Paper: PMTCT in High Income Countries

CONCLUSIONS AND IDEAS FOR FUTURE RESEARCH

Global epidemiology of HIV infection is rapidly evolving, and the widespread use of important achievements in biomedical interventions to prevent MTCT is leading to progressive decrease in rates of infant HIV infection and potential elimination of the problem, in particular in high-resource countries. It is fundamental to remember that this goal represents an ongoing process and interpretation of clinical and epidemiological studies is crucial for the development of evidence-based recommendations to guide management of HIV-infected pregnant women and their exposed neonates. Although significant progress has been made, heterogeneity between countries in specific PMTCT interventions still exists, which may address future research. Also, other measures like immunotherapies in infants or pregnant mothers could be a useful tool and need to be further explored.152 It is vital to remember that as potentially preventable transmissions continue to occur 8,10,153,154 even in developed countries dedicated efforts to support medication adherence and retention in care for women and infants are essential (Table 1). Elimination of perinatal HIV infection in the USA and other high-income countries: achievements and challenges. Nesheim S1, Harris LF, Lampe M. Author information Abstract PURPOSE OF REVIEW: To describe progress and challenges to elimination of mother-to-child HIV transmission (EMCT) in high-income countries. RECENT FINDINGS: Despite ongoing declines in the number of perinatally HIV-infected infants in most high-income countries, the number of HIV-infected women delivering may be increasing, accompanied by apparent changes in this population, including higher percentages with antiretroviral 'pretreatment' (with possible antiretroviral resistance), other coinfections, mental health diagnoses, and recent immigration. The impact of antiretroviral resistance on mother-to-child transmission is yet to be defined. A substantial minority of infant HIV acquisitions occurs in the context of maternal acute HIV infection during pregnancy. Some infant infections occur after pregnancy, for example, by premastication of food, or breastfeeding (perhaps by an uninfected woman who acquires HIV while breastfeeding). SUMMARY: The issues of EMCT are largely those of providing proper care for HIV-infected women. Use of combination ART by increasing proportions of the infected population may function as a structural intervention important to achieving this goal. Providers and public health systems need to be alert for HIV-serodiscordant couples in which the woman is uninfected and for changes in the population of HIV-infected pregnant women. Accurate data about HIV-exposed pregnancies are vital to monitor progress toward EMCT. Original Contribution August 11, 1999 Trends in Perinatal Transmission of HIV/AIDS in the United States Mary Lou Lindegren, MD; Robert H. Byers, Jr, PhD; Pauline Thomas, MD; et alSusan F. Davis, MD; Blake Caldwell, MD, MPH; Martha Rogers, MD; Marta Gwinn, MD, MPH; John W. Ward, MD; Patricia L. Fleming, PhD Author Affiliations JAMA. 1999;282(6):531-538. doi:10.1001/jama.282.6.531 Abstract Context Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission. Objective To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations. Design, Setting, and Participants Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998. Main Outcome Measures Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states. Results Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100,000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n=6990) to 1995 (n=5797). Among infants, PCP rates per 100,000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%. Conclusions According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.