HIV This Week

Drake AL, John-Stewart GC, Wald A, Mbori-Ngacha DA, Bosire R, Wamalwa DC, Lohman-Payne BL, Ashley-Morrow R, Corey L, Farquhar C. Herpes simplex virus type 2 and risk of intrapartum human immunodeficiency virus transmission. Obstet Gynecol 2007;109:403-9.

Drake and colleagues determined whether herpes simplex virus type 2 (HSV-2) infection was associated with risk of intrapartum human immunodeficiency virus type 1 (HIV-1) transmission and to define correlates of HSV-2 infection among HIV-1-seropositive pregnant women. The authors performed a nested case control study within a perinatal cohort in Nairobi, Kenya. Herpes simplex virus type 2 serostatus and the presence of genital ulcers were ascertained at 32 weeks of gestation. Maternal cervical and plasma HIV-1 RNA and cervical herpes simplex virus DNA were measured at delivery. Their results showed one hundred fifty-two (87%) of 175 HIV-1-infected mothers were herpes simplex virus 2 (HSV-2) seropositive. Among these 152 HSV-2-seropositive women, nine (6%) had genital ulcers at 32 weeks of gestation, and 13 (9%) were shedding herpes simplex virus in cervical secretions. Genital ulcers were associated with increased plasma HIV-1 RNA levels (P=.02) and an increased risk of intrapartum HIV-1 transmission (16% of transmitters versus 3% of nontransmitters had ulcers; P = .003), an association which was maintained in multivariable analysis adjusting for plasma HIV-1 RNA levels (P=.04). The authors found a borderline association for higher plasma HIV-1 RNA among women shedding HSV (P=.07) and no association between cervical herpes simplex virus shedding and either cervical HIV-1 RNA levels or intrapartum HIV-1 transmission (P=.04 and P=.05, respectively). The authors concluded that herpes simplex virus type 2 is the leading cause of genital ulcers among women in sub-Saharan Africa and was highly prevalent in this cohort of pregnant women receiving prophylactic zidovudine. After adjusting for plasma HIV-1 RNA levels, genital ulcers were associated with increased risk of intrapartum HIV-1 transmission. These data suggest that management of herpes simplex virus 2 (HSV-2) during pregnancy may enhance mother-to-child HIV-1 transmission prevention efforts.

Editors’ note: Genital herpes has been known for years to increase the risk of both HIV acquisition and transmission sexually so it is not surprising that it increases mother-to-child transmission. For overt genital ulceration detected during labour, Caesarean section is usually recommended to prevent neonatal herpes. Randomised controlled trials of herpes suppressive treatment to reduce HIV infectivity during sexual intercourse are underway however, clinical trials are also needed to assess whether long term herpes suppressive therapy in pregnancy will reduce mother-to-child transmission of HIV.

Boisseau C, Degui H, Bruneton C, Rey JL. [Poor access to antiretroviral treatment in French-speaking Africa: situation in 2004]. Med Trop (Mars) 2006;66:589-92.

Boisseau and colleagues carried out a survey by questionnaire and interview with persons in charge of purchasing in central structures and AIDS control programs in 18 French-speaking African countries between June and October 2004. Survey data showed that a total of 3300 patients received antiretroviral treatment during the study period. This corresponds to a treatment rate of 0.1 to 9.6% of the number of patients requiring antiretroviral treatment. All countries reported interruptions of the antiretroviral supply for a variety of reasons. The main causes were budgetary issues and procedural complexity involving financial aid. The prices charged to the patients varied greatly in function of national policies. Cost price also varied in function of the negotiating leverage of the purchasing central. The authors conclude that in order to improve general access to antiretroviral treatment and to reduce the number of supply shortages more training will be required in management and distribution of medicines. They conclude that it would also be useful to improve communications between the persons in charge of national purchasing structures.

Editors’ note: Patient access and adherence to treatment are known preoccupations of treatment programmes but antiretroviral drug shortages and financing problems are management concerns at the level of central procurement that have to be urgently addressed for effective supply chain management.

Deng R, Li J, Sringernyuang L, Zhang K. Drug abuse, HIV/AIDS and stigmatisation in a Dai community in Yunnan, China. Soc Sci Med 2007 Jan 23; [Epub ahead of print]

The latest data indicate that between 540,000 and 760,000 people are infected with HIV in China. Although minority nationalities represent 8.1% of China's total population, they account for more than 30% of the reported HIV cases. Deng and colleagues examined stigma and discrimination against drug abusers and people living with HIV in a Dai minority nationality community in Yunnan, China. The authors used qualitative research methods, which included participatory observations, in-depth interviews, focus-group discussions, transect walking and community mapping. A combination of different sampling strategies was used to maximise diversity of the initially selected sample. The data revealed deeply entrenched stigma and overt discrimination against drug abusers and people living with HIV that manifested in familial, work, civil and institutional contexts. The stigma reflected pre-existing cultural, religious sanctions against "deviant behaviours". Intervention programmes that were insensitive to the local culture and religion may have also contributed in part to the stigmatisation of drug abusers and people living with HIV. The major impact of stigma was that it created a vicious cycle of social isolation, marginalisation and thus addiction relapse. This in turn reinforced the stigmatisation and discrimination against drug abusers and thus hindered efforts towards prevention and control of HIV.

Editors’ note: Stigma and discrimination drive the epidemic underground, undermining HIV prevention and delaying treatment provision to those most in need. Sustained efforts to overcome them are essential to progress towards universal access.

Hong R, Banta JE, Kamau JK. Effect of maternal HIV infection on child survival in Ghana. J Community Health 2007;32:21-36.

Hong and colleagues measured the association between maternal HIV infection and infant mortality in Ghana. The authors used a censored synthetic cohort life table based on the birth history of 3639 childbirths during 1999-2003 obtained from the interviews of a nationally representative sample of 5691 women age 15-49 in 6251 households in the 2003 Ghana Demographic and Health Survey. The survey collected demographic, socioeconomic, and health data of the respondents and, as well, obtained voluntary counselling test for HIV infection from all eligible women. The effects of maternal HIV status and other factors on infant mortality were estimated using multivariate survival regression analysis and the results are presented as Hazard Ratios (HR) with 95% confident interval (95% CI). Children born to HIV infected mothers were three times as likely to die during infancy as those born to uninfected mothers (HR = 3.01; 95% CI: 1.64, 5.50). Controlling for other factors affecting infant mortality further sharpens this relationship (HR = 3.51; 95% CI: 1.87, 6.61). Not receiving antenatal care, low birth weight, and living in households that use high pollution cooking fuels were associated with a higher risk of infant mortality. The authors conclude that maternal HIV status is a strong predictor of infant mortality in Ghana, independent of several other factors. The results suggest that the HIV epidemic has had great impact on child well-being and child survival. This impact tends to increase as the HIV epidemic matures and infection in adults increases.

Editors’ note: The association between maternal HIV infection and infant mortality is likely the result of direct effects of mother-to-child HIV transmission as well as indirect effects. The latter would include maternal illness affecting parenting capacity and immune deficiency leading to reduced levels of protective maternal antibodies to childhood diseases such as measles. The antibodies normally cross the placenta to provide passive protection during the first months of life.

Nikolic DS, Garcia E, Piguet V. Microbicides and other topical agents in the prevention of HIV and sexually transmitted infections. Expert Rev Anti Infect Ther 2007;5:77-88.

According to information from UNAIDS, more than 42 million individuals are living with HIV worldwide. Most infected individuals live in developing countries where the availability of antiretroviral agents is still limited. As this pandemic is increasing largely through mucosal transmission, new methods of prevention are urgently needed. Nikolic and colleagues discuss how if available, agents that block HIV prior to or early after contact with mucosal epithelia would decrease the incidence of HIV infection and, therefore, potentially save millions of lives over the next few decades. The authors subdivide topically applied microbicides acting against HIV-1 into four subgroups, including agents directly inhibiting pathogens, agents acting on genital pH, agents blocking pathogen entry and replication inhibitors. In addition, the authors note how microbicides might also allow fighting against other sexually transmitted infections, such as herpes simplex viruses. The authors conclude that with concerted efforts directed towards developing efficient microbicides, topical anti-infective compounds may well become a new weapon against sexually transmitted infections, including HIV, in everyday clinical practice.

Editors’ note: Despite the recent stopping of the cellulose sulfate trials, the microbicide field remains very active with other products based on different subgroups continuing in Phase III trials.