CDC Calls HIV a Major Problem in Women and Children

ATLANTA--To date, more than 58,000 cases of AIDS have been reportedamong adult and adolescent women in the United States, as wellas more than 5,000 cases among children who acquired the diseaseperinatally. In 1994 alone, more than 14,000 women (25% of thetotal to date) were reported with AIDS.

In light of these figures, the Centers for Disease Control andPrevention (CDC) considers HIV infection a major cause of illnessamong women of childbearing age and their children, and has issuedrecommendations for HIV counseling and testing for pregnant women.

In the United States in 1993, HIV infection was the fourth leadingcause of death among women aged 25 to 44, and the seventh leadingcause of death in children aged 1 to 4. According to a study doneat the National Institute of Allergy and In-fectious Diseases(NIAID), HIV-infected women are one third more likely than mento die without progressing to full-blown AIDS.

The investigators, led by Sandra L. Melnick, DrPH, and LawrenceR. Deyton, MD, both of the NIAID Division of AIDS, could not pinpointwhy women have a greater risk of relatively early death, but theysuggested that socioeconomic factors (eg, domestic violence andlack of social support) may play a role (JAMA, Dec. 28, 1994).

Among blacks and Hispanics, the statistics are even more alarming,according to the CDC. New Jersey, Massachusetts, New York, andFlorida are the hardest hit states.

Approximately half the AIDS cases in women have been attributedto intravenous drug use and one third to heterosexual contact.Almost all HIV infections in children are the result of perinataltransmission. An increasing number of those cases are the resultof the mother having sex with an infected man whose HIV statusand/or risk she did not know.

Perinatal Transmission

The HIV Survey in Childbearing Women indicates that between 1989and 1993, 7,000 HIV-positive women gave birth each year, and about2,000 of their children were born HIV-infected.

HIV can be transmitted from mother to newborn during pregnancy,labor, and breast-feeding. According to the CDC, research indicatesthat although transmission can occur anytime during the prenatalor intrapartal period, it is most likely close to or during labor,and breast-feeding may increase the rate of transmission by 10%to 20%.

Early diagnosis of HIV infection and prompt intervention can reducemorbidity and mortality, as well as vertical transmission. Unfortunately,according to the CDC, studies have shown that most infected peopledo not find out their HIV status until they become symptomatic.However, counseling and testing for pregnant women and those ofchildbearing age provide an opportunity for early diagnosis andtreatment.

Ongoing monitoring of CD4 and T-lymphocyte levels during pregnancycan determine the appropriate time for initiation of antiretroviraltreatment and prophylaxis against opportunistic diseases, as wellas oncologic and infectious manifestations of HIV infection.

The US Public Health Service has developed recommendations regardingzidovudine (Retrovir, AZT) treatment of pregnant women. Theserecommendations result from a multicenter randomized, placebo-controlledclinical trial, which showed that AZT given to HIV-infected womenduring pregnancy and labor, and to their newborns, reduced therisk of perinatal transmission by 71.5%. AZT therapy was welltolerated by both the women and their babies, with only mild transientside effects.

As a result of the recommendations, the FDA approved the use ofAZT to prevent perinatal HIV transmission.

Long-term effects of such treatment are unknown, and concernshave been raised about possible negative effects of prenatal counselingand testing programs.

For instance, if counseling is not done in a way that emphasizesthe voluntary nature of testing, women might be reluctant to returnfor further prenatal care. Other concerns include loss of confidentialitywith resultant job or health-care discrimination, damaged familyrelationships, domestic violence, and adverse psychological reactions.However, the CDC said, there is neither significant anecdotalnor research evidence of these possible adverse effects of HIVtesting.

The CDC has issued draft guidelines recommending that health-careproviders routinely counsel all pregnant women about the availabilityof HIV testing and encourage them to be tested as early as possiblein the pregnancy. In so doing, providers should stress the importanceof knowing HIV status, as well as the risk that HIV infectionposes to the fetus and the woman herself.

Testing should remain voluntary and should be preceded by informedconsent, the guidelines state. Women who refuse may not be reportedto state or local health authorities, and they may not be discriminatedagainst by health-care providers. Uninfected women should be retestedin their third trimester.

Women in labor who have not received prenatal care should be rapidlyassessed for HIV infection and, if positive, considered for HIVtreatment during labor and the postpartum period.

The guidelines state that if a woman tests positive early in pregnancy,she should be considered for AZT therapy to treat the viral infectionand protect against HIV-related opportunistic diseases and malignancies.She also should be counseled about the benefits of giving AZTto her infant for its first 6 weeks of life.