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.

Interleukin-6 release by cultured peripheral blood mononuclear cells inversely correlates with height velocity, bone age, insulin-like growth factor-I, and insulin-like growth factor binding protein-3 serum levels in children with perinatal HIV-1 infection

Spontaneous and phytohemagglutinin (PHA)-stimulated interleukin (IL)-6 release by cultured peripheral blood mononuclear cells was related to height velocity, bone age, insulin-like growth factor-I (IGF-I), and IGF binding protein-3 (IGFBP-3) serum level standard deviation scores (SDS) of 32 children [aged 91 (median; range 13-151) months] with human immunodeficiency virus-type 1 (HIV-1) perinatal infection and severe disease. Spontaneous and PHA-stimulated IL-6 release inversely correlated with height velocity, bone age, IGF-I, and IGFBP-3 SDS. Ten children with height velocity SDS </= -2, compared to 22 children with height velocity SDS > -2, showed higher spontaneous and PHA-stimulated IL-6 release and lower IGF-I and IGFBP-3 SDS (irrespective of CD4-positive T-lymphocyte counts, viral load, liver disease, or nutrition status). IL-6 overproduction may be a mechanism of IGF-I and IGFBP-3 down-regulation and impaired linear growth in children with perinatal HIV-1 infection. Growth-promoting strategies, including targeted anticytokine treatments, could be devised for such children.

Symptomatic HIV-infection in infants according to serostatus of mothers during pregnancy

OBJECTIVE

To ascertain the pattern of symptomatic HIV infections, HIV seropositivity and mother to child transmission (MTCT) rate during a two-year follow up period at 6, 12, 18, and 24 months according to mothers serostatus during pregnancy.

DESIGN

A longitudinal cohort study with socio-economic, medical, and demographic history of all participating pregnant women from recruitment; and of the child at birth recorded separately on pre-constructed questionnaire. The medical condition of each infant was recorded at the periodic follow-ups.

SETTING

The maternal and paediatric wards of the Harare Central Hospital, Harare, Zimbabwe.

SUBJECTS

Three hundred and eighty six HIV-seropositive and 372 HIV-seronegative Zimbabwean pregnant women attending maternal and paediatric wards of Harare Central Hospital.

INTERVENTIONS

About 10 ml of umbilical (venous) blood was collected at birth, centrifuged after clotting and stored frozen until HIV tests were carried out. Also capillary blood for filter paper storage was taken at six and 16 months and venous blood at one and two years of age for HIV serology, using ELISA. HIV serostatus was confirmed using Western Blot (WB) technique.

MAIN OUTCOME MEASURES

The HIV-serostatus of participating pregnant women and of infants at birth, patterns of symptomatic HIV infections and HIV seropositivity among infants and the number of deaths during a two year follow up at periodic intervals.

RESULTS

A total of 108 infant deaths occurred within the follow up period. Significantly more deaths (82 versus 25, p < 0.0001; excluding one infant whose HIV serostatus was not determined), parotitis, palpable neck and groin lymph nodes occurred among infants born to HIV positive than those born to HIV negative mothers. Palpable axillary lymph nodes were significantly more common at 12, 18, and 24 months of follow up in infants born to HIV positive women. The maternal HIV serostatus during pregnancy and of infants at all periodic follow ups showed no association with persistent diarrhoea, fever and cough. However prolonged fever became significantly associated at 24 months.

CONCLUSION

Mother to child transmission (MTCT) rate based on the HIV-serostatus of 272 infants; 17.4% in utero and 11.1% via breast milk respectively. Multivariate analysis showed that an infant presenting with faltering growth (Odds Ratio [OR] = 5.597), palpable neck (OR = 5.919) and axillary lymph nodes (OR = 4.197) was likely to be HIV positive at 24 months.

[Care for the Cuban child born to an HIV-seropositive mother]

Up to this moment, 25 children have been born from mothers seropositive to HIV. Of these, only 12 who are seropositive have been studied. Four of these children had developed the disease (33.3%), and the route of transmission was a blood transfusion. From the moment they were born, these children had been followed up monthly at the out-patient service and the polymerase chain reaction test, as well as ELISA and western blot is performed at 3, 6, and 9 months of age. Also, the same test are performed at 18 and 36 months of age for diagnostic confirmation in order to know whether they are virus carriers.

Caries experience and cariogenic markers in HIV-positive children and their siblings

The purpose of this cross-sectional, masked study was to compare the oral status of perinatally HIV-infected children with their uninfected siblings living in the same environment. A secondary purpose was to compare HIV-positive children for differences in oral health with respect to disease advancement. One hundred forty-seven children were examined in their homes and meeting places, using NIH criteria for caries diagnosis. Significant differences were found in the number of caries-free children (P < 0.05), past caries experience (P < 0.003), subsurface demineralizations (P < 0.0001), and caries-related bacteria (P < 0.05). However, differences in caries prevalence were not found in the 3- to 6-year-old subgroup. Caries prevalence (P < 0.001) and levels of caries-related flora in saliva were correlated to years since diagnosis (mutans streptococci P < 0.008, lactobacilli P < 0.02). Children with a more advanced disease stage had significantly more caries (P < 0.02). Among the HIV-infected children, the frequency of carbohydrate intake was clearly correlated to caries (P < 0.003) and to lactobacilli levels (P < 0.0001). It is concluded that children with perinatally acquired HIV are at greater risk for caries than their siblings, more so with advancing disease.

Neonatal characteristics in rapidly progressive perinatally acquired HIV-1 disease. The French Pediatric HIV Infection Study Group

OBJECTIVE

To identify clinical and laboratory parameters at birth that are associated with the rapidly progressive form of human immunodeficiency virus type 1 (HIV-1) disease in children born to infected mothers.

DESIGN

Multicenter, prospective study of infants born to HIV-seropositive mothers.

SETTING

A total of 62 obstetric and pediatric centers in France.

PARTICIPANTS

Of 1386 children born to HIV-1-seropositive mothers at least 18 months before the cutoff date, 267 were infected. Infection was defined as serological positivity at 18 months or death from HIV disease before the age.

MAIN OUTCOME MEASURE

Category C events (including opportunistic infections, recurrent severe bacterial infections, cancers, specific encephalopathy, and wasting syndrome) in the new pediatric Centers for Disease Control and Prevention classification during the first year of life, according to clinical, immunological, and virological findings at birth.

RESULTS

The risk of category C manifestations at 12 months was significantly higher when an infected newborn had liver and/or spleen enlargement and/or adenopathies (38.1% vs 15.1%; relative risk [RR], 2.5; 95% confidence interval [CI], 1.4 to 6.0; P<.02) or a low proportion (<30%) of CD4+ cells at birth (45.5% vs 15.0%; RR, 3.0; 95% CI, 1.4 to 6.4; P<.005). Similarly, HIV-1 culture and/or polymerase chain reaction positivity during the first week of life was associated with a higher risk of the early, severe form of HIV infection (26.4% vs 9.3%; RR, 2.8; 95% CI, 1.3 to 6.1; P<.006). In case of positive antigenemia at birth, the risk was 50.0% vs 14.4% (RR, 3.5; 95% CI, 1.9 to 6.2; P<.001). These parameters, determined at birth, were strongly interrelated and could reflect active disease onset in utero in some cases of early, severe HIV-1 disease in childhood.

CONCLUSIONS

These prognostic markers, particularly virological parameters, are of value in monitoring children infected by HIV and might serve as a basis for early therapeutic intervention.

Identification of levels of maternal HIV-1 RNA associated with risk of perinatal transmission. Effect of maternal zidovudine treatment on viral load

OBJECTIVE

To determine if there are levels of human immunodeficiency virus type 1 (HIV-1) associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which zidovudine treatment reduces perinatal transmission.

DESIGN

A nonrandomized prospective cohort study.

SETTING

University medical center and two general hospital affiliates from May 1989 to September 1994.

PATIENTS

Ninety-two HIV-1-seropositive women (95 pregnancies) and their 97 infants.

INTERVENTION

Forty-two mothers (43 pregnancies) received zidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic zidovudine for the first 6 weeks after delivery.

MAIN OUTCOME MEASURE

HIV-1 infection status of the infant.

RESULTS

Twenty of the 97 infants were perinatally infected with HIV-1. Transmitting mothers were more likely to have plasma HIV-1 RNA levels higher than 50000 copies per milliliter at delivery than nontransmitting mothers (15 [75.0%] of 20 transmitters vs four [5.3%] of 75 nontransmitters; P < .001). None of the 63 women with less than 20000 HIV-1 RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral zidovudine during gestation showed an eightfold median decrease in plasma RNA levels (median [25th and 75th percentile], 43043 [5699 and 63053] copies per milliliter before zidovudine vs 4238 [603 and 5116] HIV-1 RNA copies per milliliter at delivery; P < .001) and none transmitted. Four zidovudine-treated women with high HIV-1 levels transmitted despite the presence of zidovudine-sensitive virus in vitro in both the mothers and their infants.

CONCLUSIONS

Maternal HIV-1 RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associated with both a high risk and a low risk of transmission. Our results also suggest that zidovudine exerts a major protective effect by reducing maternal HIV-1 RNA levels prior to delivery and that further strategies are needed to prevent perinatal transmission in women with high or increasing virus levels and/or zidovudine-resistant virus.

Health care and its costs for children with perinatally acquired HIV infection

OBJECTIVE

To describe survival patterns, use of health services and related costs for Australian children with perinatally acquired human immunodeficiency virus (HIV) infection.

METHODOLOGY

A retrospective cross-sectional survey was made of 20 children with HIV infection (91% of those diagnosed) and 13 children with maternal antibodies who subsequently seroreverted, treated at 10 medical centres. Details of disease progression and use of health services were obtained from hospital medical records. Monthly costs for three phases of infection were estimated by linking service usage rates with estimates of the unit cost of each service. The average lifetime cost was estimated by combining monthly costs and phase duration estimates from the literature.

RESULTS

Patterns of disease progression were similar to those reported internationally, with a median survival of 8 years. Use of health services increased with severity of illness. Mean monthly costs were $120 per month (1992 Australian dollars) for children with maternal antibodies who subsequently seroreverted, $320 per month for children with HIV infection but no acquired immunodeficiency syndrome (AIDS)-defining illness, and $1830 per month for children with AIDS. The present value of total lifetime cost for a child with HIV infection was $48174, 46% of which was for treatment of AIDS.

DISCUSSION

The mean lifetime cost for a perinatally infected child was just over half that for a man with HIV in Australia. Health service usage and costs were lower for Australian than American children with HIV.

Repeatedly positive human immunodeficiency virus type 1 DNA polymerase chain reaction in human immunodeficiency virus-exposed seroreverting infants

Three human immunodeficiency virus type 1 (HIV-1)-exposed children who had repeatedly positive DNA polymerase chain reaction (PCR) tests for HIV in > or = 5 samples before seroreversion to HIV-negative status are reported. The children belong to a cohort of 210 infants who were born to HIV-infected mothers and were tested at intervals of 1 to 3 months by HIV viral culture, PCR, and p24 antigen; only the PCR was positive in > or = 5 samples in the children reported here. Their clinical features were indistinguishable from other seroreverters. All three children had a transient drop in CD4:CD8 ratio to < 1.0. The transiently positive DNA PCR in HIV-exposed infants may indicate either that HIV infection was eliminated by a strong host immune response or that infection was caused by an attenuated/defective strain of virus.

Phytohemagglutinin-inducible p24 in peripheral blood mononuclear cells as a predictor of human immunodeficiency virus type 1 vertical transmission and infant clinical status

We sought to determine whether the detectability of phytohemagglutinin-inducible p24 (PHA-p24) in short term cultures of peripheral blood mononuclear cells correlates with an increased risk of vertical transmission among human immunodeficiency virus type 1 (HIV-1)-infected pregnant women and more severe symptomatology among HIV-1-infected infants. The assay for PHA-p24 was performed on specimens obtained from HIV-1-infected women during their pregnancy and from infants during the first 6 months of life. Infants were followed prospectively to determine HIV-1 infection outcome and symptomatology. Among PHA-p24 positive women 9 of 19 (47.4%) gave birth to HIV-1-infected infants compared with 4 of 25 (16.0%) of PHA-p24-negative women (P = 0.02). Among women who tested PHA-p24-positive and had a CD4+ lymphocyte count < 500 cells/mm3, 8 of 15 (53.3%) gave birth to HIV-1-infected infants compared with 4 of 26 (15.4%) not meeting these conditions (P = 0.01). Among HIV-1-infected infants 4 of 5 (80%) of those testing PHA-p24-positive by one month of age developed an opportunistic infection or encephalopathy by 12 months of age, compared with none of the 11 infants testing PHA-p24-negative (P = 0.003). We conclude that PHA-p24 may be a useful in vitro measure for increased risk of vertical transmission among HIV-1-infected pregnant women and increased risk for rapid development of severe disease among HIV-1-infected infants.

Autoptic findings in HIV-1 positive children

The growing incidence of AIDS in children and newborns has been related to increasing incidence of AIDS in women. Case records were composed by 14 children with death occurring at different ages--from 1 hour to 12 years--and 1 female fetus, all with serological confirmation of AIDS. Brain and internal organs samples were collected at autopsy for morphological, immunohistochemical and "in situ" hybridization's technical examination. The prevailing extracerebral pathology observed at autopsy consisted of opportunistic infections. The cerebral findings were HIV-encephalopathy; cytomegalovirus encephalitis; vascular alterations such as necrosis and hemorrhage; calcifications and edema. Neurologic symptoms were reported in 3 children of intravenous drug-abuser mothers as drug withdrawal syndrome. HIV positivity in one or both the intravenous drug-abuser parents is the main risk factor of congenital AIDS. This factor means lack of care during the gestational stage and may determine relevant differences in the course of disease. The cerebral changes due to opportunistic infection must be differentiated from HIV-specific lesions; it has to be stressed that "diffuse" leukoencephalopathy is not AIDS-specific but can be found in every chronic encephalitis/encephalopathy especially in newborns and children. Chronologically, HIV encephalopathy appears as late manifestation of the disease, due to an infiltration of CNS of HIV-infected macrophages and not to an impairment of neuronal or glial cells infected by HIV in the early stages of the disease.

Age-related standards for T lymphocyte subsets based on uninfected children born to human immunodeficiency virus 1-infected women. The European Collaborative Study

The T lymphocyte subsets in the peripheral blood of 459 uninfected children born to white human immunodeficiency virus 1-infected women included in the European Collaborative Study were measured at regular intervals from birth. More than 2400 observations were used to create smooth age-related reference ranges for CD4 and CD8 counts and percentages, CD4:CD8 ratio and absolute lymphocyte count. Standards are presented for children up to 4 years of age. CD4, CD8 and absolute lymphocyte count rose after birth, peaked at around 6 to 9 months of age and then declined toward adult values. CD4 percentage and CD4:CD8 ratio declined steadily from birth onwards. Centile lines for CD4 count and CD4:CD8 ratio converged markedly with age. For the CD4 values, only 3 to 5% of the variation was attributable to differences between the 10 participating centers. These standards allow T lymphocyte abnormalities to be used more effectively as markers for disease progression and assist in the clinical follow up of human immunodeficiency virus 1-infected children. They also provide a basis for initiating antiretroviral treatment or antimicrobial prophylaxis.

Diarrhea among African children born to human immunodeficiency virus 1-infected mothers: clinical, microbiologic and epidemiologic features

Diarrhea and weight loss are common features of pediatric and adult human immunodeficiency type 1 (HIV-1) infection, particularly in developing countries. We studied prospectively episodes of diarrhea in 559 children, ages 10 to 15 months, participating in a longitudinal study of perinatal HIV-1 infection in Kinshasa, Zaire. Children with HIV-1 infection had more frequent episodes of diarrhea and were more likely to present with fever or moderate or severe dehydration and to have persistent or fatal diarrhea. Of 9 HIV-1-positive infants with diarrhea, 3 had enteroadherence factor-positive Escherichia coli, compared with 5 of 74 HIV-1-negative children with diarrhea (P = 0.04); no other pathogen was associated with HIV-1 infection. In a logistic regression model diarrhea was significantly associated with HIV-1 infection in the child, moderate or severe malnutrition and symptoms of acquired immunodeficiency syndrome in the mother. Diarrhea among children with perinatal HIV infection in Zaire is more severe than among uninfected children and is associated with malnutrition and advanced disease in the mother.

Immunization in children with HIV seropositivity at birth: antibody response to polio vaccine and tetanus toxoid

OBJECTIVE

To evaluate the humoral response to routine childhood immunization of HIV-infected children.

DESIGN

Response rate, antibody titres and persistence after polio and tetanus vaccination were compared in 72 children with HIV seropositivity at birth and divided according to HIV infection status as determined by clinical and laboratory tests.

METHODS

Polio antibodies were titred in a microneutralization test (positive titres, > or = 1:4), and antibody to tetanus toxoid with a passive haemagglutination method (protective titres, > or = 1:1024).

RESULTS

The response rates to polio and tetanus vaccination (> 80 and > 75%) were similar in the HIV-infected and non-infected children, as were antibody levels. In the subgroup with sera obtained some months after the last dose of vaccine, polio antibody levels decreased in all four HIV-infected and in three of the seven non-infected children; protective tetanus antitoxin levels were detected in three of the six infected and in all three non-infected children.

CONCLUSIONS

This study demonstrates the ability of children with HIV infection to respond adequately to the two vaccines considered, although tetanus antitoxin levels were inferior, compared with those in the seroreverted children. The unsatisfactory antibody levels observed in the admittedly few HIV-positive children studied some months after the last vaccination could be the result of a lower initial protective level and not necessarily an expression of severely impaired immunocompetence. The administration of booster doses in addition to the traditional immunization schedule could be useful in children with HIV infection.

[Molecular analysis of the principal neutralization epitope (V3 loop) of human immunodeficiency virus type 1 in Argentina]

The main goal of the present paper was to analyze the molecular diversity of the principal neutralizing domain (V3 loop) of the HIV 1 gp120 in samples from patients of Argentina. The study was carried out on a total of 30 HIV 1 positive blood samples, obtained during 1991-1992, belonging to 15 intravenous drug users (group A), 5 homosexual men (group B), 8 children born to HIV 1 positive mothers (group C) and 2 AIDS patients (group D). By using extracted DNA from peripheral blood lymphocytes and from infected cells of the viral isolates in the case of the 2 AIDS patients, the V3 loop region was amplified by means of polymerase chain reaction. Direct sequencing by Sanger methodology was then performed on DNA fragments and nucleotide sequences obtained were translated into the correspondent amino acids. Consensus sequences for each group and a general consensus sequence were established (Table 1). Its alignment with V3 loop amino acid sequences of the major HIV 1 strains isolated worldwide is showed in table 2. Homology analysis between each sequence of the study population and sequence of different HIV 1 isolates showed that most of these samples share high homology with SF2 and BH10 strains. In contrast a low homology was found with JH3 and MN isolated (table 3). The presence of highly conserved amino acid residues as substitutions and insertions was determined in the Argentinian V3 loop sequences giving them a local pattern. The present paper is of great importance for our country, considering that the V3 loop is the main neutralizing domain becoming a major target in the development of HIV 1 vaccine. To our knowledge, this is the first report on the sequencing of the principal neutralizing domain of the Human Immunodeficiency Virus type 1 in Latin America.

Infants born to HIV infected mothers

Eighty infants born to HIV-infected mothers were studied prospectively at Children's Hospital, Bangkok, Thailand from February 1989 to June 1991. The risk factors for acquisition of HIV infection were analyzed in 33 mothers (41.25%) including a history of being sex workers and having husbands who had extramarital sexual contact (22.5% each), having other sexually transmitted diseases (20.0%) and being IV drug users (6.25%). All infants appeared clinically normal without congenital anomaly, 22.5% (18 of 80) were of low birth weight with 91.43% (64 of 70) positive for HIV-antibody at birth. On follow up 56.25% (9 of 16) seroreversed during age 6 to 15 months, whereas 5 infants who were HIV-Ab negative at birth remained Ab negative on follow up for up to 15 months. One of 49 infants who attended the follow up clinic had been suffering from recurrent diarrhea, failure to thrive and encephalopathy since 9 months old; she weighed 6.7 kg at 15 months of age and remained positive for HIV-Ab.

Acute hemiplegia associated with HIV infection

An acute hemiplegia secondary to a large cerebral infarct is described in a 16-month-old infant with congenitally-acquired human immunodeficiency virus infection. Serial imaging studies during the next year documented improvement in his hemiplegia and a static underlying human immunodeficiency virus encephalopathy. Acquired immunodeficiency syndrome should be included in the differential diagnosis of children with acute hemiplegia.

[Prenatal development and postnatal morbidity of newborn infants of HIV positive mothers]

Does the maternal HIV-infection itself influence fetal development and neonatal morbidity or are adverse effects related to maternal opiate and nicotine abuse? 17 neonates of HIV-positive women (7 drug users) and 37 controls (17 healthy and 21 opiate exposed newborns) were examined prospectively. A discriminant analysis showed that opiate and nicotine abuse during pregnancy were associated with fetal growth retardation and neonatal morbidity, while HIV-infection of the mother did not influence these parameters. Symptoms of an HIV-embryopathy were not seen.

Effects of congenital HIV infection on neurodevelopmental status of babies in foster care

High rates of neurological complications related to congenital HIV infection have been reported, but often it has been difficult to delineate those clinical impairments specifically related to viral infection of the developing nervous system. The present study attempted to hold causative environmental factors constant by comparing the neurodevelopmental and growth status of two matched control groups of infants in foster care, one HIV seronegative and one seropositive. All were over the age of 15 months and had been born to seropositive mothers. The seropositive group showed significantly more neurological involvement than the seronegative group, and a different pattern of cognitive deficits. There were no significant differences in growth measures between the two groups. Babies born to HIV seropositive mothers were generally at high risk for developmental impairments.

How frequent and how early does the neurological involvement in HIV-positive children occur? Preliminary results of a prospective study

To study the natural history of the neurological involvement in pediatric human immunodeficiency virus (HIV) infection, 77 children born to seropositive mothers have been followed up since birth. The median follow-up time has been 17.5 months. Fourteen children were classified as infected, 34 as not infected, and 21 as indeterminable. Only two children with full-blown acute immune deficiency syndrome had severe neurological manifestations. "Soft" neurological signs were found in six infected, and ten non-infected children (chi 2, P < 0.05). The mean development quotient and IQ scores in the infected and the non-infected children were 82.22, and 93.15, respectively (Mann-Whitney test, P > 0.05). These data suggest that neurological and developmental abnormalities do not occur early in the course of vertical HIV infection and that they are associated with severe immunodeficiency.

Cytomegalovirus encephalopathy in an infant with congenital acquired immuno-deficiency syndrome

A female infant born pre-term to a HIV seropositive mother presented at birth with seropositivity for HIV and CMV viruria. At five months of age she developed an AIDS-related complex. Six months later she died from rapidly progressive diffuse encephalopathy. Post mortem examination revealed generalized CMV infection. Neuropathological examination showed a nodular encephalitis with occasional cytomegalic cells containing characteristic CMV inclusion bodies. There was no evidence of HIV encephalitis; immunostaining for HIV antigen (gp 41) was negative. Opportunistic infections in infants with congenital AIDS are the exception. To our knowledge, only one case of CMV encephalitis in an infant with congenital AIDS has been reported previously. In that case, as in the present one, a reactivation of a congenital CMV infection is likely.

Central-nervous-system methyl-group metabolism in children with neurological complications of HIV infection

To assess methyl-group metabolism in the central nervous system in infection with human immunodeficiency virus (HIV), levels of 5-methyltetrahydrofolate, methionine, and S-adenosylmethionine were measured by high-performance liquid chromatography in cerebrospinal fluid (CSF) from six children with congenital HIV infection and neurological complications. Total neopterins were also measured, as a marker of macrophage activation. In all six children concentrations of one or more methyl-group carriers were lower than those in a reference population of children, and all of the five in whom CSF neopterins were measured had higher than normal levels. Defective methylation may play a part in the neurological damage caused by HIV infection.

[Follow-up of perinatal HIV infection]

The clinical course of a perinatal HIV infection in a 3 1/2-year-old girl is presented. The girl became HIV-positive at the age of 6 months, at about the same time as her mother. She is receiving continuous prophylactic treatment with immunoglobulins and cotrimoxazol. The pathological findings and the stage according to the classification of the Centers for Disease Control are discussed.

[Prospective study of newborn infants born to mothers infected with human immunodeficiency virus]

Perinatal transmission of Human immunodeficiency virus (HIV) from mother to child is at the present time the most important cause of AIDS in children. Since August 1985 we have observed 24 babies with anti-HIV antibodies born to HIV-infected mothers. Their present status is: 6 have symptomatic infection, 6 undetermined infection, 10 had became seronegative and 2 were lost for follow-up. Our results suggest that the risk of infection for the baby is high and the onset of symptoms relatively early. Follow-up studies in babies born to HIV-infected mothers are needed in order to classify the true risk of infection in them and the natural history of the disease.

Babies of HIV infected women in Edinburgh

Acquired Immune Deficiency Syndrome (AIDS) was first recognised in children in 1982. This paper describes a paediatric counselling and screening clinic in Edinburgh for babies born to women who are Human Immunodeficiency Virus Positive.

Epidemiology, clinical features, and prognostic factors of paediatric HIV infection. Italian Multicentre Study

486 children born to HIV-positive mothers, 57 children infected by blood products, and 1 child for whom the personal history was not available were studied. Perinatal infection had a more varied clinical picture and a worse outcome compared with infection acquired later in childhood. Severe secondary infections, neurological disorders, and hepatitis (but not lymphoid interstitial pneumonia) were linked to a high mortality rate in perinatally infected children, in whom an early onset of symptoms was also a bad prognostic factor. Perinatal HIV infection occurred in 32.6% of children born to seropositive mothers, with a higher transmission rate in children born by vaginal delivery and then breast-fed. Preterm delivery and low birthweight seemed to be related to drug abuse during pregnancy, not to intrauterine HIV infection. Girls had a higher rate of perinatal infection and, of those infected, had an increased mortality.

Mother-to-child transmission of HIV infection. The European Collaborative Study

271 children born to HIV-infected mothers in 8 European centres are being followed up from birth in a multicentre, collaborative study. By June, 1988, 45% had been followed for over 1 year: 10 had developed AIDS or AIDS-related complex, all by the age of 9 months, of whom 5 had died. 22 other children had symptoms or signs suggestive of HIV infection; of these, 12 had immunological abnormalities, 9 of whom were infected. 5 children had problems not related to HIV, including 3 neonatal deaths. The other 234 children are immunologically normal and clinically well. The median age of antibody loss was 10.3 months, although 1 did not lose antibody until over 18 months. None lost antibody and then became and remained seropositive. Of 100 children followed for more than 15 months, 19 had persistent antibody, and 5 were antibody-negative but presumed to be infected because of virus isolation or antigen detection; these 5 children were clinically and immunologically normal. The estimated vertical transmission rate was 24%.

Morphological aspects of the placenta in HIV pregnancies

Forty-nine placentae from HIV-seropositive mothers were collected in various hospitals in France and Belgium. Twenty [corrected] placentae with seven fetuses from interrupted pregnancies and 29 [corrected] placentae from spontaneous deliveries, including two stillborns and a set of twins, were studied morphologically. No significant abnormalities were observed in the aborted material. The placentae corresponding to deliveries presented no significant gross abnormalities but the ratio of fetal to placental weight was significantly decreased in the study group compared with the control group (6.13 versus 7.41; P less than 0.001), associated with a congestive and mature aspect of the parenchyma. Histologically a high incidence of chorioamnionitis (43 per cent) was found, contrasting with the absence of villitis. A relative villous hypercellularity was observed in the study group compared with the control group. Ultrastructural studies of 13 placentae corresponding to gestations of 10 to 40 weeks are presented. In six cases, retrovirus-like particles were found at various sites, such as villous fibroblasts, syncytiotrophoblast and endothelial cells, and in the free membranes.

Infection of the fetus and the newborn: prevention, treatment and related handicap

Congenital infection is uncommon and the cause of only a small proportion of handicap seen in children but some infections may be preventable or even treatable. As an example, the congenital rubella syndrome first described in the 1940s is preventable by use of the vaccine but cases still occur. It is hoped that with the introduction of the measles, mumps, rubella immunization for young children, rubella will become as rare in the UK as it is in the USA. Cytomegalovirus is now a more common cause of handicap than rubella but no vaccine has been developed. Although antiviral drugs are available for herpes simplex virus and vaccinia, infection mortality in the newborn is high, even following the use of these agents; many HSV infections in the newborn arise following primary and asymptomatic maternal infections so that treatment may start late in the course of the illness. The obstetrician needs to understand the natural history as well as possible investigations available for congenital infections. There may be warning signs which require action, such as herpetic lesions in the genital tract of the mother. Less specific abnormalities during pregnancy, such as intra-uterine growth retardation and spontaneous onset of preterm labour, may point to congenital infection. This chapter describes both antenatal and postnatal management of the major congenital infections. We have included recent research data that should influence clinical practice; studies on HSV which suggest that, for women with a history of recurrent infection, routine viral culture of the genital tract at the end of pregnancy is unnecessary; reports from both the USA and the UK that rubella immunization performed inadvertently during early pregnancy has not resulted in the congenital rubella syndrome. The chapter would not have been complete without a discussion of human immunodeficiency virus, of concern to the obstetrician and midwife. There is still much to be learned about the natural history of this infection in both the mother and infant.