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

OBJECTIVES: To describe the uptake of interventions to reduce mother-to-child transmission of HIV infection. DESIGN: Voluntary confidential reporting of HIV infection in pregnancy and childhood; telephone interview with key professionals in all London maternity units. SUBJECTS AND SETTING: HIV-infected pregnant women and children in the United Kingdom and Ireland. MAIN OUTCOME MEASURES: Trends in breastfeeding, use of zidovudine, mode of delivery and terminations of pregnancy. RESULTS: 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. CONCLUSIONS: 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.     

Routine prenatal screening for HIV in a low-prevalence setting

BACKGROUND: The objectives of this study were to assess the effect of British Columbia's June 1994 guidelines for prenatal HIV screening on the rate of maternal-fetal HIV transmission and to estimate the cost-effectiveness of such screening. METHODS: The authors conducted a retrospective review of pregnancy and delivery statistics, HIV screening practices, laboratory testing volume, prenatal and labour management decisions of HIV-positive women, maternal-fetal transmission rates and associated costs. RESULTS: Over 1995 and 1996, 135,681 women were pregnant and 92,645 carried to term. The rate of HIV testing increased from 55% to 76% of pregnancies on chart review at one hospital between November 1995 and November 1996. On the basis of seroprevalence studies, an estimated 50.2 pregnancies and 34.3 (95% confidence interval 17.6 to 51.0) live births to HIV-positive women were expected. Of 42 identified mother-infant pairs with an estimated date of delivery during 1995 or 1996, 25 were known only through screening. Of these 25 cases, there were 10 terminations, 1 spontaneous abortion and 14 cases in which the woman elected to carry the pregnancy to term with antiretroviral therapy. There was one stillbirth. One instance of maternal-fetal HIV transmission occurred among the 13 live births. The net savings attributable to prevented infections among babies carried to term were $165,586, with a saving per prevented case of $75,266. INTERPRETATION: A routine offer of pregnancy screening for HIV in a low-prevalence setting reduces the rate of maternal-fetal HIV transmission and may rival other widely accepted health care expenditures in terms of cost-effectiveness.     

Disability, the risk of disability and changes in work capacity-- unacceptable conditions for insurance in occupational injuries and diseases

OBJECTIVE: To identify factors associated with failure to return for HIV post-test counselling in pregnant women in Kigali (Rwanda). SUBJECTS AND METHODS: In the context of a study on the impact of HIV infection on pregnancy, HIV-1-antibody testing was offered to all pregnant women attending the antenatal clinic of the Centre Hospitalier de Kigali from July 1992 to August 1993. Pre-test counselling was performed after verbal informed consent was obtained. Two weeks later, we formally enrolled all HIV-positive women and a corresponding number of HIV-negative women in a cohort. At this visit, post-test counselling was given to those wishing to be informed of their HIV serostatus. Level of knowledge about modes of HIV transmission and condom use were recorded. Four months after delivery, another interview was conducted to determine the proportion of women who used condoms regularly. RESULTS: A total of 1233 pregnant women were screened. The HIV seroprevalence was 34.4% [95% confidence interval (CI), 31.7-37.1]; 271 (63.9%) out of 424 HIV-positive and 577 (71.3%) out of 809 HIV-negative women asked for their HIV serostatus (P = 0.008). In multivariate analysis, the only variable significantly associated with failure to return for post-test counselling was a positive HIV test result (odds ratio, 0.7; 95% CI, 0.5-0.9; P = 0.009), independently of obstetrical history and socioeconomic characteristics. Among the 848 women who had post-test counselling, 50.9% of the HIV-positive women and 94.6% of the HIV-negative women stated that they planned to inform their partner of their serostatus (P = 0.0001). More than 95% of the women interviewed knew about sexual and parenteral transmission of HIV, but half were unaware of mother-to-child transmission. More than 80% of the women had seen a condom before, but 14% only had used it at least once. Among women who were sexually active 4 months after delivery, 8.8% of the HIV-positive and 3.9% of the HIV-negative women reported using a condom (P = 0.04). CONCLUSION: Innovative approaches for HIV testing and counselling programs are needed and the importance of psychosocial and cultural factors associated with HIV testing should be emphasized in African populations.     

Incidence and consequences of pregnancy in women with known duration of HIV infection. Italian Seroconversion Study Group

BACKGROUND: The increasing incidence of human immunodeficiency virus (HIV) infection in women of childbearing age led us to evaluate whether pregnancy affects the natural history of this disease. OBJECTIVES: To conduct a prospective study of women with known dates of HIV seroconversion to describe the incidence and outcome of pregnancy and to assess differences according to age and exposure group. To compare the rate of disease progression between pregnant and nonpregnant women. PATIENTS: All participants, recruited from 14 clinical centers in Italy, had documented HIV-seronegative test results followed by confirmed positive test results within 2 years. RESULTS: A total of 331 women, who had seroconversion between 1981 and 1994, were followed up for a median of 5.5 years from seroconversion; 94 developed HIV-related diseases, 47 developed acquired immunodeficiency syndrome, and 53 had at least 1 CD4 cell count lower than 0.10 x 10(9)/L (< 100 cells/mm3). Thirty-eight women (11.5%) were pregnant at the time of HIV seroconversion and 31 (9.4%) became pregnant after HIV seroconversion (cumulative incidence of pregnancy within 8 years of seroconversion, 28.9%; 95% confidence interval, 21.6%-36.2%). Forty-five (65.2%) of the 69 pregnancies were carried to term. There were no discernible differences in these findings by age or exposure group. Pregnant women did not experience a more rapid rate of progression of disease, even when adjusting for age, exposure group, CD4 cell count, or use of treatment (adjusted relative hazards: HIV-related diseases, 0.72; acquired immunodeficiency syndrome, 0.69; CD4 cell count <0.10 x 10(9)/L, 1.24). CONCLUSION: Women infected with HIV continue to become pregnant after seroconversion, yet pregnancy does not appear to influence the rate of progression of HIV disease.     

Understanding pregnant women's decision making concerning prenatal screening.

Objective: This study is aimed at enhancing understanding prenatal screening decision making through testing a hypothesized decision model based on decision theory and health behavior theory. Design: We obtained questionnaires from 1,666 pregnant women who were offered prenatal screening for Down's syndrome. Path analysis (using LISREL) resulted in a final model with reasonable model fit, which was verified by split-sample cross-validation. Main outcome measures: These included perceived probability, perceived severity, attitude toward termination, response efficacy, attitude toward prenatal screening, subjective norm, child-related anxiety, and intention to undergo prenatal screening. Results: Attitude toward termination of pregnancy, perceived test efficacy, and subjective norm regarding the desirability of having prenatal screening determined a woman's attitude toward having a prenatal test. Anxiety was influenced by perceived risk and perceived severity of having a child with Down's syndrome, and by subjective norm, but this appeared to be a weak predictor of intention to test. Pregnant women with a positive attitude toward prenatal screening, and who perceived a subjective norm in favor of undergoing prenatal screening, showed a greater intention to have prenatal screening done. Conclusion: These findings suggest that more attention should be paid toward the values and social context of pregnant women during the counseling process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

HIV infection in women: an escalating health concern

The proportion of women infected with the human immunodeficiency virus (HIV) continues to increase. Over one-half of women acquire the virus through heterosexual contact. The diagnoses that define the acquired immunodeficiency syndrome and the use of antiretroviral therapy are similar in men and women, except in pregnancy. However, management decisions differ significantly regarding contraceptive and gynecologic care. Besides abstinence, use of the latex condom continues to be the most effective way of preventing transmission of HIV. The management of human papillomavirus-associated disease, pelvic inflammatory disease and vaginal candidiasis is especially challenging in women with HIV infection. A positive status for the virus does not appear to affect pregnancy outcome. Each year, up to 2,000 infants are born infected with HIV. Transmission can occur by transplacental or intrapartum spread or through breast milk. Since 1994, prophylaxis with zidovudine has been shown to be an effective method of limiting transmission to infants. It is important to offer all pregnant women a test for HIV, with counseling provided both before and after the test, even if testing does not become mandatory under the law.     

Inadequate weight gain among pregnant adolescents: risk factors and relationship to infant birth weight

OBJECTIVE: Our purpose was to identify behavioral markers for inadequate weight gain (< 20 pounds) during pregnancy among adolescents < 18 years old. STUDY DESIGN: A total of 337 adolescents who were delivered of a term infant at our institution between March 10, 1992, and November 28, 1994 participated in this study. A comprehensive structured interview conducted at the first prenatal visit elicited demographic information and behavioral risk factors. Maternal weights, reproductive history, evidence of sexually transmitted disease, and infant birth weight were extracted from medical records. Logistic regression and chi 2 analyses compared characteristics and infant birth weights between those who gained < 20 pounds with those who gained > or = 20 pounds. RESULTS: A total of 11.6% (39/337) of the total sample gained < 20 pounds during the pregnancy. Adolescents who gained < 20 pounds compared with > or = 20 pounds were delivered of significantly lighter (2942 gm vs 3392 gm) infants and were more likely to be delivered of infants weighing < 2500 gm (13% vs < 1%). Stepwise logistic regression revealed that adolescents who were battered (odds ratio 5.3) or had a sexually transmitted disease (odds ratio 2.3) or an unplanned pregnancy (odds ratio 8.1) were at increased risk for insufficient weight gain during pregnancy. CONCLUSION: Our data suggest that behavioral risk factors are important in the identification of adolescents at greatest risk for inadequate weight gain. Early identification during pregnancy is essential to modify nutritional practices and thus minimize poor obstetric outcomes.     

Fetal anomaly detection by second-trimester ultrasonography in a tertiary center

OBJECTIVE: Our purpose was to determine the relative accuracy of indicated versus screening second-trimester ultrasonography for detection of fetal anomalies and to assess the cost effectiveness of anomaly screening. STUDY DESIGN: The study population consisted of 2031 pregnant women with singleton gestations who prospectively underwent ultrasonographic scanning between 15 and 22 weeks and received complete obstetric care at the Medical University of South Carolina between July 1, 1993, and June 30, 1996. Patients were divided into two groups: (1) indicated and (2) screening. The cost of screening ultrasonography was compared with the cost of newborn care for selected anomalous fetuses. RESULTS: Forty-seven fetuses (2.3%) were diagnosed by ultrasonography as having a major anomaly: 8.6% in the indicated group and 0.68% in the screening group (p=0.001). The sensitivity for detecting the anomalous fetus was 75.0% overall: 89.7% in the indicated group and 47.6% in the screening group (p=0.001). Of the 47 patients diagnosed with fetal anomalies, 11 (23.4%) chose pregnancy termination; of the 35 (74.5%) live-born anomalous infants, 29 (82.9%) were discharged alive. Projected newborn cost savings offset the cost of routine midtrimester screening. CONCLUSIONS: Detection of anomalous fetuses was significantly better in the indicated compared with the screening group. Nevertheless, routine ultrasonographic screening appeared cost-effective in our population.     

Alternatives for measuring knee extension strength of the elderly at home

The objective of this study was to determine whether pregnancy is associated with an acceleration of human immunodeficiency virus (HIV) disease progression in women who have a pregnancy while HIV infected. A retrospective review of all women aged 15-35 years who attended an HIV outpatient program from January 1989 through August 1995, was undertaken. The 192 women who had a term pregnancy after testing positive for HIV were compared with 164 women who were not pregnant during the same period. The main outcome measures were death, the occurrence of a first acquired immunodeficiency syndrome (AIDS)-defining condition, or a condition indicative of symptomatic HIV. Disease progression was assessed using the Kaplan-Meier method and multivariate proportional hazards models. Compared with nonpregnant women, women with a term pregnancy were significantly more likely to be African-American (88% vs. 78%, p < 0.05), younger than 22 years of age (51 % vs. 11%, p < 0.001), and to have entered the clinic with a higher median CD4 count (519 vs. 433 cells/microl, p < 0.001). After adjusting for entry CD4 count and other factors, pregnancy was not associated with progression to any of the study outcomes. Thus, in women attending a publicly funded clinic, pregnancy does not appear to accelerate the progression of HIV disease.     

Antenatal HIV antibody testing in Australia

OBJECTIVE: To evaluate the role of voluntary antenatal testing in HIV surveillance and prevention by examining antenatal HIV antibody testing practice and policy in Australia. DESIGN: Cross-sectional study using a self-administered questionnaire. SUBJECTS AND SETTING: Specialist obstetricians and gynaecologists and general practitioners (GPs) affiliated with the Royal Australian College of Obstetricians and Gynaecologists and Australian public hospital antenatal clinics, August-November 1992. MAIN OUTCOME MEASURES: The percentage of public hospital antenatal clinics and specialist and GP obstetricians in Australia who tested pregnant women for HIV antibody as part of their antenatal care, and the proportion of pregnant women in Australia who had an antenatal HIV antibody test in the 1991-92 financial year. RESULTS: Questionnaires concerning antenatal HIV antibody testing were completed by 90% (993/1108) of specialists, 87% (2134/2461) of GPs and 93% (215/230) of public hospitals surveyed. Of the 706 specialists and 1503 GPs who reported that they were currently engaged in obstetric care, approximately 60% (430/706) and 935/1503, respectively) offered antenatal HIV testing either to all pregnant women or to selected groups at risk. There were significant differences in testing patterns between States and Territories. For the 95 public hospitals with antenatal clinics, 81% (77) offered the HIV antibody test to all or selected groups of pregnant women; these percentages did not differ significantly between States and Territories. It was estimated that 25% of pregnant women seen by specialists, 29% seen by GPs and 9% seen in public hospital clinics were tested for HIV antibody as part of their antenatal care in 1991-92. CONCLUSIONS: In Australia approximately one in five pregnant women were tested for HIV antibody as part of their antenatal care in 1991-92. Voluntary HIV testing in pregnancy may provide unrepresentative data for measuring the prevalence of HIV infection in pregnant women.     

Sequence analysis of genes encoding rodent homologues of the human tumor-rejection antigen SART-1

OBJECTIVE: To assess pregnant women's knowledge of, and attitudes towards, antenatal HIV testing, and its acceptability to them. SETTING: Antenatal clinic at Guy's Hospital, London, six community antenatal clinics and a midwifery group practice. POPULATION: Eight hundred and forty-three women attending the antenatal clinics. METHOD: The women received a leaflet explaining HIV testing, and completed a questionnaire before and after their booking appointment. This included an assessment of their knowledge of, and attitudes towards HIV testing, and its acceptability. RESULTS: Seven hundred and eighty-nine women (94%) completed questionnaires. Fifty-one percent (n = 405) were Caucasian, 25% (n = 195) African, 11% (n = 86) West Indian and 13% (n = 100) were from other ethnic groups. Fifty-eight percent received the HIV information leaflet, of whom 86% had read it. Knowledge relating to HIV was good, the median knowledge score being 6 out of a possible 8, but it was less in non-Caucasian women and those with lower educational qualifications. Knowledge was not related to uptake of testing. Thirty-five percent of women accepted the offer of an HIV test, rates being higher in hospital clinics (41%) than in the midwifery group practice (10%) and the community clinics (30%). Women more likely to accept the offer of an HIV test were non-Caucasian (P = 0.0443), those who had thought about the HIV test before this pregnancy (P = 0.0298) and those seeing one particular midwife (P = 0.0003). Most women (67%) thought that all pregnant women should be offered the HIV test and then make their own decision. Overall, 64% women did not change their original pre-discussion decision on testing for HIV. Thirty-six percent of women changed their decision from 'yes' to 'no' or 'don't know' after seeing the midwife. Women attending the community clinics (P = 0.003) and those who had been tested before (P = 0.0451) were more likely to change their decision. CONCLUSION: This study, in a multiethnic population, has shown that knowledge regarding HIV is good but does not increase the uptake of testing. Women prefer to be offered the HIV test and make their own choice regarding whether to accept it.     

Need for systematic HIV serological study during pregnancy

BACKGROUND: To evaluate human immunodeficiency virus (HIV) screening usefulness in pregnancy and to know the prevalence of this infection in an urban area of Spain. PATIENTS AND METHOD: Routine prenatal screening for antibodies to HIV was offered to pregnant women from Fuenlabrada-Leganés Health Care Area (Madrid) from 1992 to 1995. Unlinked anonymous screening of HIV was done with the sera from women refusing the assay or if it had not been offered. RESULTS: HIV prevalence was 0.28% (CI: 95%; 0.19 to 0.40) in the 11.021 pregnant women group studied. 87.1% pregnant seropositive women were detected by consented screening. 55.6% of them recognized risk behavior (73.33% by intravenous drug use) and 44.4% did not do it. With a second anamnesis in this group 75% admitted risk conducts and 25% confirmed their ignorance about them. CONCLUSIONS: HIV seropositive screening in pregnant women selected only by risk behavior may be unsuccessful. For that reason, it is more convenient the perform a routine test for detection of HIV antibodies after informed consent in high prevalence areas of HIV infection.     

New approaches to syphilis control. Finding opportunities for syphilis treatment and congenital syphilis prevention in a women's correctional setting

BACKGROUND: With prostitution and drugs the most common reasons for arrest among New York City (NYC) women, female arrestees are at high risk for acquiring syphilis and delivering congenitally infected babies. Despite routine syphilis screening of all NYC inmates, many are released before the need for treatment is recognized, and once released, few could be found for treatment. GOALS: To improve syphilis treatment rates among female correctional inmates in NYC. STUDY DESIGN: At a women's correctional health clinic, on-site, rapid, qualitative nontreponemal syphilis testing (STAT rapid plasma reagin [RPR]) and on-line access to the local syphilis case registry were introduced to supplement the usual admission medical evaluation. Treatment decisions made using the authors' jail protocol were compared with treatment criteria used in NYC's sexually transmitted disease (STD) clinics. Patients consisted of a consecutive sample of 685 remandees admitted one or more times during the day shift, March 24, 1993, to July 31, 1993, who had a full complement of mandatory admission medical tests. Using the study protocol, syphilis treatment decisions were made and needed treatment was furnished at the end of the admission medical evaluation. The main outcome measures were correct identification and treatment of syphilis in this population, compared with standard NYC Department of Health (DOH) STD clinic practice, as well as the effect of the jail protocol on pregnancy outcomes and need to treat offspring for congenital syphilis. RESULTS: Compared with NYC DOH STD clinic practice, the study protocol was 95% sensitive and 88% specific in arriving at appropriate treatment for syphilis. Treatment at the end of the admission medical evaluation increased syphilis treatment rates from 7% to 84% of women with indications for treatment and to 88% of pregnant women with indications for treatment. Prospective follow-up for birth outcomes revealed no spontaneous abortions and eight live births. Seven of the eight did not need congenital syphilis treatment because their mothers were adequately treated while incarcerated. CONCLUSIONS: Qualitative (or STAT) RPR testing and access to DOH syphilis case registry data provide prompt and accurate diagnostic information that can lead to an overall increase in the number of inmates appropriately treated (with a minimum amoung of overtreatment) in a women's correctional facility. This protocol may be applicable in other high-risk, transient populations.     

Is adverse pregnancy outcome predictable after blunt abdominal trauma?

OBJECTIVE: The aim of the study was to evaluate the following: (1) pregnancy outcome after blunt abdominal trauma and (2) factors that may predict preterm birth and adverse peripartum outcomes. STUDY DESIGN: All women who had noncatastrophic abdominal trauma and came to the labor and delivery suite July 1994-August 1997 were prospectively evaluated and admitted for continuous uterine and fetal monitoring. A complete blood cell count, coagulation profile, and Kleihauer-Betke stain were performed. Ultrasonographic examination was performed to rule out hematoma. Tocolytic agents were administrated in cases with persistent contractions. Pregnancy outcomes and risk factors were compared between those with preterm birth before 37 weeks' gestation and those who were delivered after 37 weeks' gestation. RESULTS: Delivery information was available for 85 women with blunt abdominal trauma from motor vehicle accident (28), falls (27), and direct assault (30, which included 17 cases of domestic abuse). Four women, 3 of whom were exposed to domestic abuse, were hospitalized twice. Thirteen patients had preterm birth and 72 patients were delivered at term. In all cases the results of Kleihauer-Betke stains, maternal vital signs, blood cell count, coagulation profile, and placental ultrasonographic examinations were normal. The differences between the 2 groups with respect to gestational age at the time of trauma, length of hospital stay, subjective reports of abdominal pain, objective findings of abdominal tenderness, patterns of uterine contractions, interval between trauma and delivery, and Apgar scores were not statistically significant. However, the preterm birth group received magnesium sulfate tocolysis more frequently (31% vs 7%) and had a significantly greater rate of peripartum complications, such as rupture of membranes and abruptio placentae, than the group of patients who delivered at term (46.2% vs 12.5%, P <.05). Women with domestic abuse had increased uterine contractions at the time of abdominal trauma (52.9% vs 19.1%, P =.01) but did not require increased use of tocolysis. Women with domestic abuse had more peripartum complications (41.8% vs 11.8%, P <.01). CONCLUSIONS: Women with noncatastrophic blunt abdominal trauma in pregnancy tend to have favorable neonatal outcomes. Findings or reports of abdominal tenderness and uterine contractions are not predictive of preterm birth. Preterm birth was associated with increased peripartum complications. However, domestic abuse was associated with repeated trauma in the index pregnancy and increased peripartum complications.     

Epidemiology and detection of HIV-1 among pregnant women in the United Kingdom: results from national surveillance 1988-96

OBJECTIVE: To describe the epidemiology of HIV-1 infection in pregnant women in the United Kingdom. DESIGN: Serial unlinked serosurveillance for HIV-1 in neonatal specimens and surveillance through registers of diagnosed maternal and paediatric infections from reporting by obstetricians, paediatricians, and microbiologists. SETTING: United Kingdom, 1988-96. SUBJECTS: Pregnant women proceeding to live births and their children. MAIN OUTCOME MEASURES: Time trends in prevalence of HIV-1 seropositivity in newborn infants (as a proxy for infection in mothers); the proportions of mothers with diagnosed HIV-1 infections, and their characteristics. RESULTS: HIV-1 prevalence among mothers in London rose sixfold between 1988 and 1996 (0.19% of women tested; 1 in 520 in 1996). Apart from in Edinburgh and Dundee, levels remained low in Scotland (0.025%; 1 in 3970) and elsewhere in the United Kingdom (0.016%; 1 in 1930). Over a third of births to infected mothers in 1996 occurred outside London. In London the reported infections were predominantly among black African women, whereas in Scotland most were associated with drug injecting. The contribution of reported infection among African women increased over time as that of drug injecting declined. In Scotland 51% of mothers' infections were diagnosed before the birth. In England, despite a national policy initiative in 1992 to increase the antenatal detection rate of HIV, no improvement in detection was observed, and in 1996 only 15% of previously unrecognised HIV infections were diagnosed during pregnancy. CONCLUSIONS: HIV-1 infection affects mothers throughout the United Kingdom but is most common in London. Levels of diagnosis in pregnant women have not improved. Surveillance data can monitor effectively the impact of initiatives to reduce preventable HIV-1 infections in children.     

Comparative study of the cytoplasmic domain of band 3 from human and rabbit erythrocyte membranes

OBJECTIVE: To identify sociodemographic characteristics associated with induced abortion of the first pregnancy and quantify the strength of association between them. MATERIAL AND METHODS: Data were gathered from a survey conducted in the district of Diez de Octubre, Havana, Cuba throughout 1991 and the beginning of 1992. The study population was divided into two comparable groups: one group of women whose first pregnancy terminated in induced abortion and a second group of women whose pregnancy terminated in childbirth. For the variables with statistically significant differences, both the crude and adjusted odds ratio were obtained for the one potentially confounding factor:age. Multivariate logistic regression analysis was employed in the final stage. RESULTS: The sociodemographic characteristic identified as risk factor for induced abortion during the first pregnancy is being younger than 24 years of age, a risk which increased with women who were less than 20 years old, whether single or in union. CONCLUSIONS: Recurrence risk of induced abortion during the first pregnancy is higher in younger women who have not achieved their professional, working or marrying expectations. This situation seem to be incompatible with maternity in the studied group.     

Pregnancy in HIV-infected women. Counseling and care--12 years' experiences and results

BACKGROUND: A specialized antenatal care unit was set up for counseling and care of HIV-infected pregnant women. The team consisted of gynecologists, a midwife, a social worker and pediatricians. METHODS: The women were referred from departments of infectious diseases, venereology or institutions for drug addicts, antenatal care units and abortion clinics, or applied themselves. Women identified in the pregnancy HIV screening program were informed primarily by the team. The women were counseled along with their partners and cared for during abortion or the antenatal period, delivery and post partum. Contraceptive services were offered and psychosocial support was given. RESULTS: Between April 1985 and March 1997, 95 HIV-infected women with 122 pregnancies attended. Twenty-one per cent were or had been drug users, 2% had been infected by transfused blood and 77% were classified as having been sexually infected, two thirds of whom were Africans. The mean age was 27.8 years. In 54 of 93 pregnancies (58%) in which the woman could make an informed decision, she elected abortion -- in 37 cases for HIV related reasons. Significantly more women with an uninfected steady partner, compared to women without a steady partner, chose to continue the pregnancy, as did women in a relatively stable social situation. Of the partners, 68 were HIV-negative, 36 HIV-positive and 18 not tested. No severe HIV-related complications occurred during pregnancy. Seven of 40 (18%) children with a known infection status were infected. During the course of follow-up, nine mothers, two fathers and three children have died. Seventeen children were at risk of being orphaned, and another five were placed in foster care. CONCLUSION: Although it is possible to reduce mother-to-infant transmission by zidovudine therapy, the negative consequences of HIV and childbearing are still substantial. Therefore HIV screening during pregnancy and pre-pregnancy counseling are important issues for the health care system.     

Attitude of pregnant women towards HIV testing in Abidjan, C?te d'Ivoire and Bobo-Dioulasso, Burkina Faso. DITRAME Study Group (ANRS 049 Clinical Trial). Diminution de la Transmission Mère Enfant du VIH. Agence Nationale de Recherches sur le SIDA

OBJECTIVE: To evaluate the attitude of pregnant women towards HIV testing in two cities of West Africa: Abidjan, C?te d'Ivoire and Bobo-Dioulasso, Burkina Faso. METHODS: In the context of a clinical trial to prevent HIV vertical transmission, HIV counselling and testing was offered systematically to women attending antenatal clinics. Informed consent was obtained and test results were given anonymously. Multiple logistic regression was performed to identify factors associated with refusal for testing and failure to return for test results. RESULTS: A total of 9724 pregnant women were interviewed from January 1995 to September 1996. In Abidjan (n=5766) and Bobo-Dioulasso (n=3958), 78 and 92.4% of the women consented to HIV testing, respectively, and 58.4 and 81.8% of them returned for the test results disclosure, respectively. In the two sites, the counsellors themselves and high educational level of the women appeared to be related to refusal of the test, whereas last trimester gestation was associated with failure to return for test results. In Abidjan, foreigners and employees were more likely to refuse testing, and HIV-infected women were three times less likely to return for results than uninfected women. CONCLUSION: Future implementation of interventions to reduce vertical transmission of HIV that require antenatal HIV testing and counselling will have to solve issue of acceptability of HIV testing by pregnant women.     

Vertical transmission of human immunodeficiency virus: six years of development 1987-1992)

BACKGROUND: According to World Health Organization estimates, from the beginning of the epidemics to the end of 1994, the number of children infected by human immunodeficiency virus (HIV) was 1.5 million. This paper describes the evolution of some clinical and epidemiologic characteristics of vertically transmitted HIV infection. PATIENTS AND METHODS: All children born to HIV-infected mothers who delivered at a university hospital in Barcelona, Spain, between 1987 and 1992, were included in the study. Rates of HIV vertical transmission, HIV infection incidence and mortality due to HIV were estimated, and trends for the study period analyzed. Odds ratios were used to assess associations between variables. RESULTS: 192 newborns were identified and allocated, with respect to the year of birth, in three cohorts of 71, 58 and 63 children. Overall HIV vertical transmission rate was 16.5% and did not differ between cohorts. Infection incidence density rates increased over time (0.2, 4.9 and 8.1 cases/100 child-years, respectively; p = 0.016), while incubation periods decreased significantly (248, 103 and 114 days; p = 0.0004). There were no changes in mortality density rates (2.2 deaths/100 child-years). Regarding mothers' characteristics, a significant temporal trend (p < 0.001) for being older at delivery, belonging to the heterosexual transmission group and having symptomatic infection was observed over time. CONCLUSIONS: Certain clinical and epidemiologic aspects of HIV vertical transmission have changed over time, however the number of new cases has remained fairly constant. In our setting, both early diagnosis and clinical management of these children have improved, but primary prevention for HIV vertical transmission has not been effective. Better counselling for HIV-infected women of childbearing age is needed.