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Drop in perinatal transmission only HIV success. (Expert Opinion).

KEY LARGO, FLA. -- The good news regarding HIV infection in the United States is that the risk of perinatal transmission is now less than 2%.

The bad news is that over Americans are becoming complacent about HIV and AIDS, Dr. May J. O'Sullivan said at an ob.gyn. update sponsored by the University of Miami.

"The perinatal transmission rate is the only major success of therapy," said Dr. O'Sullivan, an attending physician in the department of obstetrics and gynecology at the University of Miami/Jackson Memorial Medical Center.

There were 224 known cases of perinatal transmission in the United States in 2002, a 75% decrease, compared with the peak of 905 cases in 1992. This lower incidence is attributed to chemoprophylaxis highly active antiretroviral therapy (HAART), and cesarean sections.

The highest rates of HIV infection in pregnant women are in New York City with 5.8 cases/1,000 pregnancies. In Washington, D.C., the incidence is 5.5/1,000, followed by 4.9 in New Jersey, and 4.5 in Florida. These rates reflect the overall geographic prevalence of HIV infection in the United States. "The Northeast and Southern parts of the United States rank extremely high in AIDS cases," she said.

Ob.gyns. and pediatricians may encounter an increasing number of patients with HIV infection. Overall, women account for 23% of new cases of HIV infection, versus only 7% in 1985. In addition, Dr. O'Sullivan said, "In the United States, take note, most infections in 13- to 19-year-olds were in' females."

The risk of adverse outcomes related to antiretroviral prescriptions during pregnancy is low. Antiretrovirals were first given to pregnant women in the late 1980s, so the first children from these pregnancies are now 12-13 years old. "Few complications have been reported."

Combination antiretrovirals do not increase the incidence of low-birth-weight, premature, or stillborn children, Dr. O'Sullivan said. However, some researchers have shown what she called a questionable increase in very-low-birth-weight babies (N. Engl. J. Med. 346[24]:1863-70, 2002).

The drug combination of dideoxyinosine (DDI) and D4T should be avoided in women; some women may have a recessive trait that predisposes them to mitochondrial toxicity from this particular therapy.

The American College of Obstetricians and Gynecologists recommends screening all pregnant women for HIV, and rescreening women determined to be at risk later in pregnancy. "Just because you screen them early in pregnancy doesn't mean you don't screen them again-be aware of their lifestyle and any risks," Dr. O'Sullivan said.

However, she also questioned the feasibility of widespread screening. "We're going to have to look at economics; health care cannot support of all this screening. Medicolegally this puts you out on a limb. We have to be selective 'and look at the potential benefit."

Complacency about HIV and AIDS is pervasive in. high-income countries like the United States, Dr. O'Sullivan said, despite some realities. For example, many people remain unaware that migration and international travel are bringing more cases to the United States--particularly from the Caribbean and Latin America.

Another reality is an increase in risky sexual behavior, particularly among teenagers and young adults. Club drugs such as 3,4-methylenedioxymeth-amphetamine (MDMA or "ecstasy") and gamma hydroxybutyrate (GHB) may be partially responsible. "Use of club drugs is growing exponentially [People] become disinhibited. When your gonads are working, your brain is not working," she said.

Public health efforts targeting AIDS prevention have dwindled, Dr. O'Sullivan said. However, there may be hope in the drug development: field, particularly regarding combination agents that increase treatment compliance and drugs that can be taken regardless of food tolerances.
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Author:McNamara, Damian
Publication:OB GYN News
Date:Apr 15, 2003
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