Round-Up
Sexual behaviour in pregnancy and risk of perinatal transmission of HIV retrospective analysis of data from a cohort
h study of 175 HIV-positive women enrolled during pregnancy or post-partum in New York City from 1986 to 1994 found that the rate of perinatal HIV transmission was greatly affected by the extent of unprotected intercourse during pregnancy. Among women with no unprotected intercourse the rate was 9 per cent (4 out of 441, 22 per cent among those with moderate frequency (20 out of 90) and 39 per cent among those with high frequency (16 out of 411. When potential covariates were included in a logistic regression model, the rate remained significantly higher among women with any unprotected sexual intercourse during pregnancy. The overall infection rate among the infants was 23 per cent. Twenty-two per cent of the women reported consistent condom use during pregnancy. The median number of episodes of unprotected heterosexual intercourse during pregnancy was 43 among transmitters and 18 among nontransmitters. Having one or more than one partner did not make a significant difference. The authors offer a number of plausible but untested explanations for how unprotected sex and the presence of HIV in semen could influence perinatal transmission of HIV, including increase in viral load, exposure to diverse or infective viral strains, and direct contact between virus and embryo. Studies are needed on whether safer sex during pregnancy would reduce the likelihood of perinatal transmission of HIV to infants.’ 1. Matheson PB et al, 19%. Heterosexual behavior during pregnancy and perinatal transmission of HIV-l. AIDS. 10(11):1249-56.
Rupture of membranes and risk of HIV infection at birth a US study of 525 pregnant women with the rate of p&natal infection with HIV twofold when the interval to birth was longer than four hours after rupture of 134
membranes. The rate of infection with vaginal delivery as opposed to caesarean delivery was not signi6cantly different. This data has important implications for obstetric practice. First, the study does not support the increased use of caesarean sections for HIV-positive pregnant women. Second, practices that prolong the time between rupture of membranes and delivery should be avoided, such as artificial rupture of membranes or use of internal fetal monitoring devices. There has been a dramatic reduction in pregnancy-related transmission of HIV since it became routine in the US to give zidovudine (AZT) to mothers and their infants perinatally. However, changes in obstetric procedure may well also have contributed to this drop.* 1. Landesman SH et al, 1996. Obstetrical factors and the transmission of HIV-l from mother to child. NewEngkndJoumalofMedicine. 334(25):1617-23.
Cleansing the birth canal to prevent HIV transmission has been thought for some time that exposure
n?to HlV in the birth canal increases the risk of HIV infection of infants. An intervention was designed to try and reduce this risk by ‘cleansing’ the birth canal, cervix and presenting part of the infant with a solution of 0.25 per cent concentration of chlorhexidfne gluconate in sterile water. This study was carried out in Malawi among 982 women with HIV, of whom 505 had the intervention and 477 did not. The overall rate of perinatal transmission was 27 per cent. The rate of infection of infants among controls increased when the interval to birth after rupture of membranes was longer than four hours. However, the rate of infection of infants among women who had the intervention was not significantly different if the interval from rupture of membranes to delivery was longer than four hours. This means that the intervention may have reduced the risk of transmission in babies born to women whose membranes were ruptured for more than four hours. Overall,
Reproductive
however,
the reduction
of risk was marginal
if all
mothers and babies in the study are considered. The authors do not recommend this as an effective public health approach to reducing perinatal HIV transmission. They believe the intervention may have failed to do what was hoped because there may have been inadequate cleansing, the cleansing may not have reached all virus-infected parts of the birth canal during delivery, the concentrate of solution may have been ineffective as a viricide and/or because the assumption that a high rate of perinatal transmission occurs from birth canal exposure may not be true.l 1. Bigger RJet al, 1996.Perinatal intervention trial in Africa: effect of a birth canal cleansing intervention to prevent HIV transmission. Lancer. 347(15 June):1647-50.
Complications after caesarean for women with HIV
higher
study in seven teaching hospitals providing
A obstetric care for women with HIV compared 156 HIV-positive women who underwent caesarean section with 156 HIV-negative women who matched for the same indication for a caesarean, the stage of labour, integrity or rupture of membranes and use of antibiotic prophylaxis. Six of the 156 HIV-positive women suffered a major complication (two cases of pneumonia, one pleural effusion, two severe anaemia and one sepsis) compared with only one HIV-negative woman, who required blood transfusion after surgery. Minor complications including post-operative fever, endometitis, wound and urinary tract infections were significantly more frequent in the HIV-positive women, in whom the only associated factor was a CD4 count lower than 200 (severe immunodeficiency).l 1. Semprini AR et al, 1995. The incidence of complications after caesarean section in 156 HIVpositive women. AIDS. 9(8):913-17. Reported in: MIDIRS Midwifery Digest. 6(1):68.
Health
Matters,
ivo 8, R;ovember
19~~6
Fatal complications afier caesarean section in HIV-positive women OST-OPERATIVE complications are common
P among
HIV-positive
women
delivering
by
caesarean section and the risk appears to be higher
among women
who are severely immuno-
suppressed. Yet in many developing countries caesareans have become more prevalent in recent years despite the risks, including in rural African hospitals where maternal mortality after caesarean sections is estimated at three per cent. In a prospective cohort study in Rwanda, 318 HIV-positive and 309 HIV-negative women were enrolled during pregnancy, of whom 20 with HIV and 10 uninfected women delivered by caesarean section. Three of the positive women died within
72 hours due to severe complications of surgery (sepsis 2, haemorrhage 11. A fourth woman with HIV died three weeks after vaginal delivery following exploratory surgery due to fever and abdominal pain. All four women who died had severe immune deficiency. None of the uninfected women suffered post-operative complications. The authors caution that major surgery like caesarean section carries serious risks for women with HIV, especially in developing countries and when immune deficiency is high. In the European Collaborative Study, women who delivered by caesarean also appeared to progress more rapidly to AIDS post-partum than women who delivered vaginally, whether with elective or emergency caesareans. They suggest that in developing countries with a high prevalence of HIV, caesarean section should probably remain the delivery method of last resort.’ 1. BulterysM et al, 1996.Fatal complicationsafter cesariamsection in HIV-infected women (Letter). ADS. 10(8):923-24.
What causes perinatal transmission? VIDENCE
HIV
exists for transmission
of HIV
E from mother to fetus both in the first and second trimester of pregnancy. However, the proportion of in-utero as opposed to birthrelated transmissions is unclear. It is estimated that about half of transmission events probably occur close to delivery but this applies only to live births, and it may be that early transmission
Women
and HIV/AIDS
leads to loss of the fetus, altering the proportion in all pregnancies. Breastfeeding is currently thought to increase the risk by 14 per cent. How infection actually occurs in all three stages of pregnancy is still unclear. The role of viral load in the mother and her immune status are also factors that make a big difference.l
information on HIV and pregnancy was available and where it was, information on how to reduce perinatal transmission was often omitted. In most units, midwives had received no training to enable them to discuss these issues with women. And nine units were unable to supply data on the number of women tested.l
1. ScarlattiG, 1996.PaediatricHIV infection. Lancet.
I. MacDonagh SE,1996.Descriptivesurveyof antenatal HIV testing in London: policy,uptake and detection.British Medical Journal. 313(31 Aug):
348(28
Sept):863-68.
532-33.
Uptake of antenatal HIV testing in London NE in 580 pregnant women in London is 0 estimated to have HIV. The Department of Health in Britain has recommended that antenatal HIV testing should be offered to all women in areas considered of high prevalence such as London, A study of policy and practice in 33 London maternity units in 1995 asked about all women booking for antenatal care over the previous 12 months. The total number of women with HIV was estimated from unlinked anonymous seroprevalence monitoring. Confidential reports of pregnant women with HIV over the same period were examined to determine how many had been diagnosed before or during the reported pregnancy. The ratio of the number of women Ilrst diagnosed during the reported pregnancy to the total number of women with HIV minus those previously diagnosed was calculated, to assess the efficiency of the screening policy. In 13 units, all women were offered an HIV test and 20/K% positive women were identified in 9 of these units. In 14 units, only women perceived to be at high risk of infection were offered a test and in 6 units only those who requested a test were tested. In these 20 units, Z/l26 positive women were identified. Thus, only 22 of an estimated 322 previously undiagnosed women with HIV booked in these units during 1993 and 1994 were identiEed. Uptake of an HIV test was under 10 per cent in units offering a test to all women and never above 1.5 per cent in those with selective/onrequest testing. In two units where uptake of testing was over 40 per cent, detection of HIV in previously undiagnosed women was still only about 20 per cent. In many units no written 136
HIV in semen and STDs study in four men who had been HIV-positive
Af or 3-10 years, but who were asymptomatic, was carried out to test the amount of HIV in semen. None of the men were taking antiretroviral therapy. The men each presented with a purulent urethral discharge which developed after unprotected orogenital sex with another man. One of the men was diagnosed with non-gonoccocal urethritis and the other three with gonoccocal urethritis; all four were treated. Blood and semen samples were taken before treatment on the day of presentation and at subsequent weekly visits for 6 weeks. Viral loads in semen dropped substantially in all four men within a week following treatment, but there were no sign&ant changes in viral load in the blood. Only a single case report has previously suggested that chlamydial urethritis may increase shedding of HIV in semen. This study helps to explain how sexual transmission of HIV ln semen may be facilitated by concomitant STD. The results support both aggressive STD treatment and use of condoms.* 1. Atkins MC et al, 1996.Fluctuations of HIV load in semenof HIV-positive patients with newly acquired STDs.
British
Medical
Journal.
313(10
Aug):341-42.
Reproductive
UNAIDS interim infant feeding
statement
on HIV and
TUDIES
suggest that one in seven babies to and breastfed by an HIV-positive woman is at risk of infection through breastmilk. Additional data are needed to identify precisely when transmission through breastmilk is likely to occur, quantify the risk, determine the associated risk factors and better assess other interventions for reducing transmission in addition to alternative infant feeding. In light of existing evidence, UNAIDS recommends that ‘women be empowered to make fully informed decisions about infant feeding, and that they be suitably supported in carrying them out. This should include efforts to promote a hygienic environment, essentially clean water and sanitation, that will minimise health risks when a breastmllk substitute is used. When children born to women living with HIV can be ensured uninterrupted access to nutritionally adequate breastmilk substitutes that are safely prepared and fed to them, they are at less risk of illness and death if they are not breastfed. However, when these conditions are not fulfilled, in particular in an environment where infectious diseases and malnutrition are the primary causes of death during infancy, artificial feeding substantially increases children’s risk of illness and death. Manufacturers and distributors of products which fall within the scope of the International Code of Marketing of Breastmilk Substitutes (1981) should be reminded of their responsibilities under the Code and continue to take necessary action to ensure that their conduct at every level conforms to the principles and aims of the Code.’ 1
s born
1. Joint UN Programme on HIV/AIDS, July 1996.
Recommendations for the development of vaginal microbicides AGINAL
microbicides are products intended to use vaginally to prevent HIV and other STDs and a number are currently under study at the pre-clinical and clinical stages. This guide to development and evaluation of existing spermicides and new products, which may or may not be spermicidal, recommends
v for women
Health
Matters,
No 8, November
1996
that in vitro activity against HIV, target STDs and sperm needs to be assessed, along with compatibility with barrier method materials. Clinical trials for safety must exclude possible irritation of vaginal and cervical mucosa, which may increase rather than reduce the risk of HIV transmission. It suggests that women (or partners) presenting with clinically apparent genital infections or lesions should be treated prior to inclusion. Whether to test for STDs in women (or their partners) who are asymptomatic is not discussed, yet STDs should be excluded as confounders in data analysis. Condom use should be encouraged and coital log charts and subject interviews are recommended for recording condom and microbicide use, as well as incidence of anal intercourse and intravenous drug use. Excluding participants with HIV in Phase III trials may not be possible, mainly for confidentiality reasons. Women who develop adverse reactions or discontinue the method should be encouraged to continue follow-up to assess genital irritation, detect potential toxicity and assess STD/HIV outcomes. This document is of interest to anyone planning a clinical trial and anyone participating in a clinical trial of one of these methods.’ 1. International Working Group on Vaginal Microbicides. Recommendations for the development of vaginal microbicides. AIDS. 10(8):UNAIDSl-UNAIDS6.
Why should women infertility treatment?
with HIV not get
N HIV-positive woman’s efforts to try for a through in vitro fertilisation (IVF) became a major media event in Britain in May this year. The woman has been HIV-positive and healthy for 10 years. Five years ago she tried to get IVF and was refused on the grounds that she was positive. She was then referred to a clinic in London where the consultant at first also refused but then changed his mind after talking to her and her husband. The chair of the hospital ethics committee approved treatment being given but many of the clinic staff were opposed, on the grounds that they could not help to bring a child into the world who might die or whose mother might die. The consultant decided to proceed
A pregnancy
Women
and HIV/AIDS
anyway, but after one treatment the woman did not fall pregnant. Whether she has tried again is not known. There were calls for tighter controls on infertility clinics from some sides, while the British Medical Association said that doctors should be trusted to use their own judgement.’ 1. Kennedy D, 1996. Test-tube baby doctor helps HN women. Times. 14 May.
Mild cervical with HIV
abnormalities
in women
HE inclusion of invasive cervical cancer to the
T list of AIDS-defining conditions was important for women with HIV, 80 per cent of whom will die of cervical cancer once they have it. Women with HIV are at high risk of human papilloma virus and of precursors to invasive cervical cancer, so the number of women with abnormal Pap smears can be expected to rise as the numbers of women with HIV infection rise. The issue of how to detect and when and whether to treat precancerous cervical conditions is controversial. In some countries repeated Pap smears or even colposcopy every 4-6 months are recommended. Response of early conditions to treatment is poor and many lesions will remain low grade in spite of lack of therapy. The question of how to avoid overwhelming clinics with repeated testing and women having to return repeatedly to be tested is not yet well answered.’ 1. Johnston C, 1996.Mild cytological atypia in women with HIV infection (Commentary). Lancet. 348(28 Sept):837-38.
Changes in men’s sexual behaviour in Tanzania
risk
clink set up in a large factory in Mwanza
fif ollowed a cohort of 752 men over at least two years each between 1992 and 1994 to study sexual behaviour changes in response to the offer of STD treatment, condoms and counselling at each visit (a mean of six months apart), and health education information and activities in the factory about AIDS. There was a clear reduction in the number of sexual partners reported over
the two year period, among men reporting two or three or more partners initially. Condom use with spouses remained very low throughout; less than one per cent reported having used a condom in the previous month. Ten per cent reported condom use with regular, noncohabiting partners and 27 per cent with casual partners at the fifth visit. A number of qualitative techniques, including in-depth interviews with the men and their regular partners were used to check their reports. There was a moderate decline in the incidence of reported and diagnosed STD, notably genital ulcers, and a larger though insignificant decline in HIV incidence. Unmarried men and men under age 30 were underrepresented in the factory population and were more likely to drop out of the study. Hence, the results cannot be generalised to the adult male population but are more typical of married men older than 25-30. Specific interventions, eg. peer education, were unlikely to have led to reported changes; rather, only the visits to the study clinic and any STD treatment may have made a difference. Only two variables studied were associated with behaviour change from low to high risk behaviour -younger age and alcohol use.’ 1.
Ng’weshemi JZL et al, 1996. Changes in male sexual
behaviour in response to the ADS epidemic: evidencefrom a cohort study in urban Tanzania. AIDS.
10(12):1415-20.