HIV This Week

Deschamps MM, Noel F, Bonhomme J, Dévieux JG, Saint-Jean G, Zhu Y, Wright P, Pape JW, Malow RM. Prevention of mother-to-child transmission of HIV in Haiti. Rev Panam Salud Publica. 2009;25:24-30.

Deschamps and colleagues set out to describe the effectiveness of a program designed to reduce the rate of mother-to-child transmission of HIV at the primary HIV testing and treatment center in Haiti between 1999 and 2004. All pregnant, HIV-positive women who attended the major HIV testing and treatment clinic in Port-au-Prince, Haiti, between March 1999 and December 2004 were asked to participate in a mother-to-child transmission prevention program. Of the 650 women who participated, 73.3% received zidovudine (AZT), 2.9% received nevirapine (NVP), and 10.1% received triple-drug therapy when it became available in 2003 and if clinical/laboratory indications were met. Approximately 13.8% received no antiretroviral medication. All participants received cotrimoxazole prophylaxis and infant formula for their children. Kaplan-Meier survival analysis and the log rank test were used to evaluate program impact on child survival. Complete data were available for 348 mother-infant pairs who completed the program to prevent mother-to-child transmission of HIV. The rate of mother-to-child transmission in the study was 9.2% (95% CI:6.14-12.24), in contrast to the historical mother-to-child transmission rate of 27% in Haiti. HIV-positive infants were less likely to survive than HIV-negative infants at 18 months of follow-up (chi(2) = 19.06, P < .001, log rank test). Infant survival improved with early paediatric diagnosis and antiretroviral treatment. The mother-to-child transmission prevention program described proved to be feasible and effective in reducing vertical HIV transmission in Haiti. The authors emphasize the need to expand testing, extend services to rural areas, and implement early HIV diagnosis to reduce infant mortality.

Editors’ note: Over the period from 1999 to 2004 the annual number of women who agreed to undergo HIV testing at the GHESKIO clinic more than doubled and the number of HIV-positive women who enrolled in the prevention of mother-to-child transmission (PMTCT) programme quadrupled. Overall 43,173 women at higher risk of HIV exposure were tested (18.3% were HIV-positive) and 5270 were pregnant (12.3% HIV-positive). Of the 650 HIV-positive pregnant women, 28.7% did not participate in the PMTCT programme, primarily because they returned to rural areas, and only 14% were able to bring their partners in for HIV testing. After delivery, 73.9% of the women were using family planning services at 18-month follow-up compared to national uptake data of 23%. Despite persistent instability and violence in Haiti, this programme in Port-au-Prince has successfully reduced HIV transmission to infants to one-third of the historical rate. With a 2007 adult (15-49 years) HIV prevalence of 2.2% (1.9-2.5), in a league with the Bahamas, Guyana, Suriname, and Belize in the Americas, Haiti clearly needs a nationwide programme integrating family planning, voluntary counselling and testing, and HIV treatment services with good referral links between centres.

Cailhol J, Jourdain G, Coeur SL, Traisathit P, Boonrod K, Prommas S, Putiyanun C, Kanjanasing A, Lallemant M; for the Perinatal HIV Prevention Trial Group. Association of Low CD4 Cell Count and Intrauterine Growth Retardation in Thailand. J Acquir Immune Defic Syndr. 2009; 50:409-413.

Each year, intrauterine growth retardation affects 20-30 million neonates worldwide, mostly in resource-limited settings. Increased perinatal and infant mortality has been associated with intrauterine growth retardation. Some studies have suggested that HIV infection could increase the risk of intrauterine growth retardation. To confirm this hypothesis, Cailhol and colleagues examined the association between HIV-related factors and the risk of intrauterine growth retardation in Thailand. Data from a cohort of 1436 HIV-infected pregnant women enrolled in the « Perinatal HIV Prevention Trial-1 », a clinical trial conducted from 1997 to 1999 in Thailand, were analyzed using a logistic regression, adjusting for risk factors usually associated with intrauterine growth retardation. The rate of intrauterine growth retardation was 7.6%. Adjusting for a short maternal height, low body mass index, small weight gain during pregnancy, and infant female sex, a low maternal CD4 percentage was independently associated with intrauterine growth retardation (odds ratio 0.96, per 1% increment, 95% confidence interval 0.93 to 0.99, P = 0.03). The current World Health Organization recommendation to initiate combination antiretroviral therapy for immunocompromised women as early as possible during pregnancy for their own health and for the prevention of HIV mother-to-child transmission is likely to also decrease the incidence of intrauterine growth retardation. Encouraging immunocompromised HIV-infected women who plan to become pregnant to wait until immune restoration has been achieved may help to reduce the risk of intrauterine growth retardation.

Editors’ note: Intrauterine growth retardation (IUGR) is the second cause of perinatal mortality after prematurity. It is associated with higher susceptibility to various conditions in the neonatal period as well as with diseases in adulthood such as diabetes, obesity, and hypertension. This Thai study used the stringent definition of IUGR of ‘birth weight below the 10 th percentile of weight for the corresponding gestational age’, rather than the low birth weight cut-off of 2500 g which can indicate prematurity. Also it used CD4 percentage which is less variable than absolute CD4 count. The finding that CD4 percentage below the median contributed 28% of the risk of IUGR in this population gives added support to the recommendation to initiate antiretroviral treatment (as opposed to antiretroviral prophylaxis) in pregnancy for women with low CD4 counts.