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Cases of Perinatal HIV Transmission Down 10-Fold Since 1994.

CHICAGO -- Perinatal HIV transmission has decreased 10-fold in the United States since 1994, Dr. Lynne M. Mofenson reported at the annual meeting of the American Academy of Pediatrics.

The number of HIV-infected infants has dropped from about 2,000 per year prior to the adoption of routine testing and prophylaxis of infected mothers in 1994 to only about 200 annually today. "Eradication of perinatal HIV infection is within our reach, but there is still a way to go before it's a reality," said Dr. Mofenson of the pediatric adolescent and maternal AIDS branch at the National Institute of Child Health and Human Development in Bethesda, Md.

The landmark 1994 study known as ACTG 076 showed that a three-part regimen of zidovudine given to a patient during pregnancy and labor and to the infant for the first 6 weeks of life decreased the HIV transmission rate by 68%. In 1996, the use of more complex prophylactic regimens with and without protease inhibitors was introduced, and these regimens are now the standard of care.

Prior to 1994, when HIV-infected women were given only prenatal zidovudine or nothing, the perinatal HIV transmission rate was 20%-25%. By 1999, the rate had dropped to 3%. "It's now a preventable disease," said Dr. Mofenson, who chaired the public health task force that developed the national recommendations for the use of antiretroviral drugs in HIV-positive pregnant women.

But infected babies continue to be born despite the success of prophylaxis. A major problem is that the demographic group most likely to become HIV infected today is the same group most likely to get pregnant and not receive prenatal care.

In a 1999 study of states with HIV reporting, 64% of 13- to 19-year-olds who were HIV infected were female, compared with 44% of the 20- to 24-year-olds and only 29% of those older than 25. In the age 13-19 group, 52% with AIDS and 50% of the females with HIV were reported to have become infected through heterosexual contact. But further investigation showed that the true proportion was actually more than 90%, Dr. Mofenson commented.

Another study of a population aged 20 and younger (the Job Corps) revealed an overall HIV prevalence of 2.8/1,000 females, compared with 2/1,000 males. African American females had the highest rate: 4.9/1,000.

Although the adolescent pregnancy rate has dropped by 13% since 1991, it is still high among minority teenagers (107/1,000 among African American teenagers, compared with 66/1,000 among all women of childbearing age). And, while only 1% of all pregnant women in the United States receive no prenatal care, the rate is 9% among pregnant women who live in urban areas and 12% among African Americans who live in urban areas.

A study from the Centers for Disease Control and Prevention showed that 15% of all HIV-infected pregnant women receive no prenatal care, Dr. Mofenson said.

The rate of prenatal diagnosis of HIV infection has increased steadily since 1994--from 68% to more than 90% in 2000-- but there is still significant variation in testing and a large amount of ambivalence on the part of the medical profession. In one physician survey, nearly all agreed that HIV testing should be routinely offered to all pregnant women, but only 50%-75% of physicians actually did so.

Respondents listed lack of time, the need for confidentiality and counseling, lack of perceived maternal risk, and embarrassment about discussing HIV infection as barriers to universal HIV screening of pregnant women.

Even if the diagnosis is late, there is still a chance for prevention of perinatal HIV transmission. In a study done in Thailand, women who took zidovudine for just 1 month prior to delivery reduced the risk of transmission by 51%, compared with a 68% reduction with the full three-part (prenatal, intrapartum, and newborn) regimen.

In an observational study in New York state, involving 454 infants born to HIV-infected women, the rates of perinatal transmission varied with the timing of zidovudine prophylaxis: When treatment was begun prenatally, the transmission rate was 6.1%, compared with 10% when begun during the intrapartum period, 9.3% when started within the first 48 hours of life, and 18.4% at day 3 of life or later. Without zidovudine, transmission occurred in 26.6% (N. Engl. J. Med. 339[20]:1409-14, 2000).

Other data suggest that elective cesarean section--with and without zidovudine--may also reduce the risk of perinatal HIV transmission. But, it is still unclear whether the benefit of surgical delivery is worth the risk in women with low viral loads or who are receiving adequate antiretroviral therapy, Dr. Mofenson said.
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Publication:OB GYN News
Date:Mar 1, 2001
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