IDENTIFICATION OF INFECTED WOMEN

science of HIV are summarized (Burger and Weiser). Perhaps the most important discoveries of the last few years have been the description of the manner in which the virus initially takes hold in the host, begins its replication, and is countered by the host’s immune system. It is the large number of viral particles (> billion), their short half-life, and the predisposition to error of reverse transcriptase that explain the rapidity with which HIV develops resistance to single agent therapy. Conversely, it is the magnitude of the response of the immune system, which despite the overwhelming nature of the viral insult, generally maintains the health of the infected individual for at least a decade. Another important advance of the last few years has been the description of cytokine receptors on the surface of the cells (lymphocytesand macrophages), which are integral to the “docking” of the virus. In fact, deletions in the base pairs of these receptors may have a significant effect on the likelihood that an exposed individual will become infected. These new discoveries, which will undoubtedly inform the efforts of scientists now seeking to develop the next generation of pharmaceutical interventions, are elegantly detailed in the article on the virology of HIV (Burger and Weiser).

IDENTIFICATION OF INFECTED WOMEN

None of the interventions that have now been demonstrated to enhance the care of HIV-infected women and that have reduced the rate of mother-tochild transmission of HIV can be utilized if the serostatus of the mother is unknown. Although the legal issues that swirl about testing problems have undergone, and continue to undergo, substantive, rapid change and though they vary dramatically from region to region, there are certain aspects of testing that supersede these parochial differences. As a part of standard prenatal care, all women should be informed about HIV disease as well as the remarkable interventions now available to women and children. AZl women should be encouraged to undergo testing. Beyond these requirements, any additional time that can be expanded discussing techniques to reduce the risk of acquisition, will help to serve the public health and potentially serve to blunt the continued spread of HIV into the wider sexually active population. The process of counseling and testing should be adaptable to busy office settings, allowing for communication of all essential information to women. The actual step-by-step approach that can be applied in a practitioner’s office or in a busy clinic setting is described in some detail (Rips). Given the tremendous advantage to the mother and child when there is access to the new pharmacologic interventions, there is a moral imperative to provide the opportunity to all women to learn their status. How aggressive or coercive that opportunity should be can only be rationally decided in the broader legal/ ethical context of HIV-as outlined in the article by Cooper. Current law will mandate that HIV testing rates climb substantially by the year 2000 or that pediatric H N rates decline. If these goals are not reached, states will be faced with the Hobson’s choice of either implementing mandatory testing or losing Federal funds earmarked for the care of HIV-infected individuals. Although physicians need not cite statutes or case law a s part of standard prenatal counseling, it is useful for them to be sufficiently informed of the full spectrum of consequences that may befall women who follow their providers’ advice and learn their status. This also may allow the physician to be more helpful in guiding the patient past potential adverse social consequences. Physicians must also be sufficiently knowledgeable about the consequences that will befall them

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PREFACE

should they fail to inform a patient of the availablity of testing, and if that woman gives birth to a child subsequently determined to be congenitally infected with HIV. As noted, the law of the land has been written, and it spells out penalties for states in which testing rates do not move dramatically upward and congenital infection rates do not follow the converse trajectory.

ANTEPARTUM MANAGEMENT

Since the early years of the epidemic, concerns have been raised about the possible interaction of HIV and pregnancy. Because pregnancy represents a time of dramatic hormonal and physiologic alteration and because immune status, in turn, may be altered by these effects, these concerns had a reasonable basis. Drs. Landers, Martinez de Tejada, and Coyne review the interactions between pregnancy and HIV disease. To date, the empiric data have not sustained the fears of an adverse interaction. Studies of immune status alterations during the pregnancy of HIV-infected women do not reveal a dramatic difference from changes among women who are not pregnant. Pregnancy outcomes also appear to be relatively unaffected by HIV serostatus, though women with advanced states of illness might be less insured to HIV’s effects. Although pregnancy does not seem to exert a markedly deleterious effect on the course of HIV disease, it is still important to ensure that the woman receives appropriate therapy. The keys to the optimal care of an HIV-infected woman during pregnancy are optimal care of the pregnancy, and optimal care of the HIV infection. The need to provide one of these services should not encroach on the clinician’s ability to provide fully for the other. Dr. Augenbraun’s article provides a thorough guide to the provision of HIV care in an era of rapidly evolving diagnostic modalities, therapeutic strategies, and as a direct consequence, clinical standards. Unquestionably, the last few years have been witness to dramatic advances in treatment, but these advances have carried some confusion in their wake. The rapidity with which drugs have been developed and approved has outpaced the clinical research community’s ability to complete large scale phase I11 trials that might have been able to more precisely guide choices and more fully document risks. The absence of defining information is particularly acute in the setting of pregnancy; however, in the presence of treatments that are obvious improvements over earlier interventions, there is a need to act, even in the absence of definitive information. A recent Public Health Service task force has codified this philosophy. With Dr. Augenbraun‘s article serving as a ”user’s manual,” the obstetrician’s principal responsibility is to ensure that pregnancy never be used as a reason to accept second tier standards of antiretroviral or prophylactic therapies. The paradigm of antiretroviral therapies in the late 1990s is, in sum, that ZDV monotherapy is no longer the standard of care for any patient whose clinical, immunologic, or virologic condition warrants antiretroviral therapy. The landmark studies of viral dynamics that outlined the explosive rate of viral replication from the onset of infection, and the concomitant risk of mutation to resistance, were in essence the death knell of monotherapy. Therefore, only if the woman’s immunologic and virologic circumstances are such that if she were not pregnant, she would not be given antiretroviral therapy, should the sole focus be on prevention of mother-to-child transmission. Undoubtedly, pregnant women deserve additional counseling regarding the use of these agents during gestation. Although follow-up of the children born to the mothers in the ACTG 076 study and other cohorts have been reassuring, animal data recently presented from the National Cancer Institute, PREFACE

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