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Project Inform - September, 1998
The Bay Area Perinatal AIDS Center (BAPAC) at San Francisco General Hospital has developed a program for prevention of mother-to-child HIV transmission. The program provides women with the latest in anti-HIV therapy along with case management, counseling and education, and has a strong focus on the basic principles of mother and child health. BAPAC has been able to reduce transmission of HIV in this setting to virtually zero. Of the 61 children that have been born in the past 3 years, 52 appear to be free of virus past 6 months of age. The remaining 9 infants are less than 6 months of age, but all have preliminary test results suggesting that they are not infected with HIV. In the BAPAC group, the majority of mothers of children born between 1994 and 1996 chose to use AZT alone during pregnancy. In 1997, 17 of 26 mothers chose two-drug therapy and 6 out of 26 chose a triple combination. In 1998, 10/17 pregnant women either started or continued triple-drug, protease inhibitor-containing combinations during their pregnancies, consistent with the Public Health Services recommendation that all women receive optimal anti-HIV therapy regardless of their pregnancy status. All mothers, regardless of the regimens they were taking, chose to have AZT administered through a vein (intravenously) during labor and chose to treat the newborn with AZT for a period of time after birth. The BAPAC program has focused on the total needs of women, addressing not only their anti-HIV therapy needs, but also their food, housing and general health concerns. The program has emphasized empowerment of women with counseling and education sessions to allow women to make their own choices about care for themselves and their newborn children. Adherence to the sometimes complex therapy regimens was difficult, especially during the first trimester and after delivery when the focus quickly shifts from a mother's own health needs to the needs of her child. Studies have shown that children are much healthier and less likely to die when an HIV-positive mother stays healthy herself. Before delivery, pregnant women and their physicians should plan ahead and discuss strategies for adherence and for preserving the mother's health. Despite difficulties with adherence, the program has clearly shown that a combination of anti-HIV therapy and a strong focus on prenatal care and maternal health can prevent almost all mother-to-child HIV transmission and leads to the best health outcomes for both women and their children.
The importance of the mother's health on the health outcomes of children was shown in a recent study of multivitamin use during pregnancy. The study included 1075 pregnant women with HIV in Africa and showed that use of multivitamins during pregnancy can significantly reduce the number of fetal deaths, low birth weight babies, and premature births. Researchers do not yet know if vitamin supplements can reduce mother-to-child HIV transmission.
Interestingly, while prenatal care, nutrition and anti-HIV therapy are independently important in improving maternal and infant outcomes, they are also related. One study showed that many women do not receive the full recommended regimen as used in the AIDS Clinical Trials Group (ACTG) 076 study—the study which led to the recommended use of AZT for preventing mother-to-child HIV transmission. In ACTG 076, mothers took 100mg AZT (zidovudine, Retrovir®) five times daily (total daily dose 500mg) until labor. During labor, they received 2mg/kg of AZT intravenously for one hour followed by 1mg/kg each hour until the child was delivered. The newborn received 2mg/kg of AZT orally (by mouth) or 1.5mg/kg intravenously every six hours for 6 weeks. Lack of prenatal care was the most common reason for not receiving the full regimen of AZT during pregnancy and throughout labor with subsequent AZT therapy to the newborn. Indeed, another study revealed the importance of receiving all regimen components. Mother and child pairs who received the full ACTG 076 AZT regimen had an HIV transmission rate of only 2.8%, much lower than the rates in women who received only partial regimens (9%) or none (31%).
There are a number of other practices that can reduce mother-to-child HIV transmission. HIV can be passed from mother to child through breast milk. Thus, whenever possible, and if nutritionally sound milk supplements are available, women with HIV should avoid breast feeding their children.
However, in many parts of the world where clean water is not available to reconstitute formula powder into a milk solution, women need to weigh the risks of HIV transmission through breast feeding with other infections that may result by using contaminated water.
In such countries, this issue is particularly confounded by lack of access to healthcare and health monitoring tools. In a third world country, an HIV-positive mother who gives birth to a child infected with HIV might best be helping that child, nutritionally, by breast feeding. If the child is not infected, however, she risks infecting the child. The tests to determine if the child is or is not infected, however, are not routinely available in the third world.
Due to the major risk of transmission at the time of delivery, researchers have compared the effects of delivering the baby by a Ceasarean section to natural vaginal birth on the rate of mother-to-child HIV transmission. Studies show that, if used along with AZT, a Ceasarean section performed before labor can reduce rates of HIV transmission compared to a vaginal delivery. However, one study showed that there is no difference in HIV transmission rates between the two methods of delivery in women who do not use AZT therapy during pregnancy and throughout delivery. Also, while Ceasarean section may reduce the risk of HIV transmission, it is a surgical procedure and thus carries a number of additional risks to the mother. Therefore, it is important for the mother to weigh the risks and benefits to both herself and her child, remembering that her health after the child is born can impact on the health of her child.
While AZT is the only drug that has been thoroughly studied in pregnant women, the Public Health Service Guidelines recommend all women receive the highest standard of care regardless of pregnancy status. Women are using a variety of therapies for their own health and to prevent HIV transmission during pregnancy. Small studies data are slowly emerging about the safety and effectiveness of combination drug regimens to prevent HIV transmission and the possible side effects these regimens may have on pregnant mothers and newborn children (see Combination Therapies on Pregnant Women Box). It is important researchers explore the effects of anti-HIV treatments not only on mother-to-child transmission, but also on the health of women with HIV. More research is also needed on the way HIV and anti-HIV therapies affect common conditions seen in pregnant women such as glucose intolerance, diabetes and nausea.
It is increasingly clear that prenatal care and attention to the mother's general
health concerns play an important role in the prevention of mother-to-child transmission.
Women with HIV who are pregnant or are considering pregnancy should remember that a
successful prenatal prevention regimen includes prenatal care, support and education in
addition to a well thought out anti-HIV treatment strategy. Physicians are reminded that
women with HIV need all important aspects of care to help prevent HIV transmission and
maintain their own health before, during and after pregnancy. It is imperative to develop
ways to help women and children adhere to therapy early in pregnancy and immediately after
delivery. Obviously, the BAPAC program, addressing the spectrum of needs of HIV-positive
pregnant women, has been able to do what ACTG 076 AZT therapy alone, could not
do—bring mother-to-child HIV transmission rates to apparently zero. Programs which
incorporate such comprehensive approaches must be established nationwide. The benefits of
programs such as the BAPAC program, in both rural and urban areas, could result in the end
of the pediatric AIDS epidemic in the U.S. and other developed nations. Those interested
in learning more about the BAPAC program and developing such a program in their area can
contact Karen Beckerman at 415-206-8276.
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