Management of HIV infection during pregnancy

Effectiveness of Short-Term and Long-Term Zidovudine Prophylaxis on Detection of HIV-1 Subtype E in Human Placenta and Vertical Transmission

Antiretroviral treatment with zidovudine (ZDV) from the 14th week until the end of pregnancy has markedly reduced the vertical transmission rate of HIV-1 in Europe and North America. A shorter duration of treatment has reduced this rate in Africa and Southeast Asia to a lesser degree. In Southeast Asia, subtype E is the major subtype rather than subtype B as in Western countries. The goals of this study were to determine the optimal duration of ZDV prophylaxis for subtype E and to confirm its effectiveness at the histologic level. Fifty pregnant women seropositive for HIV-1 subtype E were given ZDV prophylaxis consisting of 300 mg administered twice daily, switching to 300 mg administered every 3 hours from the onset of labor until delivery. Twenty-seven received "short-term" ZDV lasting 14 to 35 days before delivery, whereas the other 23 received "long-term" ZDV lasting 62 to 92 days. The effectiveness of ZDV prophylaxis was assessed by detection of HIV-1 in the placenta using in situ polymerase chain reaction (PCR). All babies in this study were tested up to one year of age. Three were not positive until after one month of age, but one was positive as a neonate. Four neonates were positive for HIV-1 as detected by PCR on peripheral blood, including one in the neonatal period. All cases were from the short-term prophylaxis group. Decidual glandular epithelial cells were the only cell type in the placenta that expressed HIV proviral DNA under ZDV prophylaxis. Sixty-seven percent of placentas in the short-term ZDV group showed more than occasional positive cells compared with 22% in the group receiving long-term ZDV prophylaxis (P < 0.02). This is first study to compare the effectiveness of short-term and long-term ZDV prophylaxis with respect to the presence of HIV in the placenta. Our study shows that longer (at least 60 days) prophylaxis is more effective in reducing HIV expression in the placenta and is associated with reduced transmission to neonates.

Pregnancy outcome among HIV-infected women in the Helsinki metropolitan area

BACKGROUND

Antiretroviral medication and good obstetric practice have greatly reduced the rate of vertical transmission of human immunodeficiency virus (HIV) infection. The incidence of HIV infection has remained low in Finland. Universal antenatal screening has been offered to all pregnant women since 1998.

METHODS

We analyzed the outcomes of 52 pregnancies among 45 HIV-infected mothers delivering at our department during 1993-2003. A multidisciplinary team planned the management strategy individually and supported the mother's adherence to treatment.

RESULTS

The incidence of HIV infection among women delivering in our hospital district increased from 0.6/10,000 (95% CI 0-1.6) to 4.8/10,000 (95% CI 1.4-8.2) between 1993 and 2002. HIV infection was diagnosed during pregnancy in 40% (18/45) of the mothers. Antiretroviral medication was used prior to pregnancy in 17 (33%) cases; in 34 (66%) cases of the pregnancies, medication was started during the pregnancy. A good virological response (i.e. HIV RNA load <1000/ml during the last trimester) to antiretroviral medication was achieved in 90% (36/40) of the patients; in 60% (24/40) of cases, the HIV RNA load was below the assay detection limit. One mother with advanced HIV infection succumbed to pneumonia shortly after delivery. Of the infants, 92% were born at term, and their mean (+/-SD) birth weight was 3350 +/- 395 g. The Caesarean section (CS) rate was 25% (13/52). All newborns were in good condition, and their mean umbilical pH was 7.23. All newborns received antiretroviral medication. One infant was infected with HIV, the mother was found HIV-positive postpartum. None of the infants born to mothers known to be HIV positive were infected.

CONCLUSIONS

A combination of universal antenatal screening and multidisciplinary management allows individualized treatment and prevents vertical transmission of HIV infection.

Cutaneous signs of neonatal and infantile immunodeficiency

Immunodeficiencies frequently present in the skin antepartum and in the first year of life. Although genetic immunodeficiencies are uncommon, the worldwide incidence of the acquired immunodeficiency human immunodeficiency virus (HIV) is growing. Early diagnosis and treatment of neonatal immunodeficiencies and associated infections result in improved quality of life and longer life expectancy for these patients. In developed countries, improvements in therapy of HIV during pregnancy have resulted in reduced transmission to the neonate. This article reviews the common presentations and therapy of genetic and acquired neonatal immunodeficiencies.

HIV-1 RNA and viral load

Viral load monitoring has become the standard of care in clinical practice to assess risk for disease progression and to monitor treatment response. Furthermore, viral load monitoring has contributed greatly to the understanding of HIV disease pathogenesis and response to various antiretroviral regimens, and has broadened its applications to include blood bank screening. The assays that are currently available are more sensitive, precise, and robust. There is now a better understanding of their limitations and the clinical scenarios and assay performance issues that result in variations of viral load results.

Transmission of HIV-1 from mother to infant

In the developed world, antiretroviral therapy (ART) administered to the mother during pregnancy and intrapartum and to the infant in the neonatal period has resulted in a reduction of the overall risk of vertical transmission of HIV-1 to approximately 8%. In some settings, ART combined with cesarean section and a reduction in duration of ruptured membranes has resulted in a further lessening of risk to levels < or = 2 percent. A number of less expensive and greatly abbreviated ART regimens, useful for application in resource poor settings, also have resulted in reductions of mother-to-infant transmission of HIV-1 by 33 to 50% compared to baseline. A multitude of studies have shown these drugs to be safe for mothers, fetuses, and newborns. Breastfeeding seems to represent a risk factor that adds to the risk of vertical transmission, especially in infants who are fed a combination of breastmilk and other liquids and solids. Studies designed to assess the possible benefits of treating genital ulcer disease, chorioamnionitis, mastitis, and malnutrition in HIV-infected women, and of applying antiseptic washes to the cervix and vagina during labor, are in progress.