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.     

Spavin in horses--clinical, radiological and scintigraphic findings

In order to identify which factors predict a parturient womans intention to take up voluntary HIV testing in the antenatal clinic, 318 women were surveyed by anonymous self-completion questionnaire. The strongest predictors of intention to be tested were the perceived benefit of the test to the woman herself, her partner, and the midwife, perceived risk of HIV infection, younger age and being single and having a poor knowledge of the sexual routes of HIV transmission. Health education strategies should therefore concentrate on: (a) increasing the parturient woman's knowledge of HIV transmission which will increase accuracy of perception of risk; and (b) stressing the potential benefits of HIV testing to all antenatal attenders, particularly to those who are older and in long term relationships.     

Informed consent: how much information is enough?

BACKGROUND: Recent judicial decisions involving informed consent have led to some medical practitioners altering the way they obtain consent. The aim of this study was to determine the degree to which patients understood the risks associated with a surgical procedure after giving routine consent and whether providing additional detailed verbal and/or written information improved their understanding. It was further determined whether the provision of more extensive information altered patients' anxiety levels. METHODS: Patients undergoing femoral popliteal bypass or carotid surgery were randomized to obtain either routine consent only or routine consent with verbal or written or verbal and written consent. Patients undertook a pre-operative risk and complication questionnaire, a pre- and postoperative anxiety and depression evaluation and a follow-up questionnaire 6 weeks after discharge. RESULTS: Thirty-two patients were included in the trial. The comprehension questionnaire resulted in a correct percentage response of 48% for the routine information only, 59% with added verbal information, 59% with added written information and 55% with added written and verbal information. Twenty-five per cent of patients stated that they had a poor understanding of the risks and complications of the procedure. CONCLUSIONS: Additional written or verbal information did not improve a patient's understanding of risks and complications of the procedure. It also did not improve patients' perceived understanding of the operation or its complications. Patients' anxiety levels were unaltered by the increase in the information they were given. The information provided to patients should be simple, easy to understand and list any possible major complications to enable the patient to determine whether to undergo or decline a procedure.     

Prevention of vertical HIV transmission with zidovudine: projected impact of HIV testing and prenatal care

We sought to estimate the impact of maternal HIV testing and prenatal care on the potential to reduce vertical transmission through zidovudine (AZT) use by HIV-infected mothers. We evaluated the prepartum maternal HIV diagnosis rate, prenatal care, disease stage, and vertical transmission rate (from a two-part mixture model) using New York State Medicaid and vital statistics data for HIV-infected mothers and their singletons in 1985-90. We used published data to estimate the effect of AZT on vertical transmission and expert input to define other parameters for the model. Our HIV-infected (N = 1514) had a vertical transmission rate of 27.0%. HIV was diagnosed prepartum for 39.5% of women in 1990. Transmission would have been 22.2% if AZT had been taken only by the subset of women diagnosed prepartum with HIV and receiving prenatal care by 34 weeks gestation (86.7%). Transmission would have dropped to 11.2% if all women had been diagnosed prepartum with HIV and received adequate prenatal care. The observed deficiencies in prenatal care and maternal HIV diagnosis rates in this Medicaid population-based cohort must be addressed to realize the promise of AZT to reduce vertical transmission.     

Addressing the needs of homeless women with mental health problems

Vertical transmission of the Human Immunodeficiency Virus is the major cause of pediatric AIDS cases. It is known that zidovudine therapy will substantially reduce the incidence of perinatal vertical transmission. Some authorities have made recommendations for universal HIV screening based on these findings. However, in an area of low prevalence of HIV, such as South Dakota, the benefits of such testing are questionable. We undertook a survey of one thousand consecutive deliveries in which a sample of cord blood was tested for HIV in an anonymous fashion. In all cases, the ELISA test was negative. Based on this extremely low incidence of HIV in our population, it is reasonable at the present time to undertake a selective screening protocol for testing for HIV during the antepartum period, based on the presence of risk factors, rather than applying universal screening to our population.     

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.     

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.     

Should infection control practitioners do follow-up of staff exposures to patient blood and body fluids?

BACKGROUND: The purpose of this study was to determine the efficiency of a joint infection control/occupational health program for the follow-up of accidental blood or bloody body fluid exposures in health care workers. METHODS: A comprehensive staff follow-up program for all blood exposures with known patient sources was initiated in 1989, consisting of patient follow-up by the Infection Control Department (risk assessment for hepatitis B virus [HBV] and [HIV] infection and obtaining of consent for HIV testing) and staff follow-up by the Occupational Health Department. In 1992 a mailed survey was conducted to examine exposure follow-up policies and responsibilities in large teaching hospitals across Canada. RESULTS: A total of 924 blood exposures with known patient sources were reported between January 1989 and December 1993. HIV and HBV screening was obtained for 67.9% and 87.6% of patients assessed as at low risk and 82.3% and 92.2% of those assessed as at high risk for infection, respectively. Two previously unknown HIV-seropositive patients were identified, one of whom had been classified as at low risk (one of 530 [0.19%] patients at low risk who underwent screening). Primary reasons for screening being missed were patient discharge (46.3%) or communication problems (18.0%). The requirement for informed written consent before HIV screening accounted for the difference in completed HIV and HBV screens. Results of the hospital survey indicated that 40.8% of Canadian hospitals follow up all patients who are involved in blood exposures; however, most hospitals still rely on the physician to obtain consent (87.6%). CONCLUSIONS: Use of ICPs to screen patients involved in staff blood exposures during regular hours may be the most efficient method of follow-up, particularly if supplemented by a backup team of health professionals on nights and weekends. Although screening all patients for HBV/HIV may detect patients with undisclosed high-risk behaviors, institutions must decide whether the practice is cost-effective in areas of low prevalence.     

Adherence-related behavior in adolescents with asthma: results from focus group interviews

OBJECTIVE: To describe the factors that contribute to vertical transmission of human immunodeficiency virus (HIV) and review means of decreasing the risk of transmission. STUDY DESIGN: Medline search of the international English-language literature pertaining to HIV in pregnancy from 1989 to the present. Special emphasis was placed on articles published in the last three years related to vertical transmission as well as to antepartum, intrapartum and postpartum management to reduce transmission. RESULTS: High levels of maternal viral load and more advanced maternal disease are associated with a greater risk of vertical transmission of HIV. Antepartum and intrapartum maternal treatment with zidovudine and postpartum neonatal zidovudine treatment decreases the risk of transmission by two-thirds, at least in patients with earlier stages of the disease. Breast-feeding is a source of postpartum HIV transmission and may double the total transmission rate. CONCLUSION: Zidovudine should be used in pregnancy to decrease the viral load and reduce transmission of HIV to the fetus. Other antiviral agents should be used during pregnancy if indicated, although current information is lacking about their effects on the fetus and any potential benefits in decreasing vertical transmission of HIV. Breast-feeding should be avoided.     

Incidence of human immunodeficiency virus antibody in a prenatal population at a community hospital

Prenatal human immunodeficiency virus (HIV) screening may reduce vertical HIV transmission. We screened 4,419 prenatal sera and found 38 repeatedly reactive specimens with an HIV-1-HIV-2 enzyme-linked immunosorbent assay. Western blot analysis confirmed four of these specimens as positive for HIV-1 antibodies. Screening detects previously unidentified HIV infections, but false-positive results may also occur.     

Human immunodeficiency virus testing and counseling: nuts and bolts

The human immunodeficiency virus poses an increasing health hazard to women. Physicians must recognize this risk and evaluate their patients for human immunodeficiency virus. Because of general increased awareness and the recommendations that all prenatal patients be offered human immunodeficiency virus testing and counseling, more and more women will be tested, yet counseling has not become a routine aspect in the evaluation of patients. This article reviews the key components of human immunodeficiency virus testing and counseling, including test interpretation, risk assessment, risk reduction, and pretest and posttest counseling. Familiarity with these areas should enable the practitioner to feel comfortable in providing this service.     

Acceptability of voluntary HIV testing by pregnant women in developing countries: an international survey. Ghent International Working Group on Mother-to-Child Transmission of HIV

OBJECTIVE: To evaluate acceptability of voluntary HIV counselling and testing (VCT) by pregnant women in the context of clinical trials assessing interventions to reduce mother-to-child transmission (MCT) of HIV in developing countries. METHODS: During September-October 1997, 13 studies located in West (Abidjan, Bobo Dioulasso), East (Nairobi, Mombasa, Dar Es Salaam, Blantyre, Lusaka, Harare) and South Africa (Soweto, Durban), and Thailand (Bangkok) were included in a cross-sectional mailing survey about the acceptability of VCT in antenatal clinics. Acceptance rate, return rate, overall acceptability of VCT (acceptance of both pre- and post-VCT sessions) were obtained using a standardized questionnaire. RESULTS: The median overall acceptability of VCT was 69% (range, 33-95%). Overall acceptability of VCT most frequently depended on return rates because acceptance rates were generally high. Where several studies were conducted in parallel in the same city or the same country, overall acceptability rates of HIV testing were generally comparable even if the intervention programmes differed. Overall acceptability rates of VCT were high in antenatal clinics where a particular effort in implementing VCT programmes had been made. CONCLUSIONS: This international survey shows that despite many obstacles, VCT is feasible and acceptable for pregnant women aiming to reduce their risk of transmitting HIV to their children.     

Autopsy case report of a rare acute iatrogenic water intoxication with a review of the literature

This study provides survey data gathered from hospital-based paediatricians in New York City regarding several key issues in the diagnosis and treatment of paediatric AIDS. These include: perceived risk of acquiring HIV through professional exposure; referral patterns in the treatment of HIV-infected children; attitudes regarding the universal testing of pregnant women and newborns; willingness to raise prevention issues during health-maintenance visits, and interest in further AIDS education. Overall levels of perceived risk are quite high although unrelated to referral procedures. The modal procedure for both asymptomatic and symptomatic children is to treat in conjunction with a specialist, followed by referral to a specialist. The majority of respondents believe that all pregnant women seen in metropolitan clinics/hospitals should be routinely screened for HIV, but that newborn testing should be reserved for high risk babies. However, the vast majority believe that high risk newborns should be screened regardless of maternal consent. Physicians report strong support for the anticipatory guidance of adolescents, and an extremely high level of interest in continuing HIV/AIDS education for paediatricians.     

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.     

Detection of hepatitis B surface antigen in pregnant women attending a public hospital for delivery: implication for vaccination strategy in Bangladesh

Routine antenatal hepatitis B surface antigen (HBsAg) screening and immunization of risk babies is very effective in preventing perinatal transmission of hepatitis B virus (HBV). We studied 1,800 parturients attending a public hospital to assess the rationale for such vaccination in Bangladesh. In one in every 29 deliveries (63 of 1,800 or 3.5%), the mother was found to be HBsAg positive. All were asymptomatic and many (41 of 63 or 65%) without risk factors would remain undetected if HBsAg screening were performed on selected groups. Most of the HBsAg-positive mothers (54 of 63 or 85.7%) were found to be chronic carriers and 30.2% (19 of 63) were also hepatitis B e antigen (HBeAg) positive, indicating high infectivity. Although 23 cord blood were positive for HBsAg or HBeAg, none were positive for IgM antibody to hepatitis B core antigen (IgM anti-HBc), suggesting transplacental transmission of the antigens rather than intrauterine infection. These findings are discussed in relation to the cost-effectiveness of routine prenatal screening and immunization of risk babies compared with universal infant immunization.     

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.     

CD44 plays a role in adhesive interactions between glioma cells and extracellular matrix components

To evaluate how individuals infected with the human immunodeficiency virus (HIV) became aware of their infection, when they first suspected they were infected with HIV and factors associated with suspecting HIV infection, we surveyed 227 patients at an urban outpatient HIV clinic. Though nearly all patients acknowledged risk factors for HIV, 60% reported that they did not suspect that they were infected until they received a positive HIV antibody test result. Non-white patients were less likely to suspect HIV infection prior to testing than white subjects (p < 0.03). Subjects not suspecting infection more often received HIV testing through a screening program or during a medical encounter (p = 0.02) and were less likely to be told by others that they might be infected (p = 0.001) than patients suspecting infection prior to testing. Forty-eight percent of subjects who suspected HIV infection prior to testing waited one year or more before obtaining their HIV antibody test. Interventions to reduce faulty personal HIV risk perception are needed to promote earlier HIV diagnosis.     

Counselling for an HIV test

Doctors may feel uncomfortable with the prospect of discussing a human immunodeficiency virus (HIV) antibody test with their patient. This is in part because they do not enquire about high risk activity as part of a medical history. With increasing medical and public awareness of both the clinical manifestations and social implications of HIV infection, it is important that all doctors receive guidance on how to deal with these issues. Counselling is not the usual term used to describe obtaining informed consent. In the general medical setting, tests for hepatitis B and syphilis are routinely carried out without specific consent even though results of these tests may have profound effects on both the patient and their sexual partners. However society and ethical considerations have made HIV testing different. HIV testing will inevitably become more widespread, and thus become a more routine part of patient investigation and management.     

Pictorial review: the radiological spectrum of vertically-acquired HIV infection

Anonymous antenatal and newborn screening demonstrates a positive HIV seroprevalence of one in 400 in areas of inner city London. European Collaborative Study data show a vertical transmission rate of 15% and suggests that 23% of infected children will develop clinical manifestations of AIDS before reaching 1 year of age [1], meaning that recognition of the radiological findings in vertically-acquired HIV is important. 75 serial cases of vertically-acquired HIV (age range 6 weeks to 12 years, mean age 35 months) presenting to a national referral centre over 48 months were reviewed; the radiographic findings we describe constitute a core of typical abnormalities together with a selection of the rarer manifestations of vertically-acquired HIV.     

Trillion virion delay: time from testing positive for HIV to presentation for primary care

BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals' initial presentation to medical care frequently occurs at a point of advanced immunosuppression. OBJECTIVES: To investigate the time between HIV testing and presentation to primary care. Also to examine factors associated with delayed presentation. METHODS: One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Sociodemographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV. RESULTS: Of 189 patients, 74 (39%) delayed seeking primary care for more than 1 year, 61 (32%) delayed for more than 2 years, and 35 (18%) for more than 5 years after an initial positive HIV serologic evaluation. The median CD4+ cell count of subjects was 0.28 x 10(9)/L (range, 0.001-1.71 x 10(9)/L). In multiple linear regression analysis the following characteristics were found to be associated with delayed presentation to primary care after HIV testing: history of injection drug use (P<.001); not having a living mother (P=.01); not having a spouse or partner (P=.08); not being aware of HIV risk before testing (P<.001); and being notified of HIV status by mail or telephone (P=.002). An interaction effect between sex and screening for alcohol abuse was significant (P=.03) and suggested longer delays for men with positive screening test results (CAGE [an alcoholism screening questionnaire containing 4 structured questions], 2+) compared with men without positive screening test results or women. CONCLUSIONS: Patients with positive HIV test results often delay for more than a year before establishing primary medical care. Information readily available at the time of HIV testing concerning substance abuse, social support, and awareness of personal HIV risk status is useful in identifying patients who are at high risk of not linking with primary care. Patients who were notified of their HIV status by mail or telephone delayed considerably longer than those notified in person. Efforts to ensure primary care linkage at the time of notification of positive HIV serostatus are necessary to maximize benefits for both individual and public health and should be an explicit task of posttest counseling.