Short-course antenatal zidovudine reduces both cervicovaginal human immunodeficiency virus type 1 RNA levels and risk of perinatal transmission. Bangkok Collaborative Perinatal HIV Transmission Study Group

Mother-to-child HIV-2 transmission: comparison with HIV-1 and evaluation of factors influencing the rate of transmission. A systematic review

A review and collection of data on HIV-2 mother-to-child transmission (MTCT) is absent in the literature. This systematic review and meta-analysis aims to provide a pooled estimate of the rate of HIV-2 MTCT and to identify factors influencing the rate of transmission. PubMed and EMBASE were used to identify eligible publications using a sensitive search strategy. All publications until February 2021 were considered; 146 full-text articles were assessed. Observational studies describing the rate of HIV-2 MTCT in a defined HIV-2 infected study population were included. Other publication types and studies describing HIV-1 or dually infected populations were excluded. Nine studies consisting of 901 mother-child pairs in West Africa, France and Portugal were included in the meta-analysis. The pooled rate estimate of HIV-2 MTCT for antiretroviral therapy-naïve women was 0.2% (95% CI 0.03 to 1.47%), considerably lower than that for HIV-1. The levels of maternal HIV RNA and CD4 cell count were positively related to the vertical transmission rate. Maternal HIV-2 infection did not significantly affect perinatal mortality. It was concluded that the vertical transmission of HIV-2 is lower than that of HIV-1. Maternal viral load and CD4 cell count appear to influence the rate of HIV-2 MTCT.

Maternal HIV drug resistance is associated with vertical transmission and is prevalent in infected infants

BACKGROUND

We aimed to assess if maternal HIV drug resistance is associated with an increased risk of HIV vertical transmission and to describe the dynamics of drug resistance in HIV-infected infants.

METHODS

A case-control study of PROMISE study participants. "Cases" were mother-infant pairs with HIV vertical transmission during pregnancy or breastfeeding and "controls" were mother-infant pairs without transmission matched 1:3 by delivery date and clinical site. Genotypic HIV drug resistance analyses were performed on mothers' and their infants' plasma at or near the time of infant HIV diagnosis. Longitudinal analysis of genotypic resistance was assessed in available specimens from infants, from diagnosis and beyond, including ART initiation and last study visits.

RESULTS

Our analyses included 85 cases and 255 matched controls. Maternal HIV drug resistance, adjusted for plasma HIV RNA load at infant HIV diagnosis, enrollment CD4 count, and antepartum regimens, was not associated with in utero/peripartum HIV transmission. In contrast, both maternal plasma HIV RNA load and HIV drug resistance were independent risk factors associated with vertical transmission during breastfeeding. Furthermore, HIV drug resistance was selected across infected infants during infancy.

CONCLUSIONS

Maternal HIV drug resistance and maternal viral load were independent risk factors for vertical transmission during breastfeeding, suggesting that nevirapine alone may be insufficient infant prophylaxis against drug-resistant variants in maternal breast milk. These findings support efforts to achieve suppression of HIV replication during pregnancy and suggest that breastfeeding infants may benefit from prophylaxis with a greater barrier to drug resistance than nevirapine alone.

HIV and SIV in Body Fluids: From Breast Milk to the Genitourinary Tract

HIV-1 is present in many secretions including oral, intestinal, genital, and breast milk. However, most people exposed to HIV-1 within these mucosal compartments do not become infected despite often frequent and repetitive exposure over prolonged periods of time. In this review, we discuss what is known about the levels of cell-free HIV RNA, cell-associated HIV DNA and cell-associated HIV RNA in external secretions. Levels of virus are usually lower than contemporaneously obtained blood, increased in settings of inflammation and infection, and decreased in response to antiretroviral therapy. Additionally, each mucosal compartment has unique innate and adaptive immune responses that affect the composition and presence of HIV-1 within each external secretion. We discuss the current state of knowledge about the types and amounts of virus present in the various excretions, touch on innate and adaptive immune responses as they affect viral levels, and highlight important areas for further study.

Herpes Simplex Virus Shedding Rate: Surrogate Outcome for Genital Herpes Recurrence Frequency and Lesion Rates, and Phase 2 Clinical Trials End Point for Evaluating Efficacy of Antivirals

Background

We tested whether genital herpes simplex virus (HSV) shedding is an appropriate surrogate outcome for the clinical outcome of genital herpes lesions in studies of HSV-2 antiviral interventions.

Methods

We analyzed prospective data from natural history studies and clinical trials of antiviral agents for HSV-2 in which HSV-2-seropositive participants provided self-collected anogenital swab specimens daily over ≥25 days for HSV DNA quantitation by polymerase chain reaction (PCR). Genital recurrences were self-reported.

Results

Among 674 participants, genital HSV shedding was detected on 17% of days, and genital lesions were reported on 10% of days. Within the same session, HSV shedding rates were strongly correlated with lesion rates (ρ = 0.61, P < .0001). The relative reduction in the recurrence rate was 72% (P = .041) for recipients of the antiviral agent pritelivir as compared to recipients of placebo, but it decreased to 21% (P = .75) after adjustment for HSV shedding rate. When evaluating valacyclovir and acyclovir, adjustment for the HSV shedding rate also led to a reduced association of these antivirals with the recurrence rate. Overall, 40%-82% of the antiviral effect on recurrences was explained by its effect on HSV shedding.

Conclusion

HSV genital shedding measured by PCR analysis in swab specimens self-collected daily is an appropriate surrogate outcome for genital herpes lesions because it is in the causal pathway to recurrences.

The Role of Immune Responses in HIV Mother-to-Child Transmission

HIV mother-to-child transmission (MTCT) represents a success story in the HIV/AIDS field given the significant reduction in number of transmission events with the scale-up of antiretroviral treatment and other prevention methods. Nevertheless, MTCT still occurs and better understanding of the basic biology and immunology of transmission will aid in future prevention and treatment efforts. MTCT is a unique setting given that the transmission pair is known and the infant receives passively transferred HIV-specific antibodies from the mother while in utero. Thus, infant exposure to HIV occurs in the face of HIV-specific antibodies, especially during delivery and breastfeeding. This review highlights the immune correlates of protection in HIV MTCT including humoral (neutralizing antibodies, antibody-dependent cellular cytotoxicity, and binding epitopes), cellular, and innate immune factors. We further discuss the future implications of this research as it pertains to opportunities for passive and active vaccination with the ultimate goal of eliminating HIV MTCT.

Managing Mother-to-Child Transmission of HIV Infection in Developed-Country Settings

This article reviews current understanding of the management of mother-to-child transmission of HIV-1 infection in the context of developed-country settings. The advent of highly active antiretroviral therapy has facilitated the virtual elimination of mother-to-child transmission of HIV infection in developed countries, reducing transmission rates to approximately 1–2%. This review describes the epidemiology of HIV infection among women of child-bearing age and the risk factors, timing and mechanisms of mother-to-child transmission, followed by a discussion of the identification of pregnant HIV-infected women and their therapeutic and obstetric management.

CD4 Cell Count: Declining Value for Antiretroviral Therapy Eligibility

Antiretroviral therapy (ART) policy for people living with human immunodeficiency virus (HIV) has historically been based on clinical indications, such as opportunistic infections and CD4 cell counts. Studies suggest that CD4 counts early in HIV infection do not predict relevant public health outcomes such as disease progression, mortality, and HIV transmission in people living with HIV. CD4 counts also vary widely within individuals and among populations, leading to imprecise measurements and arbitrary ART initiation. To capture the clinical and preventive benefits of treatment, the global HIV response now focuses on increasing HIV diagnosis and ART coverage. CD4 counts for ART initiation were necessary when medications were expensive and had severe side effects, and when the impact of early ART initiation was unclear. However, current evidence suggests that although CD4 counts may still play a role in guiding clinical care to start prophylaxis for opportunistic infections, CD4 counts should cease to be required for ART initiation.

Comparison of anti-retroviral therapy treatment strategies in prevention of mother-to-child transmission in a teaching hospital in Ethiopia

BACKGROUND

More than 90% of Human immunodeficiency virus (HIV) infection in children is acquired due to mother-to-child transmission, which is spreading during pregnancy, delivery or breastfeeding.

OBJECTIVE

To determine the effectiveness of highly active antiretroviral and short course antiretroviral regimens in prevention of mother-to-child transmission of HIV and associated factors Jimma University Specialized Hospital (JUSH).

METHOD

A hospital based retrospective cohort study was conducted on HIV infected pregnant mothers who gave birth and had follow up at anti-retroviral therapy (ART) clinic for at least 6 months during a time period paired with their infants. The primary and secondary outcomes were rate of infant infection by HIV at 6 weeks and 6 months respectively. The Chi-square was used for the comparison of categorical data multivariate logistic regression model was used to identify the determinants of early mother-to-child transmission of HIV at 6 weeks. Cox proportional hazard model was used to analyze factors that affect the 6 month HIV free survival of infants born to HIV infected mothers.

RESULTS

A total of 180 mother infant pairs were considered for the final analysis, 90(50%) mothers received single dose nevirapine (sdNVP) designated as regimen-3, 67 (37.2%) mothers were on different types of ARV regimens commonly AZT + 3TC + NVP (regimen-1), while the rest 23 (12.8%) mothers were on short course dual regimen AZT + 3TC + sdNVP (regimen-2). Early mother-to-child transmission rate at 6 weeks for regimens 1, 2 and 3 were 5.9% (4/67), 8.6% (2/23), and 15.5% (14/90) respectively. The late cumulative mother-to-child transmission rate of HIV at 6 months regardless of regimen type was 15.5% (28/180). Postnatal transmission at 6 months was 28.5% (8/28) of infected children. Factors that were found to be associated with high risk of early mother-to-child transmission of HIV include duration of ARV regimen shorter than 2 months during pregnancy (OR=4.3, 95%CI =1.38-13.46), base line CD4 less than 350 cells/cubic mm (OR=6.98, 95%CI=0.91-53.76), early infant infection (OR=5.4, 95%CI=2.04-14.4), infants delivered home (OR=13.1, 95%CI=2.69-63.7), infant with birth weight less than 2500 g (OR=6.41, 95%CI=2.21-18.61), and mixed infant feeding (OR=6.7, 95%CI=2.2-20.4). Antiretroviral regimen duration less than 2 months, maternal base line CD4 less than 350 cells/cubic mm and mixed infant feeding were also important risk factors for late infant infection or death.

CONCLUSION

The effectiveness of multiple antiretroviral drugs in prevention of early mother-to-child transmission of HIV was found to be more effective than that of single dose nevirapine, although, the difference was not statistically significant. But in late transmission, a significant difference was observed in which infants born to mother who received multiple antiretroviral drugs were less likely to progress to infection or death than infants born to mothers who received single dose nevirapine.

The role of cell-associated virus in mother-to-child HIV transmission

Mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) continues to contribute to the global burden of disease despite great advances in antiretroviral (ARV) treatment and prophylaxis. In this review, we discuss the proposed mechanisms of MTCT, evidence for cell-free and cell-associated transmission in different routes of MTCT, and the impact of ARVs on virus levels and transmission. Many population-based studies support a role for cell-associated virus in transmission and in vitro studies also provide some support for this mode of transmission. However, animal model studies provide proof-of-principle that cell-free virus can establish infection in infants, and studies of ARVs in HIV-infected pregnant women show a strong correlation with reduction in cell-free virus levels and protection. ARV treatment in MTCT potentially provides opportunities to better define the infectious form of virus, but these studies will require better tools to measure the infectious cell reservoir.

Anaerobes and bacterial vaginosis in pregnancy: virulence factors contributing to vaginal colonisation

The aetiology and pathogenesis of bacterial vaginosis (BV) is unclear but it appears to be associated with factors that disrupt the normal acidity of the vagina thus altering the equilibrium between the normal vaginal microbiota. BV has serious implications for female morbidity, including reports of pelvic inflammatory disease, adverse pregnancy outcomes, increased susceptibility to sexually transmitted infections and infertility. This paper reviewed new available information regarding possible factors contributing to the establishment of the BV vaginal biofilm, examined the proposed role of anaerobic microbial species recently detected by new culture-independent methods and discusses developments related to the effects of BV on human pregnancy. The literature search included Pubmed (NLM), LISTA (EBSCO), and Web of Science. Because of the complexity and diversity of population groups, diagnosis and methodology used, no meta-analysis was performed. Several anaerobic microbial species previously missed in the laboratory diagnosis of BV have been revealed while taking cognisance of newly proposed theories of infection, thereby improving our understanding and knowledge of the complex aetiology and pathogenesis of BV and its perceived role in adverse pregnancy outcomes.

Cervicovaginal HIV-1 shedding in women taking antiretroviral therapy in Burkina Faso: a longitudinal study

BACKGROUND

Antiretroviral therapy (ART) reduces transmission of HIV-1. However, genital HIV-1 can be detected in patients on ART. We analyzed factors associated with genital HIV-1 shedding among high-risk women on ART in Burkina Faso.

METHODS

Plasma viral load (PVL) and enriched cervicovaginal lavage HIV-1 RNA were measured every 3-6 months for up to 8 years. Random-effects logistic and linear regression models were used to analyze associations of frequency and quantity of genital HIV-1 RNA with behavioral and biological factors, adjusting for within-woman correlation. The lower limit of detection of HIV-1 RNA in plasma and eCVL samples was 300 copies per milliliter.

RESULTS

One hundred and eighty-eight participants initiated ART from 2004 to 2011. PVL was detectable in 16% (171/1050) of visits, in 52% (90/174) of women. Cervicovaginal HIV-1 RNA was detectable in 16% (128/798) of visits with undetectable plasma HIV-1 RNA in 45% (77/170) of women. After adjusting for PVL, detectable cervicovaginal HIV-1 RNA was independently associated with abnormal vaginal discharge and use of nevirapine or zidovudine vs. efavirenz and stavudine, respectively; longer time on ART and hormonal contraception were not associated with increased shedding. The presence of bacterial vaginosis, herpes simplex virus-2 DNA, and the use of nevirapine vs efavirenz were independently associated with an increased quantity of cervicovaginal HIV-1 RNA.

CONCLUSIONS

Certain ART regimens, abnormal vaginal discharge, bacterial vaginosis, and genital herpes simplex virus-2 are associated with HIV-1 cervicovaginal shedding or quantity in women on ART after adjusting for PVL. This may reduce the effectiveness of ART as prevention in high-risk populations.

Effect of HIV-1 exposure and antiretroviral treatment strategies in HIV-infected children on immunogenicity of vaccines during infancy

INTRODUCTION

We studied the effect of maternal HIV-exposure and timing of antiretroviral treatment (ART) in HIV-infected infants on antibody responses to combined diphtheria-toxoid-tetanus-toxoid-whole cell pertussis and Haemophilus influenzae type b conjugate vaccine (HibCV) and monovalent hepatitis B vaccine (HBV).

METHODS

HIV-uninfected infants born to HIV-infected (HEU) or HIV-uninfected (HUU) mothers were enrolled in parallel with HIV-infected children with CD4⁺ ≥25%, who were randomized to initiate ART immediately upon confirmation of HIV-infection (ART-Immed) or when clinically and/or immunologically indicated (ART-Def). Infants received three doses of diphtheria-toxoid-tetanus-toxoid -wP-HibC/HBV at 7.3, 11.4 and 15.4 weeks of age. Antibody to diphtheria-toxoid, tetanus-toxoid, pertussis toxin, filamentous hemagglutinin (FHA) and hepatitis B surface antigen (HBsAg) were measured by Luminex multiplex-immunoassay and polyribosyl-ribitol phosphate (PRP) antibodies by standard ELISA and bactericidal assay.

RESULTS

Prevaccination antibody geometric mean concentrations (GMCs) were higher in HUU than HEU infants for tetanus-toxoid, but lower for HBsAg, diphtheria-toxoid and FHA. Postvaccination GMCs and proportion with seroprotective antibody levels or sero-conversion rates were similar between HUU and HEU infants for all vaccines. Postvaccination GMCs were higher in HUU for tetanus-toxoid, diphtheria-toxoid, HBsAg and FHA than ART-Immed infants; and for tetanus-toxoid, HBsAg and pertussis-toxoid than ART-Def infants. Nevertheless, there was no difference in proportion of HUU and HIV-infected infants who developed sero-protective vaccine-specific antibody levels postvaccination. The timing of ART initiation generally did not affect immune responses to vaccines between HIV-infected groups.

CONCLUSION

Vaccination with DTwP-HibCV/HBV of HEU and HIV-infected infants initiated on early-ART confers similar immunity compared with HUU children.

Antiretroviral therapy and mother-to-child transmission of HIV-1

The advent of highly active antiretroviral therapy has facilitated the virtual elimination of mother-to-child transmission of HIV infection in developed countries, reducing transmission rates to approximately 1 to 2%. In these settings, highly active antiretroviral therapy has also transformed pediatric HIV infection into a chronic disease; although there are associated costs in terms of side effects and the heavy pill burden. In less developed settings, easier-to-use adaptations of antiretroviral therapy regimens, such as short-course and single-dose antiretroviral strategies or neonatal postexposure prophylaxis can also substantially prevent mother-to-child transmission, although to a lesser degree than highly active antiretroviral therapy. However, postnatal transmission of infection through breastfeeding significantly reduces the longer-term efficacy of these strategies. Ongoing research is focusing on the use of antiretroviral therapy in the breastfeeding period.

The role of co-infections in mother-to-child transmission of HIV

In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.

Genital HIV-1 RNA predicts risk of heterosexual HIV-1 transmission

High plasma HIV-1 RNA concentrations are associated with an increased risk of HIV-1 transmission. Although plasma and genital HIV-1 RNA concentrations are correlated, no study has evaluated the relationship between genital HIV-1 RNA and the risk of heterosexual HIV-1 transmission. In a prospective study of 2521 African HIV-1 serodiscordant couples, we assessed genital HIV-1 RNA quantity and HIV-1 transmission risk. HIV-1 transmission linkage was established within the partnership by viral sequence analysis. We tested endocervical samples from 1805 women, including 46 who transmitted HIV-1 to their partner, and semen samples from 716 men, including 32 who transmitted HIV-1 to their partner. There was a correlation between genital and plasma HIV-1 RNA concentrations: For endocervical swabs, Spearman's rank correlation coefficient ρ was 0.56, and for semen, ρ was 0.55. Each 1.0 log(10) increase in genital HIV-1 RNA was associated with a 2.20-fold (for endocervical swabs: 95% confidence interval, 1.60 to 3.04) and a 1.79-fold (for semen: 95% confidence interval, 1.30 to 2.47) increased risk of HIV-1 transmission. Genital HIV-1 RNA independently predicted HIV-1 transmission risk after adjusting for plasma HIV-1 quantity (hazard ratio, 1.67 for endocervical swabs and 1.68 for semen). Seven female-to-male and four male-to-female HIV-1 transmissions (incidence <1% per year) occurred from persons with undetectable genital HIV-1 RNA, but in all 11 cases, plasma HIV-1 RNA was detected. Thus, higher genital HIV-1 RNA concentrations are associated with greater risk of heterosexual HIV-1 transmission, and this effect was independent of plasma HIV-1 concentrations. These data suggest that HIV-1 RNA in genital secretions could be used as a marker of HIV-1 sexual transmission risk.

The Effect of Commiphora molmol (Myrrh) in Treatment of Trichomoniasis vaginalis infection

BACKGROUND

Trichomoniasis vaginalis is now an important worldwide health problem. Metronidazole has so far been used in treatment, but the metronidazole-resistant strains and unpleasant adverse effects have been de-veloped. Myrrh is one of the oldest known medicinal plants used by the ancient Egyptians for medical purposes and for mummification. Commiphora molmol (Myrrh) proved safe for male reproductive organ which is the main habitat of T. vaginalis and this study aims to evaluate the efficacy of the herbal against T. vaginalis in females.

METHODS

In the present study, 33 metronidazole-resistant T. vaginalis females were treated with a combined course of metronidazole and tinidazole. Those still resistant to the combined treatment were given C. molmol. Also, natural plant extract purified from pomegranate (Punica granatum, Roman) was in-vitro investigated for its efficacy against T. vaginalis on Diamond media.

RESULTS

The anti-T. vaginalis activity of both P. granatum (in-vitro) and C. molmol (in-vivo) extracts gave promis-ing results.

CONCLUSION

The anti-T. vaginalis activity of P. granatum and C. molmol showed promising results indicating to sources of new anti-Ttrichomonas agents.

Antiretroviral use during pregnancy for treatment or prophylaxis

INTRODUCTION

Antiretrovirals are recommended for all pregnant women either for treatment of HIV-1 infection or for prevention of mother-to-child transmission. Distinguishing between HIV-1-infected pregnant women who meet treatment criteria and those who do not (who use antiretrovirals during pregnancy for prophylaxis) is accomplished by assessing the HIV-1 disease stage and has important implications regarding when antiretroviral drugs are initiated during pregnancy, what drugs are used and antiretroviral use after delivery.

AREAS COVERED

This review addresses antiretroviral use by HIV-1-infected women during pregnancy. Specifically, the review focuses on antiretroviral therapy for HIV-1-infected pregnant women who meet criteria for treatment and antiretroviral prophylaxis for HIV-1-infected pregnant women (to prevent mother-to-child transmission of HIV-1). The review primarily addresses antiretroviral use in resource-rich settings, but use in resource-poor settings is briefly addressed.

EXPERT OPINION

Antiretrovirals represent only one component of the overall management of HIV-1 infected pregnant women and, therefore, cannot be viewed in isolation from other components of optimal care for HIV-1-infected women and from other efficacious interventions to prevent mother-to-child transmission of HIV-1. Antiretrovirals can be used safely and effectively during pregnancy. We concur with current guidelines regarding the threshold that differentiates which women need antiretroviral therapy for HIV-1 infection for their own health versus those who need prophylaxis to prevent transmission of HIV-1 infection to their child. We thus recommend that lifelong antiretroviral therapy be initiated in patients with an AIDS-defining illness, a CD4 count < 350 cells/mm(3) or other co-morbid conditions such as acute opportunistic infections, HIV-1-associated nephropathy or hepatitis B co-infection. Irrespective of whether or not antiretrovirals are used during pregnancy, or whether antiretrovirals during pregnancy are used for treatment or prophylaxis, all infants of HIV-1-infected women should receive antiretroviral post-exposure prophylaxis.

Advances in prevention of mother-to-child HIV transmission: the international perspectives

We have sufficient knowledge and unprecedented access to global resources to dramatically reduce the transmission of HIV-1 from mother to children worldwide. Most transmission occurs during delivery and after birth through breastfeeding. For this reason, efforts to interrupt transmission have focused on peripartum period and safe infant feeding. This includes the use of antiretroviral therapy, elective cesarean section, avoidance of breastfeeding, and exclusive breastfeeding. This review summarizes recent studies and new international development on the prevention of mother-to-child HIV transmission. Prevention of mother-to-child transmission of HIV should now be integrated as part of basic maternal and child health services.

Prevention of mother-to-child transmission of HIV: antiretroviral strategies

The World Health Organization's Strategic Approaches to the Prevention of HIV Infection in Infants includes 4 components: primary prevention of HIV-1 infection; prevention of unintended pregnancies among HIV-1-infected women; prevention of transmission of HIV-1 infection from mothers to children; and provision of ongoing support, care, and treatment to HIV-1-infected women and their families. This review focuses on antiretrovirals for secondary prevention of HIV-1 infection-prevention of HIV-1 transmission from an HIV-1-infected woman to her child. Antiretroviral strategies to prevent the mother-to-child transmission of HIV-1 in nonbreastfeeding populations comprise antiretroviral treatment of HIV-1-infected pregnant women needing antiretrovirals for their own health, antiretroviral prophylaxis for HIV-1-infected pregnant women not yet meeting criteria for treatment, and antiretroviral prophylaxis for infants of HIV-1-infected mothers. The review primarily addresses antiretroviral strategies for nonbreastfeeding, HIV-1-infected women and their infants in resource-rich settings, such as the United States. Antiretroviral strategies to prevent antepartum, intrapartum, and early postnatal transmission in resource-poor settings are also addressed, albeit more briefly.

Clinical care of the exposed infants of HIV-infected mothers

Infants born to HIV-infected mothers are at risk for mother-to-child transmission of HIV. Since the beginning of the epidemic, medical advances have dramatically reduced transmission rates from the mother to the child. Clinical care of the HIV-exposed infant involves unique management considerations. Clinicians caring for these infants must be knowledgeable about postexposure antiretroviral prophylaxis, understand the HIV diagnostic testing necessary to determine the infant's HIV status, and be able to provide relevant anticipatory guidance. This article presents the pertinent management considerations needed for clinicians to provide optimal care to the HIV-exposed infant.

Fetal immune activation to malaria antigens enhances susceptibility to in vitro HIV infection in cord blood mononuclear cells

Mother-to-child-transmission (MTCT) of human immunodeficiency virus (HIV) remains a significant cause of new HIV infections in many countries. To examine whether fetal immune activation as a consequence of prenatal exposure to parasitic antigens increases the risk of MTCT, cord blood mononuclear cells (CBMCs) from Kenyan and North American newborns were examined for relative susceptibility to HIV infection in vitro. Kenyan CBMCs were 3-fold more likely to be infected with HIV than were North American CBMCs (P=.03). Kenyan CBMCs with recall responses to malaria antigens demonstrated enhanced susceptibility to HIV when compared with Kenyan CBMCs lacking recall responses to malaria (P=.03). CD4(+) T cells from malaria-sensitized newborns expressed higher levels of CD25 and human leukocyte antigen DR ex vivo, which is consistent with increased immune activation. CD4(+) T cells were the primary reservoir of infection at day 4 after virus exposure. Thus, prenatal exposure and in utero priming to malaria may increase the risk of MTCT.

Management of pregnancy in an HIV elite controller

Elite control of HIV infection has been defined as spontaneous and sustained maintenance of HIV RNA to <50 copies/mL in the absence of therapy. It is estimated to occur in approximately one in 300 HIV-infected individuals. We present the case of a Zimbabwean woman who tested positive for HIV-1 infection on routine antenatal bloods at 15 weeks gestation. Her CD4 count was 500 cells/mm3; however, HIV-1 RNA viral load measured below the level of detection on several assays. A Cavidi ExaVir reverse transcriptase assay was below the level of detection. Pro-viral DNA was positive using long terminal repeat primers and sequencing demonstrated subtype C virus. Zidovudine monotherapy (250 mg twice daily) was commenced at 24 weeks for the prevention of mother to child transmission. She was keen for a standard vaginal delivery, having had one previously, and she delivered a healthy baby without complications at 39 weeks gestation. The neonate received four weeks of Zidovudine and tested negative for HIV infection. We discuss some challenges involved in the management of a pregnant ‘elite controller’.

German-Austrian recommendations for HIV1-therapy in pregnancy and in HIV1-exposed newborn, update 2008

In Germany during the last years about 200-250 HIV1-infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV1-infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV1 was reduced to 1-2%. - This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, caesarean section scheduled before onset of labour, anti-retroviral post exposition prophylaxis in the newborn and refraining from breast-feeding by the HIV1-infected mother. To keep pace with new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV1-infected adults, in 1998, 2001, 2003 and 2005 an interdisciplinary consensus meeting was held. Gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) were participating in this conference to update the prevention strategies. A fifth update became necessary in 2008. The updating process was started in January 2008 and was terminated in September 2008. The guidelines provide new recommendations on the indication and the starting point for HIV-therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified again. - With these current guidelines in Germany and Austria the low rate of vertical HIV1-transmission should be further maintained.

Maternal herpes simplex virus type 2 coinfection increases the risk of perinatal HIV transmission: possibility to further decrease transmission?

OBJECTIVES

To evaluate the association between maternal herpes simplex virus type 2 seropositivity and genital herpes simplex virus type 2 shedding with perinatal HIV transmission.

STUDY DESIGN

Evaluation of women who participated in a 1996-1997 perinatal HIV transmission prevention trial in Thailand.

METHODS

In this nonbreastfeeding population, women were randomized to zidovudine or placebo from 36 weeks gestation through delivery; maternal plasma and cervicovaginal HIV viral load and infant HIV status were determined for the original study. Stored maternal plasma and cervicovaginal samples were tested for herpes simplex virus type 2 antibodies by enzyme-linked immunoassay and for herpes simplex virus type 2 DNA by real-time PCR, respectively.

RESULTS

Among 307 HIV-positive women with available samples, 228 (74.3%) were herpes simplex virus type 2 seropositive and 24 (7.8%) were shedding herpes simplex virus type 2. Herpes simplex virus type 2 seropositivity was associated with overall perinatal HIV transmission [adjusted odds ratio, 2.6; 95% confidence interval, 1.0-6.7)], and herpes simplex virus type 2 shedding was associated with intrapartum transmission (adjusted odds ratio, 2.9; 95% confidence interval, 1.0-8.5) independent of plasma and cervicovaginal HIV viral load, and zidovudine treatment. Median plasma HIV viral load was higher among herpes simplex virus type 2 shedders (4.2 vs. 4.1 log(10)copies/ml; P = 0.05), and more shedders had quantifiable levels of HIV in cervicovaginal samples, compared with women not shedding herpes simplex virus type 2 (62.5 vs. 34.3%; P = 0.005).

CONCLUSION

We found an increased risk of perinatal HIV transmission among herpes simplex virus type 2 seropositive women and an increased risk of intrapartum HIV transmission among women shedding herpes simplex virus type 2. These novel findings suggest that interventions to control herpes simplex virus type 2 infection could further reduce perinatal HIV transmission.

No association between antepartum serologic and genital tract evidence of herpes simplex virus-2 coinfection and perinatal HIV-1 transmission

OBJECTIVE

The purpose of this study was to assess the risk of perinatal HIV-1 transmission in women who are coinfected with herpes simplex virus-2 (HSV-2).

STUDY DESIGN

We performed a nested case-control study of 26 women whose HIV-1 was transmitted to their infants and 52 control subjects whose HIV-1 was not transmitted. We assessed antepartum serologic evidence of HSV-2 by HSV-2 serostatus and genital tract evidence of HSV-2 by presence of HSV-2 DNA.

RESULTS

There was no significant association between antepartum serologic evidence of HSV-2 coinfection and the risk of perinatal HIV-1 transmission. There was also no association between antepartum genital tract evidence of HSV-2 coinfection and risk of perinatal HIV-1 transmission.

CONCLUSION

Women who were infected with HIV-1 with antepartum serologic and genital tract evidence of HSV-2 coinfection did not appear to have an increased risk of perinatal HIV-1 transmission. However, further investigations are needed to assess HSV-2 reactivation and the risk of perinatal HIV-1 transmission at the time of delivery.

Intrapartum transmission after mucosal exposure to HIV was not observed with single-dose nevirapine for mother and child

BACKGROUND

Intrapartum transmission of HIV has been reported to be associated with HIV in oropharyngeal secretions (OPSs) of the child. In this study, we analyze the frequency of intrapartum transmission after mucosal exposure to HIV after administration of single-dose nevirapine.

METHODS

Eighty mothers and their children participating in a prevention of mother-to-child transmission of HIV program in Uganda who took a single dose of nevirapine according to the HIVNET012 protocol participated in the study. HIV-1 was quantified by polymerase chain reaction (PCR) in the mothers' and children's plasma, in cervicovaginal secretions (CVSs), and in the children's OPSs. Intrapartum transmission was defined as a positive HIV-1 RNA PCR result at week 1 or 2 after birth and a previously negative PCR result.

RESULTS

Ninety-seven percent of children had detectable nevirapine in their OPS (median = 592 ng/mL). Fifty-seven (81%) children had HIV-negative OPSs, and 13 (19%) had HIV-positive OPSs. All children of mothers with HIV-negative CVSs had HIV-negative OPSs. HIV-1 levels of OPSs and CVSs correlated (r = 0.33, P = 0.027). None of the babies with detectable HIV-1 in the OPSs became infected by means of intrapartum transmission.

CONCLUSION

Intrapartum HIV infection was not observed after mucosal exposure to HIV-1 after administration of a single dose of nevirapine to the mother and child.

Biological mechanisms of vertical human immunodeficiency virus (HIV-1) transmission

In the absence of interventions, 30-45% of exposed infants acquire human immunodeficiency virus type 1 (HIV-1) through mother-to-child transmission. It remains unclear why some infants become infected while others do not, despite significant exposure to HIV-1 in utero, during delivery and while breastfeeding. Here we discuss the correlates of vertical transmission with an emphasis on factors that increase maternal HIV-1 levels, either systemically or locally in genital secretions and breast milk. Immune responses may influence maternal viral load, and data suggest that maternal neutralising antibodies reduce infection rates. In addition, infants may be capable of mounting HIV-specific cellular immune responses. We propose that both humoral and cellular responses are necessary to reduce infection because cell-free as well as cell-associated virus appears to play a role in vertical transmission. These distinct forms of the virus may be targeted most effectively by different components of the immune system. We also discuss the use of antiretrovirals to reduce transmission, focusing on the mechanisms of action of regimens currently used in developing country settings. We conclude that prevention relies not only on reducing maternal HIV-1 levels within blood, genital tract and breast milk, but also on pre- and/or post-exposure prophylaxis to the infant. However, HIV-1 has the capacity to mutate under drug pressure and rapidly acquires mutations conferring antiretroviral resistance. This review concludes with data on persistence of low-level resistance after delivery as well as recent guidelines for maternal and infant regimens designed to limit resistance.

Quantification of genital human immunodeficiency virus type 1 (HIV-1) DNA in specimens from women with low plasma HIV-1 RNA levels typical of HIV-1 nontransmitters

Studies of human immunodeficiency virus type 1 (HIV-1) transmission suggest that genital HIV-1 RNA and DNA may both be determinants of HIV-1 infectivity. Despite its potential role in HIV-1 transmission, there are limited quantitative data on genital HIV-1 DNA. Here we validated an in-house real-time PCR method for quantification of HIV-1 DNA in genital specimens. In reactions with 100 genomes to 1 genome isolated from a cell line containing one HIV-1 provirus/cell, this real-time PCR assay is linear and agrees closely with a commercially available real-time PCR assay specific for a cellular housekeeping gene. In mock genital samples spiked with low numbers of HIV-1-infected cells such that the expected HIV-1 DNA copy number/reaction was 100, 10, or 5, the average copy number/reaction was 80.2 (standard deviation [SD], 28.3), 9.1 (SD, 5.4), or 3.1 (SD, 2.1), respectively. We used this method to examine genital HIV-1 DNA levels in specimens from women whose low plasma HIV-1 RNA levels are typical of HIV-1 nontransmitters. The median HIV-1 DNA copy number in endocervical secretions from these women (1.8 HIV-1 DNA copies/10,000 cells) was lower than that for women with higher plasma HIV-1 RNA levels (16.6 HIV-1 DNA copies/10,000 cells) (P=0.04), as was the median HIV-1 DNA copy number in vaginal secretions (undetectable versus 1.0 HIV-1 DNA copies/10,000 cells). These data suggest that women with low plasma HIV-1 RNA and thus a predicted low risk of HIV-1 transmission have low levels of genital HIV-1 cell-associated virus. The assay described here can be utilized in future efforts to examine the role of cell-associated HIV-1 in transmission.

Association between paired plasma and cervicovaginal lavage fluid HIV-1 RNA levels during 36 months

OBJECTIVE

To determine the patterns and predictors of genital tract HIV-1 RNA levels during a 36-month period.

METHODS

HIV-1 RNA levels were measured blood in plasma and the genital tract (by cervicovaginal lavage [CVL]) at baseline before highly, active antiretroviral therapy, at 2 and 4 weeks and every 6 months. Viral loads were measured using nucleic acid sequence-based amplification assay with a lower limit of detection of 2.6 log10 copies/mL.

RESULTS

Ninety-seven women had a median of 30.4 months' follow-up, with 530 paired PVL and CVL specimens. The strongest predictor of CVL fluid HIV-1 RNA detection was PVL of more than 2.6 log10 copies/mL, with an odds ratio of 13.7 (P < 0.0001). Each log10 unit increase in PVL increased the odds of detecting HIV-1 RNA in CVL fluid by 2.6 folds (P = 0.0002). Cervicovaginal lavage fluid HIV-1 RNA exceeded PVL on 5% of visits. When patients achieved undetectable levels of HIV-1 RNA in both plasma and CVL fluid, rebound of HIV-1 RNA occurred in plasma first or concurrently with CVL fluid HIV-1 RNA.

CONCLUSIONS

Plasma viral load is the strongest predictor of CVL fluid HIV-1 RNA detection. Cervicovaginal lavage fluid HIV-1 RNA levels are generally lower than PVL. Plasma viral load is more likely to rebound first or at the same time as CVL fluid viral load.

Use of Sno Strip filter-paper wicks for collection of genital-tract samples allows reproducible determination of human immunodeficiency virus type 1 (HIV-1) RNA viral load with a commercial HIV-1 viral load assay

To assess the reproducibility of measurements of cervical and vaginal human immunodeficiency virus (HIV) viral load, 92 duplicate cervical and 88 duplicate vaginal samples were collected from 13 HIV-infected women using Sno Strip filter-paper wicks. RNA was eluted from the strips, extracted, and assayed using a modified protocol for the Roche Cobas Amplicor HIV-1 Monitor assay. Pearson's correlation coefficient (R), coefficient of determination (D), and Bland-Altman plots (BA) were used to compare paired log10-transformed viral loads. Analysis of duplicate same-site samples showed good reproducibility (cervix: R = 0.72, D = 52%, BA = 89% within range; vagina: R = 0.72, D = 51%, BA = 87% within range); paired cervix/vagina measurements showed moderate correlation only (R = 0.56; D = 31.3%). Standardized sample collection and simple modification of the Roche Cobas Amplicor HIV-1 Monitor assay allows reproducible measurement of genital viral load.

Human papillomavirus (HPV) detection among human immunodeficiency virus-infected pregnant Thai women: implications for future HPV immunization

BACKGROUND

Human immunodeficiency virus (HIV)-infected women are at increased risk for developing cervical cancer and for infection with human papillomavirus (HPV). Prophylactic vaccines targeting HPV types 16 and 18 are being evaluated for efficacy among young women.

GOAL

The goal was to assess the prevalence of HPV among HIV-infected pregnant women in Bangkok and to evaluate the need for prophylactic HPV vaccines studies in this population.

STUDY DESIGN

The study population consisted of 256 HIV-infected pregnant women who participated in a mother-to-child HIV transmission trial. Stored cervicovaginal lavage samples were tested for the presence of HPV DNA by polymerase chain reaction with PGMY09/11 primers and reverse line-blot hybridization for determination of anogenital HPV types.

RESULTS

HPV prevalence was 35.5% (91/256); high-risk HPV prevalence was 23.4% (60/256). HPV type 16 or 18 was present in 8.2% (21/256). Almost half of all infections were multiple. Furthermore, overall HPV detection was associated with abnormal cervical cytology (P<0.001) and higher HIV-plasma viral load (P=0.007).

CONCLUSIONS

Only one-quarter of HIV-infected pregnant women in Bangkok had high-risk HPV types; less than 10% had HPV types 16 or 18. As the HPV prevalence is expected to increase during HIV disease, prophylactic vaccines targeting HPV types 16 and 18 should be studied among HIV-infected women not yet infected with these HPV types and not previously exposed.

A faculty trainer model: increasing knowledge and changing practice to improve perinatal HIV prevention and care

Although routine counseling and HIV testing of pregnant women is recommended, it is not yet universally offered. This paper reports on a project that trained health care providers from 2000 to 2002 using a faculty trainer (or train-the-trainer) model. The goals of the projects were to increase knowledge and change practice, increase HIV counseling and testing in prenatal care, and improve management of HIV in pregnant women. In four jurisdictions of the southeastern United States, 193 health care providers attended faculty trainer workshops using a standardized curriculum. Eighteen providers used the curriculum to train an additional 545 health care providers over 2 years. Participants in both faculty trainer workshops and trainerled seminars reported significant increases in perceived knowledge in all content areas and the intention to change clinical practice. The number of providers who became faculty trainers and then led seminars varied widely among the jurisdictions. Six-month follow-up of faculty trainers, although limited by a 63% response rate, found that over 90% of respondents reported the workshop had a positive impact on their care of women with and at risk for HIV. Our findings indicate the faculty trainer model is an effective way to educate practicing clinicians. Key elements to successful implementation were: ongoing support of faculty trainers by acquired immune deficiency syndrome (AIDS) educators, involvement of local HIV experts as trainers and resource persons, and use of a standardized curriculum based on national guidelines.

Genital Herpes Simplex Virus Infection and Perinatal Transmission of Human Immunodeficiency Virus

OBJECTIVE

To assess the risk of perinatal human immunodeficiency virus (HIV) transmission in HIV-infected women clinically diagnosed with genital herpes simplex virus (HSV) infection during pregnancy.

METHODS

This retrospective analysis included 402 HIV-infected pregnant women who enrolled from 1994-1999 in a multicenter prospective cohort study in New York City, who delivered a liveborn singleton infant with known HIV infection status, and who had information on diagnosis of genital HSV infection during pregnancy. Study participants were determined to have genital HSV infection during pregnancy by documentation of clinical diagnosis.

RESULTS

Forty-six (11.4%) of the study participants delivered HIV-infected infants. Twenty-one (5.2%) had clinical diagnosis of genital HSV infection in pregnancy. Six (28.6%) of the 21 HIV-infected women with a clinical diagnosis of genital HSV infection delivered an HIV-infected infant. In univariate analyses, HIV-infected pregnant women with clinical diagnosis of genital HSV infection during pregnancy had a significantly increased risk of perinatal HIV transmission (odds ratio 3.4, 95% confidence interval 1.3-9.3; P = .02). When other factors associated with perinatal HIV transmission were included in a logistic regression model (lack of zidovudine therapy during pregnancy or delivery, prolonged rupture of membranes, and preterm delivery), clinical diagnosis of genital HSV infection during pregnancy remained a significant independent predictor of perinatal HIV transmission (adjusted odds ratio 4.8, 95% confidence interval 1.3-17.0; P = .02).

CONCLUSION

Clinical diagnosis of genital HSV infection during pregnancy in HIV-infected women may be a risk factor for perinatal HIV transmission. If future studies confirm this association, therapy to suppress genital HSV reactivation during pregnancy may be a strategy to reduce perinatal HIV transmission.

Perinatally Acquired HIV-1 Infection: Prevention and Evaluation of HIV-Exposed Infants

Perinatal transmission of human immunodeficiency virus type 1 (HIV-1) is the primary cause of pediatric HIV infections. In recent years, perinatal HIV-1 transmission rates in the United States have declined markedly because of several factors that include enhanced voluntary counseling and HIV-1 testing (VCT) for pregnant women, widespread use of antiretroviral prophylaxis or combination antiretroviral therapy, avoidance of breastfeeding, and elective cesarean delivery. However, perinatal transmission of HIV-1 still occurs, and 300 to 400 infected infants are born annually, primarily because of missed prevention opportunities. The pediatrician plays a vital role in the prevention of perinatal transmission of HIV-1 by identifying newborns born to infected mothers who were not tested during pregnancy, administering antiretroviral prophylaxis, and ensuring follow-up to confirm or exclude the diagnosis of HIV-1 infection in early infancy. This article reviews recent advances in the prevention of perinatal transmission of HIV-1, discusses evaluation and treatment of infants exposed to HIV-1, and highlights certain unique features of HIV-1 infections in infants, with a focus on early diagnosis, clinical manifestations, treatment, and prognosis.