HIV Infection In Pregnancy Research Articles

HIV-infected women's experiences of pregnancy and motherhood in Cape Town, South Africa

Antenatal services provide a valuable opportunity for the uptake of prevention of mother-to-child transmission (PMTCT) of HIV interventions and antiretroviral treatment (ART) for maternal health. While knowledge of HIV status during pregnancy is beneficial to both mother and child, PMTCT programmes may focus more on prevention and the physical aspects of health than the psychosocial impact of HIV on pregnancy and motherhood. The objective of this study was to examine South African women's perceptions of HIV infection in pregnancy and how they related to motherhood in the context of HIV infection. In-depth interviews were conducted with 17 HIV-positive pregnant and 11 ≤ 6-month postpartum women to elicit perspectives on HIV-positive pregnancy and motherhood. For most women who tested in pregnancy, the primary rationale for testing stemmed from a concern for their children; and anxiety around the risk of vertical transmission was highly prevalent. Women did not perceive any superficial differences between themselves and non-infected pregnant women and they compared HIV to any other chronic condition. However, they voiced anxiety about being infected and were preoccupied with keeping their children safe, both in pregnancy and postpartum. They described a diminished sense of pride about motherhood and an additional burden of guilt associated with carrying a vulnerable child, which made pregnancy different for them in comparison to uninfected women. Feeding posed a particularly difficult issue because by choosing formula feeding, women were protecting their children, yet this seemed to diminish their status as a mother, while at the same time publicising messages about being infected with HIV. While women identified externally with the social value of motherhood, the burden of HIV infection was seen as a destabilising threat to their identity as mothers.

Complex Decisions in Managing HIV Infection During Pregnancy

Both the World Health Organization and the United States Department of Health and Human Services have recently substantially revised perinatal HIV treatment guidelines based on emerging data, much of it from the developing world. Management of HIV infection in pregnancy and delivery is complicated by concerns for maternal and fetal drug toxicity, acquisition of antiretroviral resistance, prior therapy, co-infections with other viruses, as well as incident opportunistic infections. Intrapartum and peripartum obstetric management, including the role of Caesarean section, continue to evolve in the setting of maternal HIV infection. Finally, new data have expanded the role of antiviral therapy in allowing safer infant feeding choices for HIV-infected mothers in resource-limited settings.

Acute HIV Infection in Pregnancy: The Case for Third Trimester Rescreening

Combination testing with anti-HIV Elisa and Western blot is both sensitive and specific for diagnosis of established HIV-1 infection but could not detect acute HIV infection (AHI). AHI is a time of extremely high viral load, which may correlate to increased risk of horizontal or vertical transmission. Thus, early identification of AHI could allow for interventions to decrease transmission. However, recognition of AHI can be challenging as symptoms could be absent or nonspecific, therefore, AHI is often not detected, particularly in pregnancy. We present a case report of AHI in a pregnant woman who presented with headache and fever. She tested negative for HIV in the first trimester and at time of AHI at 26 3/7 weeks by anti-HIV Elisa, but was diagnosed with AHI based on an HIV RNA viral load of 434,000 copies/mL. This report presents a case for improved awareness of AHI in pregnancy, and the need for repeat HIV testing in late pregnancy, and highlighted that early detection of AHI might be possible with adding HIV RNA testing at time of standard anti-HIV Elisa screening test in pregnancy. Novel laboratory approaches including pooling of sera for HIV RNA could reduce the cost of HIV RNA testing.

A review of the management of HIV positive pregnant patients in a District General Hospital setting

BackgroundDiagnosis of HIV infection in pregnancy and treatment with antiretrovirals is key to preventing vertical transmission. However, treatment has been shown to be associated with increased incidence of pregnancy complications...

Risk Factors for Helminth, Malaria, and HIV Infection in Pregnancy in Entebbe, Uganda

BackgroundInfections during pregnancy may have serious consequences for both mother and baby. Assessment of risk factors for infections informs planning of interventions and analysis of the impact of infections on health outcomes.ObjectivesTo describe risk factors for helminths, malaria and HIV in pregnant Ugandan women before intervention in a trial of de-worming in pregnancy.MethodsThe trial recruited 2,507 pregnant women between April 2003 and November 2005. Participants were interviewed and blood and stool samples obtained; location of residence at enrolment was mapped. Demographic, socioeconomic, behavioral and other risk factors were modelled using logistic regression.ResultsThere was a high prevalence of helminth, malaria and HIV infection, as previously reported. All helminths and malaria parasitemia were more common in younger women, and education was protective against every infection. Place of birth and/or tribe affected all helminths in a pattern consistent with the geographical distribution of helminth infections in Uganda. Four different geohelminths (hookworm, Trichuris, Ascaris and Trichostrongylus) showed a downwards trend in prevalence during the enrolment period. There was a negative association between hookworm and HIV, and between hookworm and low CD4 count among HIV-positive women. Locally, high prevalence of schistosomiasis and HIV occurred in lakeshore communities.ConclusionsInterventions for helminths, malaria and HIV need to target young women both in and out of school. Antenatal interventions for malaria and HIV infection must continue to be promoted. Women originating from a high risk area for a helminth infection remain at high risk after migration to a lower-risk area, and vice versa, but overall, geohelminths seem to be becoming less common in this population. High risk populations, such as fishing communities, require directed effort against schistosomiasis and HIV infection.

High HIV incidence during pregnancy: compelling reason for repeat HIV testing

To determine the incidence of HIV during pregnancy as defined by seroconversion using a repeat HIV rapid testing strategy during late pregnancy. Cross-sectional study nested in a prevention of mother-to-child transmission program Pregnant women were retested between 36 and 40 weeks of gestation, provided that they had been tested HIV negative at least 3 months prior. Among the 2377 HIV-negative women retested, 1099 (46.2%) and 1278 (53.4%) were tested at urban and rural health facilities, respectively. Seventy-two women (3%) were HIV-positive (679 woman years of exposure) yielding a HIV incidence rate of 10.7/100 woman years [95% confidence interval (CI) 8.2-13.1]. HIV incidence in pregnancy was higher but not statistically significant at the urban facilities (12.4/100 woman years versus 9.1/100 woman years) and at least two-fold higher among the 25-29 and 30-34-year age groups (3.8 and 4.5%, respectively) as compared with the less than 20-year age group (1.9%). Single women were at 2.5 times higher risk of seroconverting during pregnancy (P = 0.017). HIV incidence during pregnancy is four times higher than in the nonpregnant population reported in a recent survey. Public health programs need to continue to reinforce prevention strategies and HIV retesting during pregnancy. The latter also offers an additional opportunity to prevent mother-to-child transmission and further horizontal transmission. Further research is required to understand the cause of primary HIV infection in pregnancy.

Testing for HIV infection in pregnancy

Testing for HIV infection in pregnancy

A comparison of HIV positive and negative pregnant women at a public sector hospital in South Africa

The aim of the study was to compare HIV positive and negative pregnant women with respect to maternal and neonatal outcome to inform the development of clinical practice guidelines. HIV infection in pregnancy places an added burden on the physical ability of the woman's body to cope with pregnancy. As a result HIV causes an exaggeration of the problems related to pregnancy. Data were collected by means of a retrospective record review conducted on 212 stratified randomly selected HIV positive and 101 matched HIV negative pregnant women. The two sample t-test and Fisher exact test were used to compare the maternal and neonatal outcomes of HIV positive and negative pregnant women. HIV positive pregnant women had a significantly lower haemoglobin (10.85 vs. 11.48 g/dl; P = 0.001), attended significantly fewer antenatal clinic appointments (4.03 vs. 4.63; P = 0.04), weighed significantly less (72.07 vs. 76.69 kg; P = 0.02) and were significantly more likely to present with an abnormal vaginal discharge (32.55 vs. 24.75%; P = 0.02) than HIV negative pregnant women. The difference in the prevalence in HIV positive pregnant women of pregnancy induced hypertension (16.98 vs. 9.90%; P = 0.06), syphilis infection (5.95 vs. 0.99%; P = 0.062) and urinary tract infection (15.53 vs. 7.92%; P = 0.06) approached significance when compared with HIV negative pregnant women. HIV positive pregnant women were significantly more likely to present with intrauterine growth retardation (4.72 vs. 0%; P = 0.03), significantly more likely to deliver earlier (37.92 vs. 38.51 weeks; P = 0.03) and significantly more likely to deliver neonates weighing less (2969.98 vs. 3138.43 g; P = 0.01) than HIV negative pregnant women. The Department of Health attributes the high rate of HIV and AIDS related maternal morbidity and mortality in South Africa to the absence of accepted and practical guidelines for midwives' antenatal assessment and management of HIV positive pregnant women. Relevance to clinical practice. This study identifies maternal and neonatal outcomes related to HIV infection in pregnancy and provides evidence required to inform the development of clinical practice guidelines.

Diagnosis of HIV infection in pregnancy: data from a national cohort of pregnant women with HIV in Italy.

We analysed the characteristics of the pregnancies with a previously undetected HIV infection in a national observational study of pregnant women with HIV in Italy. In a total of 443 pregnancies with available date of HIV diagnosis, 118 were characterized by a previously undetected HIV infection (26.6%, 95% CI 22.5-30.8). The following factors were independently associated with this occurrence in a multivariate analysis (adjusted odds ratios; 95% CIs): foreign nationality (5.1, 2.8-9.3); no pre-conception counselling (35.9, 4.8-266.1); first pregnancy (2.1, 1.2-4.0); asymptomatic status (6.8, 1.5-30.6). Women with previously undetected infection started antiretroviral treatment significantly later during pregnancy (P < 0.001). Missed diagnosis was responsible for one case of transmission. A high rate of previously undetected HIV infection was observed. This suggests a good HIV detection during pregnancy, but also the need to reinforce HIV testing strategies among women of childbearing age. We identified some determinants which may be considered for intervention measures.

A multi-district audit of the management of HIV infection in pregnant women and the prevention of mother-to-child transmission: Yorkshire HIV pregnancy audit

A regional audit was performed to compare clinical practice against the British HIV Association guidelines for the management of HIV infection in pregnancy. Data were collected from 2000 to 2002 from eight clinics across Yorkshire using a questionnaire. There were 22 live births to 22 HIV + pregnant women. There were no cases of transmission of HIV from mother to child. The majority (20/22) of mothers received therapy as recommended in the guidelines, with only two initially receiving inappropriate dual therapy. In all, 16/22 (73%) had elective caesarean sections, 5/22 (23%) emergency sections after the onset of labour and one had a vaginal delivery. Also, 12/22 (55%) definitely received intravenous zidovudine during delivery. Added to these, 19/22 infants received appropriate antiretroviral medication for four to six weeks after birth. No mothers were known to have breast-fed.

Mother to child transmission of HIV in Vitória, Brazil: Factors associated with lack of HIV prevention

Screening HIV infection in pregnancy provides an ideal opportunity to make an early diagnosis in women in order to provide treatment to reduce vertical transmission to the newborn. The objectives were to describe the profile of HIV-infected pregnant women attending municipal hospitals in Vitória and to identify the causes associated with the lack of HIV therapeutic prophylaxis. Descriptive analysis of antenatal and HIV surveillance data of pregnant women in Vitória, Brazil from 1997 to 2001 was performed. HIV infection was reported in 208 pregnant women. Their median age was 23 years, antenatal care was reported in 96.2% and HIV infection was diagnosed during antenatal care in 60.1%. Zidovudine (ZDV) therapy was initiated in 88% of the cases, 57.9% of which started before 20 weeks of gestation. The remaining 12% of the total of pregnant women received no therapy. Factors associated with lack of mother to child transmission (MTCT) prevention were: test not available (14 cases), delay of test result (seven cases) and patient's refusal to take medication (four cases). After delivery, 8.2% of the newborn did not receive ZDV and 14 women breastfed. Among the 196 live births, 3.1% (95%CI 1.9–4.3) of MTCT was reported. These data from an area with comprehensive HIV and antenatal surveillance provide an opportunity to identify gaps in public health efforts to reduce MTCT.

Cost-effectiveness of antenatal HIV-testing: reviewing its pharmaceutical and methodological aspects

This paper reviews the pharmacoeconomic aspects of antenatal testing for HIV. HIV is a retrovirus which is transmitted among humans through sexual contact, infected blood or blood products (needle sharing or percutaneous accidents) and from mother to child (vertical transmission). Vertical transmission from the HIV-infected mother can occur in utero during and after delivery, through breastfeeding. Effective interventions available to reduce the risk of vertical transmission include: pharmacotherapy prior, during and after delivery; voluntary caesarean section; and replacing breastfeeding by bottle-feeding [1,2]. The existence of these effective interventions underlies the need to detect yet undiagnosed HIV-infection in pregnancy through antenatal testing. Contemporary pharmacotherapy consists of a combination of three or more antiretroviral drugs, also referred to as highly-active antiretroviral therapy (HAART). For newly detected HIV-infected mothers, the Centers for Disease Control suggests the use of a zidovudine-comprising combination with one other nucleoside analogue reverse transcriptase inhibitor and a protease inhibitor (PI) [3]. As HIV in pregnancy may be asymptomatic, structured antenatal HIV-testing therefore seems to offer an attractive prevention strategy. Two broad types of approaches exist: selective or targeted testing versus universal testing. The availability of effective – but expensive – combination therapies since 1996 has greatly enhanced the importance of pharmacoeconomic assessments in the field of HIV-infection. Treatment of the mother will incur additional costs but will also make any programme more effective. Furthermore, avoiding children becoming infected with HIV will also incur monetary benefits, as children are also being treated with HAART. In summary, the background of antenatal HIV-testing has undergone major changes compared with the early 1990s. This review of the pharmacoeconomics of antenatal HIV-testing followed a systematic approach as it was performed according to prespecified criteria, allowing valid comparisons in methodologies and findings of those studies that have yet been conducted in this area.

Maternal Nutrition—Effect on Fetal Growth and Outcome of Pregnancy

During the first half of the 20th century, chronic energy undernutrition due to low dietary intake, repeated infections, and rapid succession of pregnancy were the factors most responsible for maternal undernutrition and consequent adverse outcomes of pregnancy. Efforts to improve dietary intake, treatment of infections, and provision of contraceptive care were the major focuses of intervention from 1950 to 1990. These interventions resulted in reduction in severe grades of undernutrition. However, there was no reduction in mild and moderate degrees of undernutrition and anemia during pregnancy and there was no significant improvement in the course and outcome of pregnancy, or in birth weight. During the 1990s, among the middle- and upper-income groups, there has been a progressive rise in obesity and consequent adverse effects. The advent of HIV infection in India in the 1980s will inevitably lead to increases in severe undernutrition associated with HIV infection in pregnancy and an adverse impact of maternal HIV infection on the fetus. Practicing physicians and nutritionists in the new millennium will therefore have to assess each person individually and provide appropriate advice regarding diet, exercise, fertility, and infection prevention and control in order to achieve optimum health and nutrition status during pregnancy and to prevent adverse pregnancy outcomes.

Seroprevalence of HIV, hepatitis B virus, and syphilis in women at their first visit to public antenatal clinics in Vitória, Brazil.

In some countries, HIV infection in pregnancy has become a common complication of pregnancy. To determine the seroprevalence of HIV, hepatitis B virus, and syphilis among pregnant women, and to assess risk factors for these infections. A cross-sectional study was performed. Pregnant women attending antenatal clinics of Vitória Municipality from March to December 1999 were included in this study after giving written informed consent. The women were systematically interviewed. During the interview, their demographics and patterns of risk behavior were explored. A blood sample was collected for testing HIV, hepatitis B virus, and syphilis. The participants in this study were 1608 pregnant women. The prevalence of HIV infection was 0.8% (95% CI, 0.4-1.2), hepatitis B virus carriers 1.1% (95% CI, 0.8-1.3), and syphilis 3% (95% CI, 2.6-3.5). The potential risk behaviors were found to be a history of STDs (6.5%), condoms never used (52.8%), prostitution (0.5%), noninjection drug use (6.3%), blood transfusion (1.5%), and intravenous drug abuse (0.7%). These results show the necessity of implementing programs aimed at preventing transmission of these infections in women and their children.

HIV testing in antenatal care: a cross-sectional study

Midwives' attitudes and practices regarding antenatal HIV testing, including integration of testing into routine antenatal care, were analysed using a self-administered structured questionnaire. This was completed by hospital and community-based midwives in an area of high HIV prevalence. In total, 162 responses were received. Most midwives (71%) agreed that HIV testing is an integral part of antenatal care but 61% also believed that only individuals with a counselling qualification should offer tests. Fifty seven per cent had attended a recent course about the management of HIV infection in pregnancy. Midwives who had attended a course were more likely to agree with integrated testing (odds ratio 5.2, 95% confidence interval 2.0–13.5). Midwives qualified between 5 and 9years ago were less likely than more recently qualified or more experienced midwives to offer tests, and this was not explained by differences in access to educational courses. Midwives' attitudes towards antenatal HIV testing are generally favourable. Despite an observed increase in uptake rates, many midwives continue to believe that only qualified counsellors should offer tests. All midwives should receive ongoing education that emphasizes the changing management of HIV infection in pregnancy and encourages testing.

Management of HIV infection during pregnancy.

Optimal management of HIV infection in pregnancy requires maternal use of potent antiretroviral therapy to prevent disease progression in the mother and vertical transmission to the newborn. Combination antiretroviral therapy substantially reduces the risk of perinatal HIV transmission and appears to be more effective than zidovudine monotherapy. The administration of single dose nevirapine to mother intrapartum and infant postpartum effectively reduces vertical HIV transmission and is less costly and cumbersome than zidovudine regimens. Elective cesarean section reduces vertical transmission of HIV but its benefit is less clear when antiretroviral therapy decreases maternal plasma HIV viral load to low levels at delivery. If possible, HIV-infected mothers should avoid breastfeeding. The present review discusses the importance of early identification of maternal HIV infection, strict adherence to combination antiretroviral regimens to prevent drug resistance, developing a better understanding of antiretroviral pharmacokinetics in pregnancy and short/long term safety of anti-HIV drugs.

Screening for Down's syndrome

Just as screening for HIV infection in pregnancy is less than hoped for, so is screening for Down's syndrome. C. Ford and colleagues (pages 855–859) performed a survey of serum screening for Down's syndrome in a deprived population with a large proportion of women of Asian origin. Over five years more than sixteen thousand women were offered serum screening, of whom about three-quarters accepted the test and of those who were positive about half agreed to amniocentesis. One in twelve of the Asian women had positive serum tests compared with one in twenty of the Caucasian women, this difference being due to differences in the normal levels of hCG between the two groups of women; despite this only one-third of the Asian women agreed to amniocentesis, compared with two-thirds of the Caucasian women. The authors wonder if there are cultural pressures against amniocentesis in Asian women. There were nineteen cases of Down's syndrome during this time, of which fifteen resulted in a live birth. Four women underwent termination of pregnancy for Down's syndrome, and this was at a cost of four miscarriages in association with amniocentesis where serum screening had been positive. The authors conclude that the benefits to public health from serum screening in this population are small, and question the ethics and economics of continuing with the programme. Ford and colleagues point out however that serum screening was intrinsically successful in their study, for it was positive in eleven out of the thirteen cases of Down's syndrome in which testing was carried out; it was the low acceptance of amniocentesis which was responsible for the poor results of the screening programme. What if the screening procedures were changed to the first trimester with more reliance on ultrasound? Our knowledge of early screening tests is imperfect, with early enthusiasm being tempered by later caution. The hopes of many investigators have rested on fetal nuchal translucency, but B. J. Whitlow and colleagues (pages 872–876) show that this measurement depends very much on the attitude of the fetus: the average when the neck is flexed was 1.0 mm, in a neutral position 1.4 mm, and when the neck was extended 2.0 mm. The effects of these differences are enormous. In the 196 pregnancies in the study none of the nuchal translucency measurements would be above the 95th centile where the fetal neck is flexed, compared with 1.5% of measurements where the neck is in a neutral position, and 22% where the neck is extended. The authors recommend that nuchal translucency measurements are performed in the neutral position, since in that position the variation in measurement by a single observer is least. Can biochemical refinements be added to nuchal translucency measurements in the first trimester? Yes, say Roberto Biagiotti and his colleagues (pages 917–922), who measured pregnancy-associated plasma protein A and free β hCG in conjunction with nuchal translucency in 32 pregnancies with Down's syndrome compared with 200 normal pregnancies. With a false positive rate of 5% the combined tests detected three-quarters of pregnancies with Down's syndrome, compared with two-thirds using nuchal translucency alone. The authors acknowledge the limitations of their study with its small size and the selection of their cases, and recommend that larger studies of combined screening in unselected populations are carried out. A pregnancy may overcome the hurdles of screening for Down's syndrome in the first trimester by nuchal translucency and in the second trimester by serum screening, but how is one to interpret subtle abnormalities of the fetus found at a routine ultrasound scan in the second trimester which are associated with Down's syndrome and other aneuploidies? Leye Thompson and Baskaran Thilaganathan (pages 860–864) have investigated the significance of isolated hydronephrosis in 423 pregnancies with previous screening by nuchal translucency and serum biochemistry, and found no case of Down's syndrome. With more than one subtle abnormality the risk of Down's syndrome was twice that of the background risk, and the risk of other aneuploidies nine times the background risk. These studies illustrate the difficulties of screening for Down's syndrome. In some populations the acceptance of serum screening in the second trimester and subsequent amniocentesis may be so low as to question the justification of the screening programme, yet research into screening in the first trimester is confounded by small studies in selected pregnancies, which although giving useful information with which to generate hypotheses, cannot provide definite answers. What is required is a large study of screening for Down's syndrome in the first trimester in an unselected population, where not only is the efficiency of the tests measured, but also the women's perceptions of the screening.

Mandatory vs voluntary screening for HIV infection in pregnancy

Mandatory vs voluntary screening for HIV infection in pregnancy

Uptake of interventions to reduce mother-to-child transmission of HIV in the United Kingdom and Ireland.

To describe the uptake of interventions to reduce mother-to-child transmission of HIV infection. Voluntary confidential reporting of HIV infection in pregnancy and childhood; telephone interview with key professionals in all London maternity units. HIV-infected pregnant women and children in the United Kingdom and Ireland. Trends in breastfeeding, use of zidovudine, mode of delivery and terminations of pregnancy. Between 1990 and 1995, 14 (4%) out of 314 women diagnosed with HIV infection before delivery breastfed compared with 109 (77%) out of 142 diagnosed after delivery. Since 1994, zidovudine use has increased in each 6-month period (14, 39, 67, and 75%; chi 2 = 17.5, P < 0.001), although in 1995 it was the policy of only 48% of London maternity units to offer zidovudine to HIV-infected women. During 1995, 44% of HIV-infected women were delivered by elective Cesarean section. Since 1990, 20% of women first diagnosed in pregnancy were reported to have their pregnancy terminated. Although detection of previously undiagnosed HIV infection in pregnancy remains low in the United Kingdom, and particularly in London, HIV-infected pregnant women who are aware of their status are increasingly active in taking up interventions to reduce transmission to their infants. If all HIV-infected women attending for antenatal care in London consented to testing and took up interventions and termination of pregnancy at the rates observed in this study, the number of vertically infected babies born in London each year could be reduced from an estimated 41 to 13.

HIV Infection in Pregnancy

HIV Infection in Pregnancy