Prevention of Perinatal HIV Transmission in an Area of High HIV Prevalence in the United States

Abstract

In 2014, the US Department of Health and Human Services modified the perinatal HIV management guidelines suggesting that women are considered low risk if they are living with HIV on antiretroviral therapy (ART) with HIV RNA ≤1000 copies per mL in late pregnancy and near delivery. In this population, it no longer recommended to administer maternal intrapartum intravenous zidovudine. In addition, for low-risk HIV-exposed infants (HEI), prophylaxis recommendation is 4 weeks of zidovudine after birth, whereas for high-risk HEI, it is 6 weeks of either a dual or triple therapy with zidovudine. This study was designed to help understand the use of these new perinatal HIV prevention interventions by evaluating the risk of perinatal HIV transmission in mother–infant pairs in a high HIV prevalence US area.In this study, researchers included 551 HIV-exposed infants (HEI) and 542 mothers living with HIV in the Washington, District of Columbia, area who were evaluated at Special Immunology Services in Children’s National Hospital between January 2013 and December 2017.A retrospective cohort analysis of these mother–infant pairs was completed, assessing a number of characteristics but, most notably, antiretroviral treatment during the pregnancy, HIV viral load at delivery, intrapartum zidovudine, delivery type (cesarean delivery versus vaginal), antiretroviral prophylaxis regimen for infant, antiretroviral prophylaxis duration for infant, and final HIV status of infant.The majority of mothers received antiretrovirals (95.5%), had HIV RNA ≤1000 copies per mL before delivery (81.9%), and received intrapartum zidovudine (65.5%). The majority of all HEIs were low risk (82.6); among these low-risk HEIs, slightly over one-half were delivered via cesarean delivery, and 62.9% received intrapartum zidovudine. In the study population, 9 infants acquired HIV perinatally and were all in the high-risk category, and not all of these infants were on dual or triple therapy with zidovudine.In this study, the researchers highlighted that the newer perinatal HIV recommendations have not been completely adopted because they showed 62.9% of the low-risk patients received intrapartum zidovudine, despite it no longer being recommended. Furthermore, of the 9 infants who acquired HIV perinatally, they were all considered high risk, but 6 were not on a dual or triple therapy. Certain factors can affect the decision to initiate combination antiretroviral therapy; however, in this study, it is suggested there were possible missed opportunities for use of this treatment as a prevention of perinatal HIV transmission.As the field of HIV and perinatal treatment of mother–infant pairs evolves and new recommendations emerge, it is essential the medical community strives to follow these recommendations as closely as possible to decrease perinatal HIV transmission. Adhering to the recommendations would minimize the medication exposures to those low-risk patients, while optimizing the antiretroviral regimen for high-risk HEIs, leading to the lowest perinatal HIV-transmission possible.