The challenge of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in women and children

FERTILITY AND STERILITY Copyright " 1988 The American Fertility Society

Vol. 49, No. 4, April1988 Printed in U.S.A.

The challenge of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in women and children

Thomas A. Peterman, M.D., M.Sc. Willard Cates Jr., M.D., M.P.H. James W. Curran, M.D., M.P.H. Centers for Disease Control, Atlanta, Georgia

I enjoy sex, but I am not willing to die for it.

-Ansell Corporation condom advertisement, Vogue magazine, November 1986

Even if all human immunodeficiency virus (HIV) transmission stopped now, the number of acquired immunodeficiency syndrome (AIDS) cases would continue to increase for years due to development of disease in persons already infected. In the absence of a cure, those already infected with HIV remain at risk of AIDS, probably for their entire lives. Projections based on currently reported cases suggest that, in 1991 alone, 74,000 people will develop AIDS (Fig. 1), including 7200 women and 1000 children. 1 These cases will still represent only a fraction of the people involved in the epidemic. For every person with AIDS, several more have AIDS-related conditions, and an even larger number are asymptomatic carriers. By 1987, the total number of infected persons in the United States was estimated to be between 945,000 and 1.4 million.2 Because no treatment or vaccine is available, options are limited. Everyone must learn about the modes of transmission of HIV. Physicians, in particular, must learn about this disease so that they can care for their increasing number of HIV-infected patients and educate their patients on ways to avoid infection. Physicians concerned with reproductive health care have a special interest in reducing HIV infection in women, as well as decreasing perinatal transmission to their patients' children. Vol. 49, No.4, April1988

RISKS FOR WOMEN

Transmission to adults occurs during sexual contact or via blood (primarily during needle sharing by intravenous [IV] drug users). Women with AIDS in the United States fall into the following categories: IV drug abusers, heterosexual partners of men infected with HIV, transfusion recipients, women who received clotting factor concentrates for coagulation disorders, and women for whom the risk has not been identified (Table 1). Of this group, the majority are related to IV drug abuse by the women or their sex partner. 3 Many of the women whose transmission category has not been identified may have had a heterosexual partner that they did not realize was infected. Because most women with AIDS acquired infection by needle-sharing, the majority have been reported from areas where HIV infection in drug abusers is highest, and the distribution of women with AIDS is different from the distribution of all persons with AIDS (Figs. 2 and 3). For instance, California has 22% of all AIDS cases, but only 5.8% of the women reported with AIDS. Considerable variation also exists in the transmission categories among women with AIDS in different areas of the country. In areas with a low incidence of AIDS in drug abusers, for example, infected transfusion recipients may be the first women reported with AIDS. Although the routes of transmission of HIV infection have been known for 7 years, a great deal more needs to be learned about the magnitude of the risks. The risk of acquiring HIV infection during sexual contact depends on the likelihood of Peterman et al. HIV and AIDS in women and children

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30000

25000

20000

D

Projected cases

~

Cases reported through April 1986

.·

.-... Cases reported May 1986 - August 1987

.,

(/)

815000

68% Confidence

..··

Bounds~--······/

......·····

10000

Figure 1 Cases of AIDS in the United States, by quarter of diagnosis. Projected from cases reported as of April 30, 1986, and shown with cases reported as of August 31, 1987.

contact with an infected partner and the likelihood of transmission if the partner is infected. In the United States, a heterosexual partner is most likely to be infected if he is a bisexual man or an IV drug abuser. One recent study of nondrug-using heterosexuals attending a sexually transmitted diseases clinic in New York City disclosed that none of 53 women and only 1 of 103 men were seropositive for HIV. 4 The seropositive man failed to return for a follow-up interview about risk factors. The more partners a person has, the greater the chance that one of them will be infected. The odds that a random heterosexual partner will be infected with HIV are greater for women than for men because there are many more infected men, even after excluding those who are exclusively homosexual. There are major racial differences in risk, primarily because of the transmission from infected black

Table 1

Risk Characteristics for AIDS for Women, Men, and Children: 36,058 Patients Reported as of June 1, 1987

Women (6.8% of total)

IV drug abusers Heterosexual contact• Blood transfusion Heterosexual countrY' Coagulation disorder Undetermined< Total

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Children (1.4% of the total)

Men (91.8% of total)

no.

%

1225 579 258 134 8 249 2453

50 24 11 5 0 10 100

Gay /bisexual IV drug abusers Gay and IV drug abuse Heterosexual countryb Blood transfusion Hemophilia Heterosexual contact• U ndeterminedc Total

• Heterosexual contact means heterosexual contact with a person known to have AIDS or a person from one of the listed risk groups for AIDS. b Heterosexual country means the route of transmission is suspected to be heterosexual contact because the person comes from a country where heterosexual contact is the most common

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and Hispanic IV drug abusers. The likelihood that a heterosexual person will be infected also has a large geographic variation, which correlates with the distribution of AIDS cases in women. For example, the cumulative incidence of AIDS in all heterosexuals in New York City is 419 per million population, while in Minneapolis it is only 5 per million. These differences are relative, not absolute. Even in Minnesota, two women in an adult "swingers" sex club were found to be infected. 5 Although the women knew that bisexual men were members of their club, they perceived AIDS as a problem for other communities, not theirs. Sexual transmission of HIV appears to be less efficient than transmission of other sexually transmitted diseases, such as syphilis and gonorrhea. 6 The risk of transmission from an infected partner has been evaluated by looking at steady sexual partners of persons infected with HIV (Table 2). The risk of male-to-female transmission has been 7% to 21% in studies of wives of seropositive hemophiliacs, transfusion recipients, and bisexual men, in most cases after several months to years of sexual contact. 7 - 12 Seropositivity rates of over 50% have been reported for female partners of IV drug abusers, military personnel, and persons with a variety of AIDS risk factors. 13- 15 These higher rates may not reflect the risk of transmission from a single infected partner, because the women in these studies may have had other undetermined risks (for example, drug abuse) or multiple infected sexual partners. The risk of female-to-male transmission is less well defined because it is more difficult to find

HIV and AIDS in women and children

no.

%

23,365 4694 2702 527 458 320 137 898 33,101

71 14 8 2 1 1 0 3 100

Mother with/at risk for AIDS Blood transfusion Hemophilia Undetermined< Total

no.

%

397 61 25 21 504

79 12 5 4 100

mode of transmission. c Many of the patients with undetermined risk have not been interviewed for risk factors, some may have had heterosexual partners that they did not know were infected with HIV, and some were probably background cases of the opportunistic diseases, not related to AIDS.

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Table 2 Risk of Infection in Steady Sexual Partners of Persons in Different Risk Groups7- 15 No. infected/total

Risk of index case

Male-tofemale

Female-tomale %

Figure 2 Female AIDS cases reported to the CDC, by state, September 7, 1987.

groups of infected women whose sexual partners are not in a risk group. Only 2 (8%) of 25 husbands of infected transfusion recipients tested positive for HIV after an average of 32 months of sexual contact. 12 Other studies have found 50% or more of the male partners of women with AIDS or AIDSrelated complex (ARC) were seropositive, but some of these men may have transmitted the infection to the women. 13•15 The risk of HIV transmission during a single sexual contact is almost impossible to determine. As with other infectious diseases, multiple exposures to an infected partner are not necessary for transmission, though multiple exposures increase the likelihood that transmission will occur. Some partners of infected transfusion recipients acquired infection after only a few sexual contacts, while others had hundreds of sexual contacts with their infected spouse without acquiring infection. 12

Figure 3 All AIDS cases reported to the CDC, by state, September 7, 1987.

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Hemophiliacs Hemophiliacs Hemophiliacs Hemophiliacs Hemophiliacs Bisexual men Military personnel Transfusion recipients IV drug users Mixed risks

2/21 2/21 2/21 4/19 10/148 12/62 517 10/55 41188 14/28

10 10 10 21 7 19 71 18 47 50

%

2/25 7/12 12/17

8 58 71

When 19 sexual partners of an infected African man living in Belgium were traced, 11 (58%) were seropositive, suggesting that he was a particularly efficient transmitter. 16 This suggests some persons may be more efficient transmitters than others (as is true for hepatitis B carriers). If so, transmission would be more likely during contact with multiple infected partners than during the same number of contacts with a single infected partner. Infected hemophiliacs appeared to be more likely to transmit infection when their T4 lymphocyte counts were low, suggesting that a person's ability to transmit infection may change over time. 17 Since many different strains of this virus exist, it is possible that strain variation could influence transmissibility, but no current evidence supports this theory. Additional factors that may influence transmission have been proposed. Genital ulcers have been associated with HIV infection in many studies. Infected prostitutes in Africa were more likely to have a history of other sexually transmitted diseases, suggesting that genital ulcers caused by other infections may predispose a person to HIV infection by disrupting the genital epithelium. 18 In Nairobi, genital ulcer disease was associated with over a 4-fold increased risk of HIV seropositivity compared with those with urethritis alone. 19 Similarly, in Zimbabwe, spouses of men with a history of genital ulcer disease had an almost 3-fold greater risk of HIV seropositivity than those whose spouses had no history of genital ulcers. 20 Seroepidemiologic correlations have been found between syphilis and HIV in Haitians in New York and Miami, in prostitutes in five cities in the United States, and in homosexual men in London and San

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Francisco. 21 Finally, serologic correlations between type 2 herpes simplex virus, another cause of genital ulcers, and HIV have been found in Seattle. 22 Further studies are needed to determine whether these associations are causal. If they are causal, the attributable risk should be determined to demonstrate the amount of HIV infection that could be prevented by preventing infections that cause genital ulcers. Of the different types of sexual activities, anal receptive intercourse has been most closely associated with AIDS and HIV infection in many studies of homosexual men. 23-25 Women who had anal intercourse with an infected partner were 2.3 times more likely to be infected than women who reported only vaginal intercourse (P = 0.05).U _Although anal intercourse may be a more efficient means of transmission than vaginal intercourse, it is not the only route of sexual transmission, since most infected women have not practiced anal intercourse. The risk of HIV transmission during oral-genital contact is almost certainly less than the risk of transmission during anal receptive intercourse, but the exact risk is difficult to determine. Studies that have addressed this have had limited power to detect a low rate of transmission and were unable to establish that the men had had oral sex with an infected partner. In Vancouver, 5 men reported having oral-genital contact but no anal intercourse for an average follow-up period of approximately 2 years; all 5 remained uninfected. 26 Another study followed 147 men in Baltimore, Chicago, Los Angeles, and Pittsburgh who had had oral-genital contact but no anal intercourse during a 6- month follow-up period; all remained uninfected. 24 Artificial insemination can transmit HIV; however, the magnitude of the risk is unclear. Four women in Australia acquired HIV infection from an infected asymptomatic semen donor. 27 The donor had provided semen for only eight recipients, so the transmission rate was 50% in this case. However, this rate of transmission is much higher than that suggested by other studies in the United States. In San Francisco, no seroconversion occurred in a group of 23 lesbian women who were artificially inseminated between 1980 and 1985 with semen from homosexual/bisexual men of unknown infection status. 28 In New York City, 1 of98 women was seropositive after receiving multiple donations of semen from five men who later tested seropositive for HIV. 29

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RISKS FOR CHILDREN

Children with AIDS have acquired infection from their mothers during the perinatal period or during a transfusion of blood products or factor concentrates (Table 1). Since the vast majority of the infected children acquired HIV from their mothers, the geographic distribution is similar to the distribution of infected women. Nearly two of every three children with AIDS are from New York, New Jersey, or Florida, but an increasing proportion are being identified in other areas. . The risk of perinatal transmission from an mfected mother to her infant has been estimated to be 65% in one series of pregnancies of women who had previously delivered children with AIDS. 30 However, women who have transmitted once may be more likely to transmit again. Many other cohort studies are in progress to define the risk of transmission. 31 ·32 Early results from these studies are difficult to interpret because maternal antibody can cause a persistently positive test in an uninfected newborn, and some children who lose antibody are actually infected with HIV and go on to . develop AIDS-like illnesses. Most perinatal transmission probably occurs m utero. Cases of fetal infection have been reported. 33 On average, children whose mothers are infected have developed AIDS at a slightly younger age than children who received blood transfusions at birth, consistent with transmission in utero. Currently, no evidence suggests that the rate of transmission is influenced by the type of delivery. In one series of 34 infected infants, 11 (32%) had been delivered by cesarean section, including 1 with intact membranes.34 Transmission of HIV by breast-feeding was suggested by the report of an infant who became infected after his mother received a postpartum transfusion from a donor who later tested positive for HIV antibody. 35 As a result of this report and reports of the isolation of HIV from breast milk, 36 infected women in the United States have been advised not to breast-feed their infants. RISKS FOR FAMILY CONTACTS

Many studies have evaluated the risk of transmission within families. 8·9·12·37 The types of contact that these family members have had with each other included hugging, kissing, sharing the same eating utensils before washing, and many other ac-

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tivities involving close contact. Despite this, none of the hundreds of people in these studies have acquired HIV infection. This provides strong evidence that casual contact (any contact that does not involve sexual intimacy or blood exposure) carries virtually no risk of HIV transmission. RISKS FOR HEALTH-CARE WORKERS

Eleven health-care workers have been reported who developed HIV antibody while caring for HIV -infected patients. 38 Six had "needle punctures" from patients with AIDS, and five had cutaneous or mucous membrane exposure to infected blood. The risk of infection after a needle stick from an infected person is less than 1%.38 This risk is much lower than the risk of hepatitis B infection after a needle puncture from a hepatitis B carrier (27%). 39 The possibility of HIV infection after getting blood on the skin is more difficult to estimate, but is probably much lower than the risk after being stuck with a contaminated needle. PROGNOSIS FOR INFECTED PERSONS

The prognosis for progression to AIDS by persons infected with HIV has been assessed in several cohort studies. Although none focused specifically on women, their prognosis is probably similar to that for men. The incubation period for AIDS can be anywhere from a few months to several years or more; because this disease is so new, it is too early to determine the long-term prognosis for developing disease. The likelihood of developing AIDS has varied from 15% at the end of 5 years 40 to 34% at 3 years after infectionY Several variables are associated with poor prognosis. Differences in these variables may be responsible for the various rates in the populations studied. First, the duration of HIV infection is important; for adults, the risk of AIDS in the first 2 years after infection is very low, much lower than the risk in subsequent years. 40 Second, patients with symptoms or signs of HIV infection have a worse prognosis for developing AIDS than do those without such signs. Lymphadenopathy patients with constitutional symptoms have a poorer prognosis: 50% (9 of 18) with constitutional symptoms and a low T-helper cell count developed AIDS over 5 years, compared with 9% (5 of 57) of those without constitutional symptoms. 42 Patients with oral or vaginal candidiasis, oral hairy leukoplakia, or

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herpes zoster were also more likely to develop AIDS during short-term follow-up than patients with asymptomatic HIV infectionY- 46 Many laboratory tests have been studied to try to identify prognostic indicators. So far, the absolute T4 count has been the best laboratory test for predicting prognosis. 47-50 One study followed 323 seropositive men for up to 4 years; 34% of participants with T4 counts less than 400 developed AIDS, compared with 14% of those with more than 400 T4 cells. 50 Although many markers of disease progression have been identified, no one has determined why some infected persons develop AIDS while others remain asymptomatic. Theoretically, other types of immunosuppression, such as that caused by corticosteroids, may act as co-factors for progression to AIDS. Infected transfusion recipients with immune disorders were more likely to develop AIDS than other infected transfusion recipients. 51 The immunosuppression of pregnancy may accelerate progression to AIDS. In one case series, 15 HIV -infected pregnant women were followed; 5 developed AIDS and 7 developed AIDS-related conditions within an average of 30 months of delivery.30 In another study, 34 mothers of infected infants in Brooklyn were followed for an average of 28 months. Although none had AIDS or ARC at delivery, 5 developed AIDS and 10 developed ARC after an average follow-up of 28 months. 52 Others have reported that pregnancy had no apparent effect on the clinical course of the mothers. 53 Estrogen and progesterone have complex effects on target cells in the immune system. 54 The effect, if any, of oral contraceptives on the risk of progression to AIDS has not been established. Any consideration of the theoretical risk of oral contraceptives should be balanced by the consideration of the real risks associated with pregnancy. Other infections may act as co-factors in progression to disease. These infections could act by suppressing the immune system or by stimulating production of the virus. In vitro studies have demonstrated that coinfection with herpes viruses may stimulate the production of HIV. 55 A protein, NFkappa B, has been identified that is unique to activated T cells and greatly enhances in vitro expression of HIV. 56 African and United States AIDS patients have a high prevalence of antibodies to multiple infectious agents, suggesting that their immune systems may be in a chronically activated state, which could facilitate the progression to

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AIDS. 57 However, no in vivo studies to date have convincingly demonstrated that co-infections increase the risk of developing AIDS. TREATMENT

Several drugs are being used to treat patients with AIDS. One of them, Zidovudine (BurroughsWellcome Co., Research Triangle Park, NC) (also known as azidothymidine [AZT]), is licensed and available. It has reduced the mortality rate for certain AIDS patients in a double-blind study, but significant bone marrow suppression was reported, and the treated patients continued to get opportunistic infections. 58•59 Another agent, Ribavirin (ICN Pharmaceuticals, Inc., Costa Mesa, CA), was reported to have some beneficial effect in one study, but not in another. 60•61 Other antiviral agents are under study for treating AIDS patients, including desciclovir, acyclovir, dideoxycytidine, ampligen, and various combinations of these. In addition, immunomodulaters, such as interferon, interleukin 2, and tumor necrosis factor, are being studied as possible adjuncts to therapy. Controlled trials are also underway to evaluate agents for efficacy in preventing progression from asymptomatic HIV infection to ARC and AIDS. Unfortunately, no drug to date has been able to eliminate the virus once infection has occurred. Therefore, treatment with these agents will need to be prolonged, perhaps lifelong. PREVENTION

In the absence of a vaccine or effective therapy, preventing HIV transmission requires educating people about safe behavior. This education can be approached in many ways. Public service announcements, posters, billboards, and general publicity by the media all provide the general public with information on the risk of AIDS and how to avoid HIV infection. These efforts are important for increasing the level of knowledge in a community. Because of public fear about AIDS, it has been necessary to educate people on the ways the virus is not transmitted as well as to inform them about routes of transmission. In the past, however, general publicity alone has had little effect on modifying behaviors that are even easier to change than sexual practices (such as convincing people to wear seat belts62 ). Moreover, with other sexually transmitted diseases, such as syphilis, non targeted pub-

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HIV and AIDS in women and children

lie information campaigns had only minor impact on morbidity trends. One reason people may fail to comply with general messages to change behavior is that they fail to perceive that they are at risk. One of the major predictors of a change in the sexual practices of homosexual men has been knowing someone with AIDS. 63 Waiting for this to occur with a disease that has a long incubation period is not acceptable. Many persons in a given area may be unknowingly infected before any develop AIDS. For example, almost one third of the 6875 homosexual men in one group in San Francisco were infected before the syndrome of AIDS was ever recognized. 64 For most heterosexual men and women, the risk of HIV infection is low, but for some it is not. One way to help women assess their risk is to ask them certain questions directly. Women who share needles or have sexual contact with an HIV-infected partner are clearly at high risk, and physicians should help them understand this fact. The risk for women with multiple heterosexual partners of unknown antibody status is more difficult to define because the prevalence of infection in heterosexual communities varies tremendously. Many persons either are unaware or deny that the virus affects their community until a "serosurvey" documents the presence of HIV infection. The number of persons seeking counseling and antibody testing nearly tripled in one California county following local publication of a blinded serosurvey that discovered two infected women. 65 If done properly, blinded serosurveys could greatly facilitate educating people in different communities by allowing accurate estimates of the true prevalence of infection. Prevention messages should be personalized as much as possible, and should be sensitive to cultural differences. The basic prevention message is simple: "Know your partner. Do not share needles or have sexual contact with someone who is infected with the virus." It is not possible to be 100% certain that a person is not infected, but some methods are highly accurate. The HIV enzymelinked immunosorbent assay (ELISA) test is extremely effective at detecting HIV antibody in a person who has been infected for at least 2 to 3 months. It is the most sensitive way to detect infection, so testing should be considered before entering a sexual relationship in which one partner may be infected. In the absence of antibody test results, the likelihood of infection will depend on the potential partner's sexual and drug use history.

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Bisexual men, IV drug abusers, persons with hemophilia, and sexual partners of these persons should be considered infected until proven otherwise. A partner's sexual history may be difficult to surmise, and some may deny risks when asked outright. However, a sizeable decrease in the rate of transmission could occur if persons consider whether prospective sexual partners may be infected with HIV before having sexual contact. When one partner may be infected, abstinence is the only certain way to avoid transmission. An infected person should inform potential sex partners of his or her HIV infection. Using condoms can reduce the risk of transmission for people who have sexual contact. Natural-membrane condoms have pores that seem to be smaller than HIV, but allow passage of parts of the hepatitis B virus. 66 Latex condoms are recommended because they do not have pores. 67 Typical pregnancy rates of up to 12% per year for condom users are primarily due to their inconsistent or improper use, 68 but condoms can break during use. The consistent use of condoms would reduce, but not eliminate, the risk of transmission from an infected partner. Spermicides containing nonoxynol-9 can kill HIV in vitro. 69 In vitro studies suggest that the use of condoms plus a spermicide may provide more protection than condoms alone. 70 Nearly all pediatric HIV infections are acquired from infected mothers, so prevention of pediatric AIDS depends on the prevention of infection in women and the prevention of transmission from infected women. Women infected with HIV should be advised to avoid pregnancy and be given the highest priority for family planning services. Since many infected women are asymptomatic, HIV antibody testing is the only reliable way to determine whether a woman who is at risk for infection is actually infected. Counseling and HIV antibody testing for women in sexually transmitted disease clinics, at drug treatment centers, and in prisons is one way of identifying those who are at particularly high risk of infection. Other facilities where women may be counseled and tested include family planning clinics, maternal/child health clinics, and adolescent health clinics. The need for routine counseling and testing programs varies greatly, depending on the prevalence ofHIV infection. In Belle Glade (FL), 3% of women tested were seropositive. 71 Prenatal testing in Brooklyn (NY) revealed that 13 (3%) of 527 women were seropositive for HIV. 72 Similar rates were

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found in unselected inner city women or newborns in Jacksonville (FL), 2 (1%) of299; Atlanta (GA), 3 (1%) of 258; and Boston (MA), 13 (2%) of 849. 73- 75 Serosurveys in other areas are needed to determine intervention requirements. The feasibility of any screening program depends on the availability of a reliable test. The HIV ELISA is an extremely good test. Approximately 98% of persons with antibody have a positive test, 76 and over 99.8% of persons with no antibody have a negative test. 77 However, the likelihood that a person with a positive test is truly infected depends on the prevalence in the population. This characteristic, the predictive value of a positive test, is particularly important when interpreting a positive test (Table 3). Because of the problem of false-positive results in a low-prevalence setting, and the serious implications of a positive antibody test, a confirmatory test, such as the Western blot, should be done whenever an ELISA is positive. The Western blot greatly reduces the problem with false-positive results, even in low-prevalence settings. The value of a screening program also depends on the seriousness of the disease, effectiveness of the intervention, practicality, and yield of cases. Infection with HIV is certainly serious enough to merit consideration of a screening program, even in a low-prevalence setting. However, the effectiveness, practicability, and yield of such screening will vary in different situations. In blood banks, every seropositive unit is discarded, so the effectiveness is extremely high. The high effectiveness, combined with the practicality, make screening blood Table 3 Predictive Value of a Positive Test• Based on the Prevalence of Infection Prevalence 30%

Test+ TestTotal

Prevalence 0.1%

Infected

Not infected

Infected

Not infected

29,100 900 30,000

140 69,860 70,000

97 3 100

200 99,700 99,900

• The predictive value of a positive test depends on the prevalence of infection in the population. For example, a test with a sensitivity of 97% and a specificity of 99.8% is used in a population with a prevalence of 30%. The predictive value of a positive test is 29,100/(29,100 + 140) = 99.5%. Using a test with the same sensitivity and specificity for a population in which 0.1% are infected, the predictive value of a positive test is 97 /(97 + 200) = 32. 7%. Therefore, a confirmatory tests is essential when a screening test is used in a population with a low prevalence. Confirmation of a positive HIV antibody ELISA usually is done by the Western blot method.

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donors desirable, despite the relatively low seraprevalence among previously unscreened donors (0.04%). 77 Since 18,000,000 components are transfused each year, testing prevents 18,000,000 X 0.04% = 7200 infections per year. Preventing transmission from an infected person is more difficult because it involves influencing human behavior. Therefore, the value of screening outside of blood banks is more difficult to evaluate. Prenatal testing, if done early, would allow more options in the management of pregnancy, yet some options might not be acceptable to some women. For example, a study at a New York methadone maintenance program found that women who were told they had a positive HIV antibody test elected to terminate their pregnancies with the same frequency as women who were told they had a negative test. 78 Screening before pregnancy is preferred because seropositive women could take precautions to avoid pregnancy and avoid transmission to their partners. This could involve using one contraceptive to avoid pregnancy and condoms to avoid transmitting infection. However, the study in the methadone maintenance clinics in New York City found no difference in condom use by seropositive and seronegative women. 78 This study illustrates the need for more effective programs of counseling and family planning and the need to evaluate existing programs so that ineffective approaches can be changed. Health-care workers should take precautions to avoid exposure to blood and other body fluids with all patients. 70•71 Screening patients for HIV antibody at the time of hospital admission would not eliminate the need for precautions. Many exposures to blood occur in emergency settings, and there are many other infections that might be transmitted by blood that tests negative for HIV antibody. Gloves should be worn whenever exposure to blood is anticipated, and additional precautions may be necessary in some circumstances. Many needle punctures occur during recapping or improper disposal of the needles. Proper disposal of needles should be emphasized. Needle disposal containers must be conveniently located or they will not be used.

research is needed to further define the risks of HIV transmission. The most important determinant of risk for persons through nonmonogamous heterosexual contact is the HIV seroprevalence in the community; therefore, blinded serosurveys are needed in many communities to define the risk, target prevention programs, and facilitate counseling about risks. Studies of risk factors for transmission from an infected person are needed to define the effects of potential co-factors, such as genital ulcers, and to quantify the protection from condoms and spermicides. The effectiveness of various prevention strategies should be determined. How effective is counseling and testing for HIV in moderate to high prevalence settings? What are the most effective methods of delivering family planning services to HIV-infected women to prevent perinatal transmission of HIV? What is the best way for clinicians to discuss AIDS with patients? Hypotheses must be proposed and tested so that we can identify prevention strategies that are effective and eliminate all others. Unanswered questions about HIV prevention should not delay the application of the knowledge we already have. We know the practices most highly associated with transmitting infection and the geographic areas with the greatest prevalence. We have an excellent antibody test that should be made available to all persons to allow informed decisions about pregnancy and sexual practices. We know that condoms are safer than unprotected intercourse, but not as safe as abstinence. Finally, as health-care workers, we know how to care for people who are ill. Compassion for the sick and willingness to serve are qualities that will become increasingly important during this epidemic. REFERENCES 1. Morgan WM, Curran JW: Acquired immunodeficiency syn-

2.

3. 4.

CURRENT NEEDS

We urgently need effective treatment and a vaccine to help persons who are either infected with HIV or at high risk of becoming infected. More

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drome: current and future trends. Public Health Rep 101:459, 1986 Centers for Disease Control: Human immunodeficiency virus infection in the United States: a review of the current knowledge. MMWR 36 (suppl. no. 5-6): 14, 1987 Guinan ME, Hardy A: Epidemiology of AIDS in women in the United States; 1981 through 1986. JAMA 257:2039, 1987 Lifson AR, Stoneburner RL, Chiasson MA, Hildebrandt DS, Schultz S, Jaffe HW: HIV infection in sexually active heterosexual adults attending a New York City STD clinic. (Abstr MP.83). Presented at the III International Conference on AIDS, Washington, D.C., June 1, 1987 Centers for Disease Control: Positive HTLV-IIIILAV antibody results for sexually active female members of social/ sexual clubs-Minnesota. MMWR 35:697, 1986

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6. Peterman TA, Curran JW: Sexual transmission of human immunodeficiency virus. JAMA 256:2222, 1987 7. Kreiss JK, Kitchen LW, Prince HE, Kasper CK, Essex M: Antibody to human T-lymphotropic virus type III in wives of hemophiliacs: evidence for heterosexual transmission. Ann Intern Med 102:623, 1985 8. Lawrence DN, Jason JM, Bouhasin JD, McDougal JS, Knutsen AP, Evatt BL, Joist JH: HTLV-III/LAV antibody status of spouses and household contacts assisting in home infusion of hemophilia patients. Blood 66:703, 1986 9. Jason JM, McDougal JS, Dixon G, Lawrence DN, Kennedy MS, Hilgartner M, Aledort L, Evatt BL: HTL V-III/LA V antibody and immune status of household contacts and sexual partners of persons with hemophilia. JAMA 255:212, 1986 10. Allain J-P: Prevalence of HTLV-III/LA V antibodies in patients with hemophilia and in their sexual partners in France (Letter). N Eng! J Med 315:517, 1986 11. Padian N, Marquis L, Francis DP, Anderson RE, Rutherford GW, O'Malley PM, Winkelstein W: Male-to-female transmission of human immunodeficiency virus. JAMA 258:788, 1987 12. Peterman TA, Stoneburner RL, Allen JR, Jaffe HW, Curran JW: Risk of HIV transmission from persons with transfusion-associated infections. JAMA. 259:55, 1988 13. Steigbigel NH, Maude DW, Feiner CJ, Harris CA, Saltzman BR, Klein RS, et a!: Heterosexual transmission of infection and disease by the human immunodeficiency virus (HIV) (Abstr W.2.5). Presented at the III International Conference on AIDS, Washington, D.C., June 3, 1987 14. Redfield RR, Markham PD, Salahuddin SZ, Sarngadharan MG, Bodner AJ, Folks TM, Ballou WR, Wright DC, Gallo RC: Frequent transmission of HTLV-III among spouses of patients with AIDS-related complex and AIDS. JAMA 253:1571, 1985 15. Fischl MA, Dickinson GM, Scott GB, Klimas N, Fletcher MA, Parks W: Evaluation of heterosexual partners, children, and household contacts of adults with AIDS. JAMA 257:640, 1987 16. Clumeck N, Hermans P, Taelman H, RothE, Zissis G, De Wit S: Cluster of heterosexual transmission of HIV in Brussels (Abstr TP.82). Presented at the III International Conference on AIDS, Washington, D.C., June 2, 1987 17. Goedert JJ, Eyster ME, Biggar RJ: Heterosexual transmission of human immunodeficiency virus (HIV): association with severe T4-cell depletion in male hemophiliacs (Abstr W.2.6). Presented at the III International Conference on AIDS, Washington, D.C., June 3, 1987 18. Kreiss JK, Koech D, Plummer FA, Holmes KK, Lightfoote M, Piot P, Ronald AR, Ndinya-Achola JO, D'Costa LJ, Roberts P, Ngugi EN, Quinn TC: AIDS virus infection in Nairobi prostitutes: spread of the epidemic to East Africa. N Eng! J Med 314:414, 1986 19. Greenblatt RM, Lukehart SL, Plummer FA, Quinn TC, Crithchlow CW, D'Costa LJ: Genital ulceration as a risk factor for human immunodeficiency virus infection in Kenya (Abstr ThP.68). Presented at the III International Conference on AIDS, Washington, D.C., June 4, 1987 20. Katzenstein DA, Latif A, Bassett MT, Emmanuel JC: Risks for heterosexual transmission of HIV in Zimbabwe (Abstr M.8.3). Presented at the III International Conference on AIDS, Washington, D.C., June 1, 1987

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21. Potterat JJ: Does syphilis facilitate sexual acquisition of HIV? (Letter). JAMA 258:473, 1987 22. Handsfield HH, Ashley RL, Rompalo AM, Stamm WE, Wood RW, Corey L: Association of anogenital ulcer disease with human immunodeficiency virus infection in homosexual men (Abstr F.l.6). Presented at the III International Conference on AIDS, Washington, D.C., June 5, 1987 23. Goedert JJ, Sarngadharan MG, Biggar RJ, Weiss SH, Winn DM, Grossman RJ, Greene MH, Bodner AJ, Mann DL, Strong DM, Gallo RC, Blattner W A: Determinants of retrovirus (HTL V-III) antibody and immunodeficiency conditions in homosexual men. Lancet 2:711, 1984 24. Kingsley LA, Detels R, Kaslow R, Polk BF, Rinaldo CR Jr, Chmiel J, Detre K, Kelsey SF, Odaka N, Ostrow D, VanRaden M, Visscher B: Risk factors for seroconversion to human immunodeficiency virus among male homosexuals. Lancet 1:345, 1987 25. Darrow WW, Echenberg DF, Jaffe HW, O'Malley PM, Byers RH, Getchell JP, Curran JW: Risk factors for human immunodeficiency virus (HIV) infections in homosexual men. Am J Public Health 77:479, 1987 26. Schechter MT, Boyko WJ, Douglas B, Maynard M, Willoughby B, McLeod A, Craib KJP: Can HTLV-III be transmitted orally? (Letter). Lancet 1:379, 1986 27. Stewart GJ, Tyler JPP, Cunningham AL, Barr JA, Driscoll GL, Gold J, Lamont BJ: Transmission of human T-cell lymphotropic virus type III (HTLV-Ill) by artificial in semination by donor. Lancet 2:581, 1985 28. Pies C, Eskenazi B, Newstetter A, Shepard C: Exposure to the AIDS virus through artificial insemination in a population of lesbians in California (Abstr MP.75). Presented at the III International Conference on AIDS, Washington, D.C., June 1, 1987 29. Stoneburner R: Unpublished data 30. Scott GB, Fischl MA, Klimas N, Fletcher MA, Dickinson GM, Levine RS, Parks WP: Mothers of infants with the acquired immunodeficiency syndrome: evidence for both symptomatic and asymptomatic carriers. JAMA 253:363, 1985 31. Mok JQ, Giaquinto C, De Rossi A, Grosch-Worner I, Ades AE, Peckham CS: Infants born to mothers seropositive for human immunodeficiency virus: preliminary findings from a multicentre European study. Lancet 1:1164, 1987 32. Selwyn PA, Schoenbaum EE, Feingold AR, Mayers M, Davenny K, Rogers M, et a!: Perinatal transmission of HIV in intravenous drug abusers (Abstr Th.7.2). Presented at the III International Conference on AIDS, Washington, D.C., June '4, 1987 33. Jovaisas E, Koch MA, Schafer A, Stauber M, Lowenthal D: LAV/HTLV-III in a 20-week fetus (Letter). Lancet 2:1129, 1985 34. Minkoff H, Nanda D, Menez R, Fikrig S: Pregnancies resulting in infants with acquired immunodeficiency syndrome or AIDS-related complex. Obstet Gynecol 69:285, 1987 35. Ziegler JB, Johnson RO, Cooper DA, Gold J: Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet 1:896, 1985 36. Thiry L, Sprecher-Goldberger S, Jonckheer T, Levy J, Van de Perre P, Henrivaux P, Cogniaux-LeC!erc J, Clumeck N: Isolation of AIDS virus from cell-free breast milk of three healthy virus carriers. Lancet 2:891, 1985

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64. Jaffe HW, Darrow WW, Echenberg DF, O'Malley PM, Getchell JP, Kalyanaraman VS, Byers RH, Drennan DP, Braff EH, Curran JW, Francis DP: The acquired immunodeficiency syndrome in a cohort of homosexual men: a sixyear follow-up study. Ann Intern Med 103:210, 1985 65. Benjamin RA: Premarital HIV antibody testing in Alameida County, California. Presented at the Conference on the Role of AIDS Virus Antibody Testing in the Prevention and Control of AIDS, Atlanta, Georgia, February 24, 1987 66. Minuk G: Passage of viral particles through natural membrane condoms (Abstr). Presented at the Conference on Condoms in Prevention of Sexually Transmitted Diseases, Atlanta, Georgia, February 20, 1987 67. Conant M: Human immunodeficiency virus and herpesvirus (Abstr). Presented at the Conference on Condoms in Prevention of Sexually Transmitted Diseases, Atlanta, Georgia, February 20, 1987 68. Trussell J, Kost K: Contraceptive failure in the United States: a critical review of the literature. Stud Fam Plann 18:237, 1987 69. Hicks DR, Martin LS, Getchell JP, Heath JL, Francis DP, McDougal JS, Curran JW, Voeller B: Inactivation of HTLV-III/LAV infected cultures of normal human lymphocytes by nonoxynol-9 in vitro (Letter). Lancet 2:1422, 1985 70. Rietmeijer CAM, Krebs JW, Feorino PM, Judson FN: In vitro tests demonstrate condoms containing nonoxynol-9 provide effective physical and chemical barriers against human immunodeficiency virus (Abstr WP.181). Presented at the III International Conference on AIDS, Washington, D.C., June 3, 1987

71. Castro KG, Lieb S, Calisher C, Witte J, Jaffe HW, The Field Study Group: AIDS and HIV infection in Belle Glade, Florida (Abstr W.2.3). Presented at the III International Conference on AIDS, Washington, D.C., June 3, 1987 72. Landesman S, Minkoff H, Holman S, McCalla S, Sijin 0: Serosurvey of human immunodeficiency virus infection in parturients: implications for human immunodeficiency virus testing programs of pregnant women. JAMA 258:2701, 1987 73. Kaunitz AM, Brewer JL, Paryani SG, deSausure L, Sanchez-Ramos L, Harrington P: Prenatal care and HIV screening. JAMA 258:2693, 1987 74. Peterson HB: Unpublished data 75. Grady GF, Berardi DP, Hoff R, Mitchell ML: HIV seropositivity in newborns: a novel method for estimating the prevalence of infection in childbearing women (Abstr ThP.175). Presented at the III International Conference on AIDS, Washington, D.C., June 4, 1987 76. Deinhardt F, Eberle J, Gurtler L: Sensitivity and specificity of eight commercial and one recombinant anti-HIV ELISA tests (Letter). Lancet 1:40, 1987 77. Schorr JB, Berkowitz A, Cumming PD, Katz AJ, Sandler SG: Prevalence of HTLV-III antibody in American blood donors. N Engl J Med 313:384, 1985 78. Selwyn PA, Feingold AR, Schoenbaum EE, Davenny K, Robertson V, Schulman J, et al: Pregnancy outcomes and HIV infection in intravenous drug abusers (Abstr MP.156). Presented at the III International Conference on AIDS, Washington, D.C., June 1, 1987

Received October 21, 1987. Thomas A. Peterman, M.D., AIDS Program, Center for Infectious Diseases, Centers for Disease Control. Present address: Treatment Branch, AIDS Program, NIAID, National Institutes of Health, Bethesda, Maryland. Reprint requests: Willard Cates, Jr., M.D., M.P.H., Division of Sexually Transmitted Diseases, Centers for Prevention Services, Centers for Disease Control, Atlanta, Georgia 30333. James W. Curran, M.D., M.P.H., AIDS Program, Center for Infectious Diseases, Disease Control.

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