twice-daily oral zidovudine was safe and well tolerated and, in the absence of breastfeeding, can lessen the risk for mother-to-child HIV-1 transmission by half. This regimen could prevent many HIV-1 infections during late pregnancy and labour in less-developed countries unable to implement the full 076 regimen.

Distinct risk factors for intrauterine and intrapartum human immunodeficiency virus transmission and consequences for disease progression in infected children. Perinatal AIDS Collaborative Transmission Study

Predictors and prognosis of intrauterine and intrapartum human immunodeficiency virus (HIV) transmission were investigated among 432 children of HIV-infected women in the Perinatal AIDS Collaborative Transmission Study. Timing of transmission was inferred from polymerase chain reaction or viral culture within 2 days of birth. Proportions of infections due to intrauterine transmission were similar among women using (29%) or not using zidovudine (30%). Preterm delivery was strongly associated with intrapartum transmission (relative risk, 3.7; 95% confidence interval [CI], 2.2-6.1), particularly among infants delivered longer after membrane rupture, but was not associated with intrauterine transmission. Progression to AIDS or death increased 2.5-fold (95% CI, 1.1-5.8) among intrauterine infected children, adjusting for preterm delivery, and maternal CD4 cell count. Early transmission appears unlikely to explain instances of zidovudine failure. Preterm infants may be more vulnerable to HIV acquisition at delivery, especially if membrane rupture is prolonged. Intrauterine infection does not appear to increase risk of preterm delivery.

Thymic dysfunction and time of infection predict mortality in human immunodeficiency virus-infected infants. CDC Perinatal AIDS Collaborative Transmission Study Group

The effect of human immunodeficiency virus (HIV)-induced thymic dysfunction (TD) on mortality was studied in 265 infected infants in the CDC Perinatal AIDS Collaborative Transmission Study. TD was defined as both CD4 and CD8 T cell counts below the 5th percentile of joint distribution for uninfected infants within 6 months of life. The 40 HIV-infected infants with TD (15%) had a significantly greater mortality than did the 225 children without TD (44% vs. 9% within 2 years). Infants with TD infected in utero had higher mortality than did those infected intrapartum (70% vs. 37% within 2 years), while no significant difference was noted between infants without TD with either mode of transmission. The TD profile was independent of plasma virus load. Virus-induced TD by particular HIV strains and the time of transmission are likely to explain the variation in pathogenesis and patterns of disease progression and suggest the need for early aggressive therapies for HIV-infected infants with TD.

International multicentre pooled analysis of late postnatal mother-to-child transmission of HIV-1 infection. Ghent International Working Group on Mother-to-Child Transmission of HIV

BACKGROUND

An understanding of the risk and timing of mother-to-child transmission of HIV-1 in the postnatal period is important for the development of public-health strategies. We aimed to estimate the rate and timing of late postnatal transmission of HIV-1.

METHODS

We did an international multicentre pooled analysis of individual data from prospective cohort studies of children followed-up from birth born to HIV-1-infected mothers. We enrolled all uninfected children confirmed by HIV-1-DNA PCR, HIV-1 serology, or both. Late postnatal transmission was taken to have occurred if a child later became infected. We calculated duration of follow-up for non-infected children from the time of negative diagnosis to the date of the last laboratory follow-up, or for infected children to the mid-point between the date of last negative and first positive results. We stratified the analysis for breastfeeding.

FINDINGS

Less than 5% of the 2807 children in four studies from industrialised countries (USA, Switzerland, France, and Europe) were breastfed and no HIV-1 infection was diagnosed. By contrast, late postnatal transmission occurred in 49 (5%) of 902 children in four cohorts from developing countries, in which breastfeeding was the norm (Rwanda [Butare and Kigali], Ivory Coast, Kenya), with an overall estimated risk of 3.2 per 100 child-years of breastfeeding follow-up (95% CI 3.1-3.8), with similar estimates in individual studies (p=0.10). Exact information on timing of infection and duration of breastfeeding was available for 20 of the 49 children with late postnatal transmission. We took transmission to have occurred midway between last negative and first positive HIV-1 tests. If breastfeeding had stopped at age 4 months transmission would have occurred in no infants, and in three if it had stopped at 6 months.

INTERPRETATION

Risk of late postnatal transmission is consistently shown to be substantial for breastfed children born to HIV-1-positive mothers. This risk should be balanced against the effect of early weaning on infant mortality and morbidity and maternal fertility.

Sensitivity and specificity of a qualitative RNA detection assay to diagnose HIV infection in young infants. Perinatal AIDS Collaborative Transmission Study

OBJECTIVE

To evaluate the sensitivity and specificity of an RNA detection assay for diagnosing perinatal HIV infection.

METHODS

Plasma and serum specimens taken during the first 3 months of life from HIV-infected and uninfected children enrolled in a cohort study were assayed for HIV RNA using the qualitative nucleic acid sequence-based amplification (NASBA) kit. Sensitivity, specificity, and predictive values were calculated. NASBA results from infected children were compared with DNA PCR results from the same blood samples. Autoantibody patterns of suspected false-positive specimens were compared with those of subsequent specimens from the same child to exclude specimen labelling errors.

RESULTS

Amongst 131 specimens from 105 HIV-infected children, the sensitivity of the qualitative NASBA assay was 13 out of 34 [38%; 95% confidence interval (CI), 22-56] at < 7 days, 56 out of 58 (97%; 95% CI, 88-100) at 7-41 days, and 37 out of 39 (95%; 95% CI, 83-99) at 42-93 days of life. Of 252 specimens from 206 uninfected children, six tested positive and one tested indeterminate by NASBA. Four of these positive specimens had discordant autoantibody patterns suggesting mislabelling; excluding these, the test specificity was 245 out of 248 (99%; 95% CI, 97-100). Amongst 128 paired specimens from infected children, NASBA results were more often positive than those from DNA PCR (103 versus 92; P=0.01). Amongst infants with specimens drawn in the first week of life, the proportion born after > 4 h of membrane rupture was greater amongst those testing negative (81%) than those testing positive (46%; P=0.05).

CONCLUSIONS

The qualitative NASBA RNA assay is highly specific and more sensitive than DNA PCR. Qualitative RNA assays may be useful for diagnosing and excluding perinatal HIV infection in children after the first week of life for such purposes as initiating antiretroviral therapy and other treatment, resolving parental uncertainty, determining timing of transmission, and providing endpoints for intervention trials.

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.

Diagnosis of perinatal human immunodeficiency virus infection by polymerase chain reaction and p24 antigen detection after immune complex dissociation in an urban community hospital

Results of polymerase chain reaction (PCR) and p24 antigen detection after immune complex dissociation (p24-ICD) were compared with antibody results after 18 months of age for human immunodeficiency virus (HIV) diagnosis in 345 prospectively followed, perinatally exposed infants. Of 59 infected and 286 uninfected infants tested at 1-6 months of age, sensitivity and specificity were, respectively, 100% and > 97% for PCR and 90% and > 97% for p24-ICD. Testing was done on > or = 2 occasions in the first 6 months of life in 43 infected infants; 77% had > or = 2 positive results with the same test. Of these infants, 68% had 2 positive p24-ICD tests. In uninfected infants, 96% had only negative tests; none had > 1 positive. By 6 months, all uninfected infants with > or = 2 PCR results could have been diagnosed. HIV status can be determined by PCR by age 6 months in most HIV-exposed infants. p24-ICD should not be used alone, because of its lower sensitivity, but may be useful in areas without advanced laboratory support.

Attitudes, practices, and infection risks of hemophilia treatment center nurses who teach infection control for the home

OBJECTIVE

To examine the practices toward infection control training and to assess the attitudes about, and risks for, exposures to blood among hemophilia treatment center (HTC) nurses who teach home infusion therapy (HIT).

DESIGN AND POPULATION

Written and telephone interview surveys of the 153 nurses who teach HIT at federally funded HTCs.

MAIN OUTCOME MEASURES

Hemophilia treatment center nurses' teaching practices and infection control messages taught, and frequency of exposures to blood.

RESULTS

The response rate to the written nurses' survey was 60% and to the telephone interview 88%. Nurses taught patients a median of three HIT sessions totaling 4 hours of instruction. Reevaluation of patients' HIT practices took place every 6 months by 22% and every 12 months by 59% of nurses. Nurses frequently reported teaching proper use of a sharps disposal container (99%) and gloves (93%), but less often reported teaching patients to wash hands after infusions (26%) and to report needlestick injuries to HTCs (11%). The respondents identified several barriers to effective infection control as it is practiced in the home by patients. Although at least 30% of HTC nurses recalled having had percutaneous exposure to blood, they considered their risk for hepatitis B infection low but greater than for infection with the human immunodeficiency virus (HIV).

CONCLUSIONS

While some important infection control messages are stressed during HIT teaching, others may be underemphasized. Failure to instruct patients about all infection control precautions may be related to nurse educators' perception of low to moderate personal risk for hepatitis B and HIV infection. Patients receiving HIT, and those who assist them, need to be fully aware of, and to have reinforced periodically, universal infection control strategies in the home.

Infection control practices in the home: a survey of households of HIV-infected persons with hemophilia

OBJECTIVE

To assess infection control practices and risk for human immunodeficiency virus (HIV) transmission in households where home infusion for hemophilia is used.

DESIGN

Cross-sectional prospective survey from 1992 through 1994.

SETTING

Hemophilia treatment centers.

PARTICIPANTS

Human immunodeficiency virus (HIV)-infected persons with hemophilia who receive home infusions of clotting factor concentrate and their household members.

MAIN OUTCOME MEASURES

Frequency of specific infection control practices in the home and the risk of HIV transmission to household members.

RESULTS

We surveyed 235 persons from 75 families (79 HIV-infected persons with hemophilia and 156 household members) about infection control practices in the home. Forty-eight percent of household members surveyed helped with the infusion process. Of 74 members who assisted with infusion, 13 (18%) had sustained a needlestick injury, 11 of whom were injured during the past year. One hundred fifty household members tested for antibody to HIV were antibody negative. These household members had a total of 903 person-years of contact after HIV was diagnosed in the index case. Household members' adherence to recommended infection control measures was highest for washing hands after cleaning up infusion equipment and waste, and for using sharps disposal containers. Adherence was lowest for wearing gloves when helping with infusions and proper disposal of bloody waste from the infusion.

CONCLUSIONS

No HIV transmission was found among persons living with HIV-infected persons with hemophilia, although there was a high rate of needlestick injuries during home infusion. Because persons who assisted with infusions often did not wear gloves and many households did not dispose of bloody waste properly, hemophilia treatment center personnel should emphasize these areas when training for home infusion. Adherence to appropriate infection control practices should help to keep the risk of HIV transmission in households extremely low.

Lack of increased risk for perinatal human immunodeficiency virus transmission to subsequent children born to infected women

BACKGROUND

Little is known about whether a woman's risk of transmitting HIV perinatally increases over time and whether the infection outcome of a previous child affects the risk of transmitting HIV to subsequent children.

METHODS

We analyzed data from 114 prospectively followed women who gave birth to at least 2 children after becoming infected with HIV to determine the risk for perinatal HIV transmission to these sibling pairs.

RESULTS

The median interval between sibling births was 19 months. HIV infection occurred in 19 (17%) older siblings and 20 (18%) younger siblings (P = 0.87). Two (11%) of the 19 children with infected older siblings were infected compared with 18 (19%) of the 95 children with uninfected older siblings (P = 0.86). The risk for transmission to younger siblings was not associated with the interval between deliveries of the two siblings.

CONCLUSIONS

These data do not demonstrate that an HIV-infected woman's risk of transmitting HIV perinatally increases with time, although the observed interpregnancy interval was relatively short. The risk for perinatal transmission does not appear to be affected by the infection outcome of previous children. These findings may be useful for counseling HIV-infected women about their risk of transmitting HIV perinatally.

Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population in Kinshasa, Zaire

Breast-fed infants born to human immunodeficiency virus (HIV)-infected mothers in Kinshasa, Zaire, were monitored a mean of 18 months. HIV infection in infants was determined by polymerase chain reaction (PCR), HIV culture, or ELISA. PCR test results for HIV DNA on venous blood drawn from children ages 0-2 days and 3-5 months were used to estimate proportions of mother-to-child transmission and transmission risks during the intrauterine, intrapartum/early postpartum, and late postpartum periods. Among 69 HIV-infected children (26% of the cohort), 23% (95% confidence interval [CI], 14%-35%) were estimated to have had intrauterine, 65% (CI, 53%-76%) intrapartum/early postpartum, and 12% (CI, 5%-22%) late postpartum transmission. The estimated risks for intrauterine, intrapartum/early postpartum, and late postpartum infection, respectively, were 6% (16/261; CI, 4%-10%), 18% (45/245; CI, 14%-24%), and 4% (8/189; CI, 2%-8%). These results support earlier studies indicating that most transmission occurs during labor and delivery or in the early postpartum period and that the risk of HIV transmission through breast-feeding during the postpartum period is substantial.

Cost-effectiveness of short-course zidovudine to prevent perinatal HIV type 1 infection in a sub-Saharan African Developing country setting

OBJECTIVE

To evaluate the cost-effectiveness of a short-course zidovudine program to prevent perinatal transmission of human immunodeficiency virus (HIV) type 1 in sub-Saharan African country settings.

DESIGN AND SETTING

Several clinical trials of short-course zidovudine during pregnancy for prevention of perinatal transmission of HIV are under way in developing countries in sub-Saharan Africa. A decision model was used to examine the cost-effectiveness of zidovudine programs in a hypothetical 1-year birth cohort in a sub-Saharan African setting from the perspective of the health care system and of society. A completed short course of zidovudine was assumed to reduce perinatal HIV transmission from 25% to 16.5%, approximately one half of the effect of the longer-course zidovudine. Estimates of program costs, lifetime HIV-related health care costs, and lost productivity costs were derived from the published literature and from preliminary data available from sites of planned clinical trials. Sensitivity analyses were conducted on all relevant parameters.

MAIN OUTCOME MEASURES

Medical costs, lost productivity costs, program costs, cost savings, and incremental cost-effectiveness, expressed as cost per infant HIV infection prevented.

RESULTS

The model estimated that a national zidovudine program in a setting with 12.5% HIV seroprevalence would reduce perinatal HIV incidence by 12% (4.9 infections per 1000 births). The costs to the health care system would be $3748 per infant HIV infection prevented. When productivity losses were included in the model, the cost decreases to $1115 per infant HIV infection prevented. The cost to implement a national zidovudine program including the cost of counseling, testing, and drugs, would be $2 million per 100,000 births or $20 per pregnant woman. In the base case, decreases in the cost of counseling and testing and increases in maternal HIV prevalence, zidovudine efficacy, and medical and lost productivity costs improved cost-effectiveness of the zidovudine program.

CONCLUSIONS

Assuming demonstrable efficacy of short-course zidovudine prevention of perinatal HIV, a national perinatal HIV prevention program with zidovudine in most sub-Saharan African country settings would reduce the incidence of infant HIV infection and, in some settings, provide societal savings; however, substantial initial investment in such programs will be required. Where health care resources are limited, as in these regions, allocation of resources to a perinatal zidovudine program will need to be considered in the context of resources required for other pressing medical care needs.

Preventing perinatal transmission of HIV--costs and effectiveness of a recommended intervention

OBJECTIVE

To calculate the national costs of reducing perinatal transmission of human immunodeficiency virus through counseling and voluntary testing of pregnant women and zidovudine treatment of infected women and their infants, as recommended by the Public Health Service, and to compare these costs with the savings from reducing the number of pediatric infections.

METHOD

The authors analyzed the estimated costs of the intervention and the estimated cost savings from reducing the number of pediatric infections. The outcome measures are the number of infections prevented by the intervention and the net cost (cost of intervention minus the savings from a reduced number of pediatric HIV infections). The base model assumed that intervention participation and outcomes would resemble those found in the AIDS Clinical Trials Group Protocol 076. Assumptions were varied regarding maternal seroprevalence, participation by HIV-infected women, the proportion of infected women who accepted and completed the treatment, and the efficacy of zidovudine to illustrate the effect of these assumptions on infections prevented and net cost.

RESULTS

Without the intervention, a perinatal HIV transmission rate of 25% would result in 1750 HIV-infected infants born annually in the United States, with lifetime medical-care costs estimated at $282 million. The cost of the intervention (counseling, testing, and zidovudine treatment) was estimated to be $ 67.6 million. In the base model, the intervention would prevent 656 pediatric HIV infections with a medical care cost saving of $105.6 million. The net cost saving of the intervention was $38.1 million.

CONCLUSION

Voluntary HIV screening of pregnant women and ziovudine treatment for infected women and their infants resulted in cost savings under most of the assumptions used in this analysis. These results strongly support implementation of the Public Health Service recommendations for this intervention.

Preventing Pneumocystis carinii pneumonia in persons infected with human immunodeficiency virus

Although the incidence of Pneumocystis carinii pneumonia (PCP) among adults infected with human immunodeficiency virus (HIV) has declined, no decline in PCP incidence has been observed among HIV-infected children, and PCP remains the most common serious opportunistic infection among both adults and children in the United States. Some evidence of airborne transmission of P. carinii exists, and some clusters of cases of PCP have been reported; however, data are insufficient to recommend that persons with PCP be separated from immunosuppressed persons as a standard practice. The incidence of PCP can be reduced substantially if persons at risk for PCP are identified and receive adequate chemoprophylaxis. Several drugs and drug combinations are highly effective in preventing PCP. For both adults and children, oral trimethoprim-sulfamethoxazole (TMP-SMZ) is the preferred form of prophylaxis. Adverse effects are commonly associated with the use of TMP-SMZ and in some cases may necessitate withdrawal of the drug until the effects resolve. However, reintroduction at the same dose or at a lower and gradually increasing dose will often permit the continued use of TMP-SMZ. For persons intolerant of TMP-SMZ, dapsone alone and dapsone plus pyrimethamine are effective alternatives. A third alternative is aerosolized pentamidine. Additional drugs of unproven efficacy but of potential use in exceptional cases are available.

Prophylaxis against Pneumocystis carinii pneumonia among children with perinatally acquired human immunodeficiency virus infection in the United States. Pneumocystis carinii Pneumonia Prophylaxis Evaluation Working Group

BACKGROUND

Pneumocystis carinii pneumonia (PCP) remains a common and often fatal opportunistic infection among children infected with the human immunodeficiency virus (HIV). HIV-infected infants between three and six months of age are particularly vulnerable. Current guidelines recommend prophylaxis in children from birth to 11 months old who have CD4+ counts below 1500 cells per cubic millimeter.

METHODS

We used national surveillance data to estimate the annual incidence of PCP among children less than one year old. We reviewed the medical records of 300 children given a diagnosis of PCP between January 1991 and June 1993 to determine why treatment according to the 1991 guidelines for prophylaxis against PCP either was not given or failed to prevent the disease.

RESULTS

In our study the incidence of PCP in the first year of life among infants born to HIV-infected mothers changed little between 1989 and 1992. Among 7080 children born to HIV-infected mothers in 1992, PCP developed in 2.4 percent. Of 300 children with PCP diagnosed from January 1991 through June 1993, 199 (66 percent) had never received prophylaxis, and for 118 of those children (59 percent) exposure to HIV was first identified 30 days or less before the diagnosis of PCP. Among 129 children less than one year old, the CD4+ count declined by an estimated 967 cells per cubic millimeter (95 percent confidence interval, 724 to 1210 cells per cubic millimeter) during the three months before the diagnosis of PCP. Among infants in whom CD4+ counts were determined within one month of the diagnosis of PCP, 18 percent (20 of 113) had at least 1500 cells per cubic millimeter, a level higher than the currently recommended threshold for prophylaxis.

CONCLUSIONS

In the United States the incidence of PCP among HIV-infected infants has not declined. If this infection is to be prevented, infants exposed to HIV must be identified earlier, and prophylaxis must be offered to more children than the guidelines currently recommend.