Editorial Comment: Within Our Reach–The End of Perinatal HIV Transmission

The elimination of perinatal HIV transmission in the United States is within reach. When antiretroviral therapy is effective in controlling maternal viremia dur-
ing pregnancy, the risk of perinatal transmission is less than 1%.^1-4 In the absence of antepartum antiretroviral therapy, the administration of antiretroviral drugs during labor and to the newborn can decrease the risk of transmission to less than 10%.⁵ Even administering prophylactic antiretroviral drugs to an exposed infant within 48 hours after birth can have a substantial impact on transmission.

Preventing transmission, however, is dependent on identifying pregnant women with HIV infection. With few exceptions, the cases of mother-to-child transmission that occur in the United States represent gaps in our increasingly fragmented health care system. While the Institute of Medicine, CDC, American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics have all called for routine prenatal HIV testing for years, this has not been implemented systematically nationwide.^6-10

Ezeanolue and Schenauer¹¹ highlight the missed opportunities for preventing perinatal HIV transmission. After a dramatic decline in the number of HIV-infected infants since 1998, Nevada has recently seen an upsurge in cases of perinatal transmission. The tragedy of the 4 cases presented by Ezeanolue and Schenauer is that all were preventable.

One infant became infected because the maternal HIV test result, although available before delivery, was not communicated to the obstetrics and pediatrics staff. Another infant seroconverted, presumably because of inadequate adherence to zidovudine prophylaxis. Moreover, HIV diagnosis was delayed until the infant was 18 months old because the standardized protocol for infant testing was not followed.

The third transmission occurred in the setting of maternal seroconversion while the mother was breast-feeding. Although the woman discontinued breast-feeding, no prophylactic antiretroviral drugs were given to the infant once exposure was identified. The final case involved a woman who was nonadherent to her antepartum antiretroviral regimen and transmitted HIV to her infant before the onset of labor.

There are numerous resources available to clinicians and policy makers to help avoid these kinds of unfortunate and preventable transmissions. The United States Public Health Service Task Force regularly updates the national perinatal HIV treatment guidelines that provide state-of-the-art recommendations to assist in managing HIV-infected pregnant women and their exposed infants.¹² Clinicians who need additional assistance can turn to the National Perinatal HIV Consultation and Referral Service (toll-free number: 888-HIV-8765).¹³ This free, around-the-clock service for medical providers offers expert consultation in managing perinatal HIV infection. In addition, the hot line coordinates a referral network of nearly 200 clinicians, linking callers with local providers who care for pregnant HIV-infected women and their exposed infants.

It is crucial that HIV clinicians and public health officials throughout the country assist with local implementation of both routine prenatal HIV testing and rapid intrapartum HIV testing. This involves identifying barriers to testing–whether patient-, provider-, or institution-related–and making certain that test results are communicated effectively to ensure appropriate medical management.¹⁴ Although screening pregnant women for HIV infection is the crucial first step, clinicians must also work with women to ensure optimal adherence to antiretroviral therapy, including the use of such novel techniques as voluntary, in-hospital, directly observed therapy for noncompliant pregnant women.^15-17

As the prevalence of HIV infection continues to increase among women and as HIV-infected women live longer, the establishment of optimized testing protocols and systems of care will only become more important. By systematically implementing proven interventions from universal opt-out prenatal HIV testing to rapid intrapartum HIV testing and comprehensive family-centered HIV care, the goal of eliminating perinatal HIV transmission will be in hand.

References:

References

1. Naver L, Lindgren S, Belfrage E, et al. Children born to HIV-1-infected women in Sweden in 1982-2003: trends in epidemiology and vertical transmission. J Acquir Immune Defic Syndr. 2006;42:484-489.>
2. Achievements in public health. Reduction in perinatal transmission of HIV infection–United States, 1985-2005. MMWR. 2006;55(21):592-597.
3. Cooper ER, Charurat M, Mofenson L, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr. 2002;29:484-494.
4. Shapiro D, Tuomala R, Pollack H, et al. Mother-to-child HIV transmission risk according to antiretroviral therapy, mode of delivery, and viral load in 2895 US women (PACTG 367). 11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004; San Francisco. Abstract 99.
5. Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus. N Engl J Med. 1998;339:1409-1414.
6. Royce R, Walter E, Fernandez M, et al. Barriers to universal prenatal HIV testing in 4 US locations in 1997. Am J Public Health. 2001;91:727-733.
7. Gerberding JL, Jaffe HW. Routine prenatal testing–the opt-out approach. Available at:

http://www.cdc.gov/hiv/topics/perinatal/resources/other/dear_colleague-2003.htm

. Accessed December 12, 2006.
8. Stoto MA, Almario DA, McCormick MC, eds. Reducing the Odds: Preventing Perinatal Transmission of HIV in the United States. Washington, DC: National Academy Press; 1999.
9. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR-14):1-17.
10. Wolf LE, Lo B, Gostin LO. Legal barriers to implementing recommendations for universal, routine prenatal HIV testing. J Law Med Ethics. 2004;32:137-147.
11. Ezeanolue EE, Schenauer C. Challenges to the elimination of mother-to-child transmission of HIV infection: four case reports. AIDS Reader. 2007;17:33-38.
12. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. Updated October 12, 2006. Available at:

http:// aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf

. Accessed December 5, 2006.
13. Fogler JA, Weber S, Goldschmidt RH, et al. Consultation needs in perinatal HIV care: experience of the National Perinatal HIV Consultation Service. Am J Obstet Gynecol. In press.
14. HIV testing among pregnant women–United States and Canada, 1998-2001. MMWR. 2002;51(45):1013-1016.
15. Bryant A, Collingham J, Till M, Garcia P. Virologic and clinical outcomes in HIV-infected pregnant women: directly observed therapy can overcome barriers to care. 11th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2004; San Francisco. Abstract 922.
16. Grobman WA, Garcia PM. The cost effectiveness of directly observed therapy late in pregnancy for HIV-infected women. 14th International AIDS Conference; July 7-12, 2002; Barcelona, Spain. Abstract TuPeC4863.
17. Fisman D, Perencevich E, Levy D, Cosgrove S. The cost effectiveness of directly observed highly active antiretroviral therapy in pregnant women with asymptomatic HIV infection. 1st International AIDS Society Conference on HIV Pathogenesis and Treatment; July 8-11, 2001; Buenos Aires. Abstract 745.