Preventing perinatal transmission of HIV: Your vigilance can pay off

,

Applied Evidence

Preventing perinatal transmission of HIV: Your vigilance can pay off

J Fam Pract. 2010 March;59(3):E1-E6

By

Michael A. Tolle, MD, MPH

These interventions can keep the risk of mother-to-child transmission at less than 2%.

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References

1. Force–Perinatal HIV Guidelines Working Group. Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. April 29, 2009. Available at: http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf. Accessed January 25, 2010.

2. Kline MW. Perspectives on the pediatric HIV/AIDS pandemic: catalyzing access of children to care and treatment. Pediatrics. 2006;117:1388-1393.

3. Tolle M, Dewey D. Prevention of mother-to-child transmission of HIV infection. In: HIV Curriculum for the Health Professional. 4th ed. Houston, TX: BCM; 2009:90-119. Available at: http://bayloraids.org/curriculum/files/6.pdf. Accessed January 25, 2010.

4. World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: toward universal access–recommendations for a public health approach. August 2006. Available at: http://www.who.int/hiv/pub/mtct/arv_guidelines_mtct.pdf. Accessed February 3, 2010.

5. Kourtis AP, Lee FK, Abrams EJ, et al. Mother-to-child transmission of HIV-1: timing and implications for prevention. Lancet Infect Dis. 2006;6:726-732.

6. Centers for Disease Control and Prevention. HIV/AIDS Surveillance in Women. Available at: http://www.cdc.gov/hiv/topics/surveillance/resources/slides/women/slides/Women.pdf. Accessed June 17, 2008.

7. Centers for Disease Control and Prevention. Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2007. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/default.htm. Accessed June 17, 2008.

8. Cohen MS. HIV and sexually transmitted diseases: lethal synergy. Top HIV Med. 2004;12:104-107.

9. Centers for Disease Control and Prevention. HIV transmission among black women—North Carolina, 2004. MMWR Morbid Mortal Wkly Rep. 2005;54:89-94.

10. Latka M. Drug-using women need comprehensive sexual risk reduction interventions. Clin Infect Dis. 2003;37(suppl S):S445-S450.

11. Kimani J, Kaul R, Nagelkerke NJ, et al. Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS. 2008;22:131-137.

12. Centers for Disease Control and Prevention. Achievements in public health: reduction in perinatal transmission of HIV infection—United States, 1985-2005. MMWR Morbid Mortal Wkly Rep. 2006;55:592-597.

13. Lindau ST, Jerome J, Miller K, et al. Mothers on the margins: implications for eradicating perinatal HIV. Soc Sci Med. 2006;62:59-69.

14. Branson BM, Handsfield HH, Lampe MA, et al. Centers for Disease Control and Prevention. Revised recommendations for the HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR14):1-17.

15. Lampe MA. Rapid HIV testing in labor and delivery: a safety net to prevent perinatal transmission. Available at: http://www.cdc.gov/hiv/topics/testing/rapid/pdf/LampePlenary2.pdf. Accessed February 3, 2010.

16. Centers for Disease Control and Prevention One test. Two lives. HIV screening for prenatal care. Available at: http://www.cdc.gov/Features/1Test2Lives. Accessed February 3, 2010.

17. Conner EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of HIV type 1 with zidovudine treatment. N Engl J Med. 1994;33:1173-1180.

18. Cooper ER, Charurat M, Mofenson L, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr. 2002;29:484-494.

19. Maggiolo F, Ripamonti D, Arici C, et al. Simpler regimens may enhance adherence to antiretrovirals in HIV-infected patients. HIV Clin Trials. 2002;3:371-378.

20. Nwokike J, Torpey K, Amenyah R, et al. Health systems-level strategic framework for improving adherence to antiretroviral therapy. AIDS 2006 - XVI International AIDS Conference: Abstract CDB1245.

21. Kind C, Rudin C, Siegrist CA, et al. Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis. AIDS. 1998;12:205-210.

22. The European Mode of Delivery Collaboration. Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. Lancet. 1999;353:1035-1039.

23. Zorrilla CD. HIV infection in women: perinatal issues and cervical cancer surveillance. Top HIV Med. 2007;15:1-5.

24. Brogly SB, Ylitalo N, Mofenson LM, et al. In utero nucleoside reverse transcriptase inhibitor exposure and signs of possible mitochondrial dysfunction in HIV-uninfected children. AIDS. 2007;21:929-938.

25. Pacheco SE, McIntosh K, Lu M, et al. Effect of perinatal antiretroviral drug exposure on hematologic values in HIV-uninfected children: an analysis of the women and infants transmission study. J Infect Dis. 2006;194:1089-1097.

26. Culnane M, Fowler MG, Lee SS, et al. Lack of long-term effects of in utero exposure to zidovudine among uninfected children born to HIV-infected women. JAMA. 1999;281:151-157.

27. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010. MMWR Morbid Mortal Wkly Rep. 2010;58(51&52):1-4.

28. Anabwani GM, Woldetsadik EA, Kline MW. Treatment of human immunodeficiency virus (HIV) in children using antiretroviral drugs. Semin Pediatr Infect Dis. 2005;16:116-124.

29. Centers for Disease Control and Prevention. Guidelines for the prevention and treatment of opportunistic infections among HIV-exposed and HIV-infected children. MMWR Recomm Rep. 2009;58(RR-11):1-176.

PRACTICE RECOMMENDATIONS

• Approach perinatal HIV transmission comprehensively, from prevention of unintended pregnancies among women with HIV to providing follow-up care to mothers with HIV and to their children. C

• All HIV-infected pregnant women should be offered highly active antiretroviral therapy (HAART). A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

A long-standing 25-year-old patient of yours reports that a home-pregnancy test proved positive. You confirm the pregnancy. This will be her first child. On routine prenatal testing, her human immunodeficiency virus (HIV) test result is also positive (enzyme-linked immunosorbent assay [ELISA], with confirmatory Western blot). She is concerned that the infection may be transmitted to her child and asks what can be done to prevent it.

With the use of appropriate interventions, the likelihood of her child becoming infected is less than 2%. In the United States today, most infants born to HIV-positive women will remain uninfected. Interventions recommended by the Public Health Service Task Force (US guidelines) include giving antiretroviral medications to the woman during pregnancy; managing the delivery, with the option of vaginal delivery vs cesarean section (to be determined closer to the time of delivery, based on her response to antiretroviral agents); giving a 6-week course of zidovudine (ZDV) to her infant; and avoiding breastfeeding.^1,2

What heightens the risk?
Perinatal transmission of HIV from mother to child can occur during pregnancy, labor and delivery, or breastfeeding.³ Risk of transmission is heightened if a mother has a high viral load and low CD4+ cell count or has advanced HIV illness or AIDS; rupture of membranes is prolonged, exceeding 4 hours; or invasive obstetrical procedures are required.³

Without intervention, the risk of transmission is 15% to 30%.⁴ Approximately 70% of transmission is believed to occur before delivery (20% before 36 weeks’ gestation, 50% from 36 weeks through labor), with roughly 30% of transmission occurring during delivery and the infant’s passage through the birth canal.⁵ Breastfeeding adds 5% to 20% to baseline risk, raising the total modifiable risk to as high as 50%.⁵

A comprehensive approach from WHO

The World Health Organization (WHO) has described a comprehensive approach to preventing perinatal transmission of HIV,⁴ which takes into consideration several factors across the spectrum of women’s and children’s health and assumes the involvement of a range of health care providers, including family physicians. The WHO approach focuses on 4 main areas and their respective interventions:

Preventing HIV infection among women of childbearing age
Preventing unintended pregnancies among women with HIV
Preventing HIV transmission from a mother to her infant
Providing appropriate care, treatment, and support to mothers with HIV and their children and families.

Preventing HIV infection among women of childbearing age
In 2007, HIV/AIDS was diagnosed in nearly 11,000 American women.⁶ African American women are 22 times more likely than white women to become infected, and Hispanic women are 5 times more likely.⁶

More than 80% of women become infected with HIV through high-risk heterosexual contact, including unprotected sex with multiple partners (eg, sex in exchange for money or narcotics), sex with men who have sex with men, and sex with injection drug users.⁷

Injection drug use is associated with 1 in 6 new HIV/AIDS diagnoses in women.^6,7 Young women of childbearing age have a higher risk of becoming HIV infected than older women,^6,7 and pregnancy itself increases a woman’s vulnerability to infection.^6,7 In addition, women may not appreciate their male partner’s risk factors for HIV infection.⁷

The presence of other sexually transmitted infections (STIs) greatly increases the risk of acquiring and transmitting HIV infection.⁸ Poverty, too, is a risk factor for acquiring HIV infection. A study of African American women in North Carolina found that unemployment, receipt of public assistance, and the exchange of sex for money or housing were significantly more likely among HIV-infected women than among uninfected women.⁹

Awareness of these risk factors is important for those who care for minority and disadvantaged populations. In treating at-risk women, consider early referral to social services and reinforce HIV prevention strategies, such as condom use with each sexual contact, to help reduce new HIV infections.^7,10 Screening of young women for gonorrhea and chlamydia and prompt treatment of these and other STIs may also have an impact on HIV transmission.^8,11

Preventing unintended pregnancies among women with HIV

FAST TRACK

Many HIV-infected women do not receive regular health care, and many do not know they are infected.

Many HIV-infected women do not receive regular health care,^12,13 including family planning services. And many do not know they are infected.¹²