Pregnancy and HIV: Resources and Publications of Interest

Epidemiology
As of June 1999, women accounted for 16.7% of the cumulative AIDS cases in the United States. Of the total AIDS cases diagnosed in 1998, women account for 23%. The proportion of women with AIDS is steadily increasing each year. The majority of these women are African-American.

92% of pediatric AIDS cases are attributed to a mother with or at risk for HIV infection.

  White Black Hispanic Asian / Pacific Islander American Indian / Alaska Native Total
Women aged 13-44 at age of diagnosis through June 1999 20 578 (21.6%) 54 777 (57.5%) 19 117 (20.1%) 434 (0.46%) 275 (0.29%) 95 181 (100%)
Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1999 Mid-year edition; 11(1):14
Available online:
http://www.cdc.gov/nchstp/hiv_aids/stats/hasrlink.htm

back to the top
Treatment Guidelines

Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States. Centers for Disease Control and Prevention Perinatal HIV Guidelines Working Group. February 25, 2000:1-37.

The current guidelines recommend therapy according to the following table:
CD4 count (cells/mm³) HIV RNA Level (particles/mL)
  <2 500 2 500 - 20 000 >20 000
>500 1 or 2 2* 3**
200 - 500 2 or 3 3 3
<200 3 3 3
* 2 = 2 nucleoside analogs (ZDV plus 3TC, d4T, ddI or ddC) or ZDV plus a non-nucleoside RT inhibitor (nevirapine, delavirdine)
**3 = ZDV plus another nucleoside analog or an NNRTI plus a protease inhibitor (saquinavir, ritonavir, indinavir, or nelfinavir)

Antenatal 100 mg ZDV by mouth 5 times a day (or 200 t.i.d.) after 14 weeks of gestation
Intrapartum Intravenous ZDV at a dose of 2 mg/kg, infused over one hour, then 1 mg/kg by continuous infusion until delivery
Neonatal Oral ZDV syrup at a dose of 2 mg.kg every 6 hours for 6 weeks, beginning 8-12 hours after birth. ZDV may be given IV if neonate is unable to take oral medication.
The guidelines also recommend the option of a single dose of nevirapine at the onset of labor followed by a single dose of nevirapine for the newborn at age 48 hours for women who present in labor who have had no prior therapy. Available in .pdf format from the HIV AIDS Treatment Information Service: http://www.hivatis.org/

back to the top
Journal Articles

  1. Guay, L.A., et al., Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet, 1999. 354(9181): p. 795-802.
  2. Shaffer, N., et al., Short-course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: a randomised controlled trial. Bangkok Collaborative Perinatal HIV Transmission Study Group. Lancet, 1999. 353(9155): p. 773-80.
  3. Maternal viral load and vertical transmission of HIV-1: an important factor but not the only one. The European Collaborative Study. AIDS, 1999. 13(11): p. 1377-85.
  4. Lindegren ML, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA. 1999 Aug 11;282(6):531-8.

    Results showed that perinatal AIDS cases peaked in 1992 and decreased by 67% through 1997.
    Perinatal Transmission of HIV
    Birth Date No. Exposed / Infected Maternal Tests AZT (any) AIDS developed <1 year
    1993 416 70% 7% 326 (78%)
    1994 396 72% 26% 272 (68.7%)
    1995 383 81% 57% 196 (51%)
    1996 374 83% 80% 109 (29%)
    1997 382 94% 92% NA
    From Hopkins-AIDS What's News, posted August 20, 1999 http://hopkins-aids.edu

  5. Chirgwin KD, et al. Incidence and risk factors for heterosexually acquired HIV in an inner-city cohort of women: temporal association with pregnancy. J Acquir Immune Defic Syndr Hum Retrovirol. 1999 Mar 1;20(3):295-9.

  6. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1994;331:1173-80.

  7. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1--a meta-analysis of 15 prospective cohort studies. The International Perinatal HIV Group. N Engl J Med. 1999;340:977-87.

    The likelihood of transmission was reduced by approximately 87 percent with both elective cesarean section and receipt of antiretroviral therapy during the prenatal, intrapartum, and neonatal periods, as compared with other modes of delivery and the absence of therapy. The results of this meta-analysis suggest that elective cesarean section reduces the risk of transmission of HIV-1 from mother to child independently of the effects of treatment with zidovudine.
    The following transmission rates were noted in this retrospective review: no AZT or C-section: 19%; C-section and no AZT: 10%; AZT and no C-section: 7% and AZT + C-section: 2%

  8. Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunodeficiency virus type 1 RNA and the risk of perinatal transmission. Women and Infants Transmission Study Group. N Engl J Med. 1999;341:394-402.

    The highest rate of transmission was among women whose plasma HIV-1 RNA levels exceeded 100,000 copies per milliliter and who had not received zidovudine. In pregnant women with HIV-1 infection the level of plasma HIV-1 RNA predicts the risk but not the timing of transmission of HIV-1 to their infants.
    Rate of Perinatal Transmission
    Maternal Viral Load Rate
    <1,000 copies/ml 0/57
    1,000 - 10,000 c/ml 32/193 (17%)
    10,000 - 50,000 c/ml 39/183 (21%)
    50,000 - 100,000 c/ml 17/54 (31%)
    >100,000 c/ml 26/64 (41%)
    >100,000 c/ml plus lack of AZT 19/30 (63%)
    From Hopkins-AIDS What's News, posted August 20, 1999 http://hopkins-aids.edu

  9. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med. 1999;341:385-93.

    Among pregnant women and their infants, all treated with zidovudine, the maternal plasma HIV-1 RNA level was the best predictor of the risk of perinatal transmission of HIV-1. Antiretroviral therapy that reduces the HIV-1 RNA level to below 500 copies per milliliter appears to minimize the risk of perinatal transmission as well as improve the health of the women. here was no perinatal transmission of HIV-1 among the 84 women who had HIV-1 levels below the limit of detection (500 copies per milliliter) at base line or the 107 women who had undetectable levels at delivery.

  10. Wilfert CM, Fleming T. Perinatal transmission--successful interventions. Where do we go from here? Int J STD AIDS. 1998;9:22-7.

back to the top
Edited Books

Sande, M. A., Volberding, P., Cohen, P. T., University of California, S. F., & San Francisco General Hospital (Calif.). The AIDS knowledge base: a textbook on HIV disease from the University of California, San Francisco School of Medicine, and San Francisco General Hospital. (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. 1999: xxiii, 966.
Section 4.12: Reproduction and HIV Disease: Pregnancy and Perinatal Care of HIV-1 Infected Women written by Karen Beckerman, Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
Available in print and online: http://hivinsite.ucsf.edu/akb/1997

Faden RR, Kass NE. HIV, AIDS, and childbearing : public policy, private lives. New York: Oxford University Press; 1996: xx, 492.
Of particular interest is Part 1: "Medical and Public Health Issues," which has seven chapters: "The Epidemiology of HIV and AIDS in Women," "The Clinical Course of HIV Infection in Women," "Gynecological and Obstetrical Issues for HIV-Infected Women," "Health Prospects for Children Born to HIV-Infected Women," "Psychosocial Issues for Children Born to HIV-Infected Mothers," "Access to, and Utilization of, Health Services for HIV-Infected Women," and "Drug Use, HIV Status, and Reproduction."

back to the top
Government publications

Stoto MA, Almario DA, McCormick MC, Institute of Medicine (U.S.). Committee on Perinatal Transmission of HIV., Board on Children Y, and Families (U.S.). Reducing the odds: preventing perinatal transmission of HIV in the United States. Washington, D.C.: National Academy Press; 1999:xiii, 397.
This study evaluates the extent to which state efforts have been effective in reducing the perinatal transmission of HIV. The committee recommends that testing for HIV be a routine part of prenatal care and that health care providers notify women that HIV testing is part of the usual array of prenatal tests and that they have an opportunity to refuse.
Available from the National Academy Press website for purchase in hardcover format or page by page .pdf format. A summary is available as well. http://books.nap.edu/catalog/6307.html

Edge City Innovations I, United States. HIV/AIDS Bureau. "Creating a circle of care": comprehensive service delivery to HIV-positive pregnant women and their newborns: a manual on best practices. Washington, D.C.: U.S. Dept. of Health & Human Services Health Resources & Services Administration HIV/AIDS Bureau; 1998:67.

United States. Health Resources Administration. Responding To The Needs Of Women With HIV, Title I And Title II, Ryan White CARE Act, March 1997. S.l.: s.n.; 1998.

United States. Public Health Service. Pregnancy and HIV: is AZT the right choice for you and your baby? Publication ; no. 96-0007. Rockville, MD (2101 East Jefferson St., Rockville 20852): U.S. Dept. of Health and Human Services Public Health Service; 1995:9.

Shepherd CM, Royal College of Midwives (Great Britain). HIV infection in pregnancy. Midwifery practice guides; 1. 1st ed. Cheshire, England: Books for Midwives Press; 1994:77.

back to the top
Websites

Centers for Disease Control HIV/AIDS Slide Sets:
Women: http://www.cdc.gov/nchstp/hiv_aids/graphics/women.htm
Pediatrics: http://www.cdc.gov/nchstp/hiv_aids/graphics/pediatri.htm
These slides are available in Adobe Acrobat or Power Point.

National Pediatric AIDS Network
http://www.npan.org/
See the section on Pregnancy Issues for links to a variety of news and research findings on pregnancy and HIV. Not all the links are still active.

National Pediatric & Family HIV Resource Center
http://www.pedhivaids.org/
Preventing Perinatal Transmission: http://www.pedhivaids.org/preventing/
Literature Updates plus a 44 page guide for providers published in May 1997, with reviews and critiques of clinical trials, counseling and testing information and documentation, cultural competence and a comprehensive bibliography.

Health Care Financing Administration
http://www.hcfa.gov/hiv/
Contact the HCFA Chicago office: 312/353-3876 or the Kansas City office: 816/426-6317

HIVInSite from the University of California, San Francisco
http://HIVInSite.ucsf.edu/topics/pregnancy_and_childbirth/

back to the top

last updated April 24, 2000