There’s no excuse’ for babies to be born today infected with HIV
Clinicians say it’s time to end perinatal transmission
Just like all human battles, the war against HIV has exacted its toll on children, including more than 15,000 infected in the United States. Most of those were infected by their mothers and many will die before the age of 13.
Some HIV and public health experts ask why we allow the disease to continue infecting children when research shows that vertical transmission of HIV can be prevented. Others recommend universal testing for HIV as a routine component of prenatal care.
"There is no excuse and no reason for a baby to be born today infected with HIV," says Stephen Thomas, PhD, director of the Institute for Minority Health Research at the Rollins School of Public Health at Emory University in Atlanta.
"There should be zero tolerance, and it’s not enough to say the reason they’re being born infected with HIV is because their mother is not in prenatal care or receiving access to services that could save her baby," Thomas adds. "We need to recognize, at a time when we know how to stop the spread of AIDS, that there are methods that are not being used."
American clinicians, health care administrators, and government agencies each have a responsibility to eliminate perinatal transmission of HIV, Thomas says.
"There is an initiative with $10 million from Congress with that target, and already [vertical] transmission has fallen," says Marc Bulterys, MD, PhD, medical epidemiologist at the Centers for Disease Control and Prevention in Atlanta.
Bulterys is participating in a program, which started in October, that will include testing women at labor and providing antiretroviral treatment either during their labor or soon after the baby’s birth.
While everyone aims for 0% transmission, instances of breakthrough transmission still will occur, even when highly active antiretroviral medication is used, he adds.
HIV researcher Lynne M. Mofenson, MD, raised the question of whether perinatal HIV can be eliminated in this country in an August 1999 article in the Journal of the American Medical Association. She answers that it is possible, but there still are barriers in the form of clinicians declining to encourage prenatal HIV testing for all pregnant women and women who may be at the most risk waiting too long to receive prenatal care.1
Mofenson is the associate branch chief for clinical research in the Pediatric, Adolescent and Maternal AIDS Branch of the National Institute of Child Health and Human Development at the National Institutes of Health in Rockville, MD.
Treatment could prevent HIV-infected babies
Prominent HIV research published in 1999 indicates that it is theoretically possible to eliminate just about all cases of HIV transmitted from non-nursing mothers to children through antire troviral medication administered during the last two trimesters of pregnancy and to babies for six weeks, Mofenson says.
"Antiretrovirals and counseling on breast-feeding are in place, but there are many hard- to-reach populations who are not having these benefits," she adds. "And as long as we don’t reach everyone, we will not eliminate it totally in the United States."
Since the early 1990s, clinicians increasingly have given antiretroviral treatment to pregnant women with HIV, and their efforts have helped to lower infant HIV rates in recent years. Perinatally acquired AIDS cases in the United States dropped by 66% between 1992 and 1997, according to the latest available data. One study showed that HIV testing of pregnant women has increased during the same period. And 91% of pregnant women, who were discovered to be HIV-infected, received prenatal, intrapartum, or neonatal zidovudine (AZT), whereas only 7% had received the treatment in 1993.2
But this only works if the woman seeks medical help while she’s pregnant, if she is asked about HIV, and if she agrees to be tested.
Moreover, HIV-infected women who receive some prenatal care but not adequate care also are far less likely to receive zidovudine treatment, says Amy Lansky, PhD, a CDC epidemiologist.
Lansky was an investigator in a study that showed women who received adequate prenatal care were nearly twice as likely to have been prescribed zidovudine as women who received inadequate prenatal care (57% vs. 30%).3
"Clearly, if women are HIV-infected and they’re not getting prenatal care, there’s not an opportunity to be prescribed the zidovudine regimen," Lansky says. "So one of the steps that needs to be taken is to have women who are pregnant get into prenatal care early and to have pregnant women tested so they know their HIV status."
Test all pregnant women for HIV
That’s where clinicians play a crucial role.
"Any woman who is pregnant should have an HIV test done," says Michael L. Tapper, MD, chief of the section of infectious diseases and hospital epidemiology at Lenox Hill Hospital in New York City.
"This should be part of the testing the way we test pregnant women for rubella and toxoplasmosis," Tapper adds. "A lot of obstetricians who have middle-class patients were more reluctant to approach a woman about HIV, so it has not been done terribly well in many settings."
New York state physicians no longer have a choice in the matter. New York’s state health department requires HIV testing of all pregnant women, and any women who are not tested during their pregnancy will be tested at the time of their delivery. The state’s decision was a political one that was not pushed by the medical community, although the medical community has supported clinicians voluntarily asking women to be tested for the virus, Tapper says.
Most states promote voluntary testing of pregnant women, and similar campaigns promoting universal voluntary testing are under way in Canada, Great Britain, and Australia. The American Academy of Pediatrics and the American College of Obstetricians and Gyne cologists support universal HIV testing as a standard part of prenatal care.
Many HIV researchers and health care experts recommend the adoption of a national policy of universal HIV testing as a routine component of prenatal care, Bulterys says. "A number of blood tests are done routinely, so HIV can be added routinely."
The Public Health Service in 1995 first recommended that providers counsel all pregnant women about HIV and encourage testing. But not all clinicians have followed that advice. A CDC study showed that women who recalled discussing HIV with their prenatal health care provider ranged from 63.4% in Maine to 86.7% in North Carolina. The percentage of mothers who recalled being tested ranged from 58% in Oklahoma to 80.7% in Florida.4 (See CDC testing chart, above.)
Support for mandatory testing has risen because of new evidence showing that rapid testing performed while a woman is in labor is very effective in protecting infants from HIV infection when clinicians immediately begin short-course antiretroviral therapy.
Rapid testing combined with zidovudine (AZT) treatment has lowered HIV transmission rates by about 38% in breast-feeding populations and by 50% in non-breast-feeding populations.5
Recent research also shows that a short-course therapy consisting of nevirapine, an antiretroviral with a long half-life and potent antiviral activity, can lower the risk of HIV transmission during the infant’s first four months of life by nearly 50% in a breast-feeding population.5
Also, perinatal treatment costs society less than caring for HIV-infected children. Even when women receive no prenatal care, clinicians can greatly reduce the HIV transmission rate and the costs of treating HIV infants by identifying and treating the women as they give birth. One study showed that if clinicians gave women a rapid HIV test during the women’s labor and then gave zidovudine treatment to the seropositive women, clinicians could save nearly $60,000 per potential HIV case.6
A short course of nevirapine, which costs only $4 per dose, is about one-tenth as expensive as other available short-course treatments, and it’s 70 times cheaper than a short course of AZT given to a woman during her last month of pregnancy. This news indicates that the savings could be even greater when that drug is used to treat women who have not sought prenatal care.
References
1. Mofenson LM. Can perinatal HIV infection be eliminated in the United States? JAMA 1999; 282:577-578.
2. Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999; 282:531-538.
3. Lansky A, Jones JL, Burkham S, et al. Adequacy of prenatal care and prescription of zidovudine to prevent perinatal HIV transmission. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 21:223-227.
4. Prenatal discussion of HIV testing and maternal HIV testing — 14 states, 1996-1997. MMWR 1999; 48:401-404.
5. Guay LA, Musoke P, Fleming T, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomized trial. Lancet 1999; 354:795.
6. Stringer JSA, Rouse DJ. Rapid testing and zidovudine treatment to prevent vertical transmission of human immunodeficiency virus in unregistered parturients: A cost-effectiveness analysis. Obstet Gynecol 1999; 94:34-39.
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