HIV and pregnancy

Sammanfattning: From the Department of Clinical Science, Divisions of Obstetrics and Gynaecology and Paediatrics and the Department of Immumology, Microbiology, Pathology and Infectious Diseases, Division of Clinical Virology, Karolinska Institute, Huddinge University Hospital, Stockholm, Sweden HIV and Pregnancy An Epidemiological, Clinical and Virological Study of HIV-infected Pregnant Women amd Their Offspring Susanne Lindgren Background: HIV infection is spread throughout most parts of the world with a substantial risk for afatal outcome within 10 years. The virus is transmitted sexually, by infected blood and from mother tochild. Whether the course of am HIV infection in women is changed by pregnancy is not known. Theinfection is tramsmitted during pregnancy, at delivery and by breast-feeding in between 15% and 40% onthe average. Women with a symptomatic HIV infection or AIDS, p24 antigenaemia, low CD4 cellcounts and/or a high viral burden are more likely to transmit the infection. The aim of this investigationwas to study the interaction between HIV and pregnancy. The main concerns were the possible HIVactivation by pregnancy and the substantial risk for the child.Subjects and Methods: HIV testing was offered to pregnant women at antenatal care units (ACU) andabortion clinics in order to identify previously unaware HIV-infected women. The purpose was to offercounselling, care amd information about preventive measures and to develop a comprehensive model, alsoconsidering the psychological and social consequences for the affected families. Through clinical,immunological and virological monitoring of childbearing and terminating women during and six monthsafter pregnancy, attempts were made to evaluate possible signs of HIV activation. By searching for HIVin foetuses and children by virus isolation, the polymerase chain reaction and in situ hybridisation,attempts were made to estimate frequencies amd timing of mother-to-offspring transmissions. In addition,the clinical outcomes of mothers and children were evaluated in relation to maternal disease and mother-to-child transmission.Results and Conclusions: Seventy of the included 155 women were diagnosed with HIV in thenational pregnancy screening programme, in which approximately 1/10 000 tests were HIV positive,with higher incidences in Stockholm (2.38/10 000) than in the rest of the country (0.57/10 000)(p<0.001) and in abortion clinics (4.4/10 000) compared to ACUs (1.8/10 000) (p<0.05). Of the 155women, 76 were African, 65 European - 60 Swedish - and 12 Asian or from the American continents.Twenty-six women were, or had been, drug users seven had become infected by blood transfusions and120 were classified as sexually infected. The origins and tramsmission routes of two women were notreported. Approximately 50% of the pregnant women who were able to make an informed pregnancydecision terminated the pregnancy; more frequently they were women without a steady partner and inunstable social circumstances.There were no major HIV-related complications during pregnancy or postpartum/postabortum in 105 of107 clinically studied women. The virus isolations, the CD4 cell counts and the p24 antigen resultsduring pregnancy and six months later showed high frequencies of plasma and cell viraemia and indicated arelatively stable HIV activity during pregnancy and possible activation within six months after delivery.In 12 studied foetuses and in 27 children studied from birth, HIV infection was not confirmed in amy ofthe foetuses or newborns. Within six months, 5 of 19 children, three of them studied also at birth, wereshown to be infected, indicating an efficient placental barrier. The frequency of tramsmission was higherwhen the mother had been infected for more, compared to less, than two years at delivery. There were noreported primary HIV infections during pregnancy. At follow-up, after a median time of 29 months, 46%of the childbearing women (giving birth before 1991) had shown progression in their infection, morefrequently in mothers of infected children. Much time was needed for pregnancy counselling and support,especially when the woman was diagnosed with HIV during pregnancy. Many women lived with anuninfected partner, who would become the caretaker after the woman's death. Still, between one third andone half of the children were at risk of being orphaned. The medical, psychological and socialconsequences of HIV were overwhelming. The women, their partners and children required much supportto cope and live with HIV.Key words: HIV, pregnancy, screening, viraemia, CD4 cell counts, counselling, perinatal transmissionStockholm 1996 ISBN 91 -628- 1976-3