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Incidence of perinatal HIV infections remain 1.75 times higher than CDC goal
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Although perinatal HIV infections among infants born in the United States have significantly declined since 2002, occurrence remains 1.75 times greater than the goal set in place by the CDC to eliminate mother-to-child transmission, according to a study published in JAMA Pediatrics.
“Although identification of HIV infection is a necessary first step in appropriate treatment and prophylaxis, reports indicate that a quarter of pregnant women have not been tested,” Allan W. Taylor, MD, MPH, from the Division of HIV/AIDS Prevention at the CDC, and colleagues wrote. “In addition, substantial proportions of women with known HIV infection did not receive adequate prenatal care or [antiretroviral] medications.”
Researchers estimated the number of perinatal infants infected with HIV in the U.S. and District of Columbia. To do so, they collected data from 2003 to 2013 in the National HIV Surveillance System, which included receipt of perinatal HIV testing, treatment and prophylaxis. The effect of delays in diagnosis and reporting on the overall estimation was accounted for by a weighted system that took into consideration the length of time between time of birth to diagnosis in each reported case.
Between 2002 and 2013, the number of perinatally infected infants decreased from 216 to 69. The majority of mothers who gave birth to HIV–infected infants identified as black (63.0%, 836 infants), followed by Latino or Hispanic (18.3%, 243 infants). Of the mothers included in the analysis between 2002 and 2005, 37.5% were diagnosed with HIV before pregnancy; however, 51.5% of mothers who were pregnant between 2010 and 2013 had a prior diagnosis.
Regarding maternal HIV treatment in 2002-2005, 22.4% of women and their infants received all prenatal, intrapartum and postnatal antiretroviral prophylaxis or treatment. This proportion increased by 2010-2013, with 31.8% receiving necessary treatment. A similar increase was seen in those who received antiretroviral prophylaxis or treatment during pregnancy (28.4% to 40.3%). A substantial portion of infants born with HIV infection (38.0%) were in five Southern states, specifically Florida, Texas, Georgia, Louisiana and Maryland. National data on perinatal HIV infection in the U.S. suggest that 1.75 per 100,000 live births involved HIV–infected infants.
“The continuing prevalence of missed prevention opportunities suggests that the remaining HIV transmissions occur in a subset of the population that is particularly difficult to reach with the recommended interventions,” Taylor and colleagues wrote. “One could hypothesize that the difficulty in reaching this population may also be reflected by the increasing percentage of women who, although infection was diagnosed before pregnancy, had not apparently been successfully linked to — and retained in — care.”
According to the researchers, “the fact that infants continue to acquire HIV infection appears to be the result of the same reasons that have been known for years and likely not as a result of a previously unrecognized factor, such as increasing [antiretroviral] resistance or an increasing incidence of women with acute HIV infection during pregnancy.” — by Katherine Bortz
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Russell Van Dyke, MD
According to the CDC estimates in this study, in 2013, there were only 69 newly infected babies in the United States, which is a remarkably low number. For the number of infected infants to have declined from its peak in 1991, estimated to be 1,760 infants, which was before we treated infected mothers during pregnancy with antiretrovirals to prevent transmission, to less than 100 infected infants in the whole country is outstanding.
This study confirms what we already know: that if proper protocols are followed, we can almost entirely eliminate mother-to-child HIV transmission. However, what also becomes clear were the ‘missed opportunities’ for prevention: pregnant women who were not receiving primary and obstetrical care during the pregnancy, tested for HIV and given appropriate therapy.
Additionally, in high-risk areas mentioned in the study, we just have to ensure that testing is repeated in the mothers late in pregnancy to find those who have acquired infection during the pregnancy. The issue is not that we don’t know how to prevent mother-to-child transmission but rater how to implement the prevention. Unfortunately, until we can prevent HIV infection among adults, this will continue to be an ongoing problem.
The bottom line is that these results represent the most successful thing we have been able to accomplish in the whole field of HIV, essentially to be able to prevent mother-to-child transmission.
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Deborah Persaud, MD
The decline from 216 in 2002 to 69 in 2013 is a good move in the right direction, but more work needs to be done. We should be close to having zero cases of perinatal HIV transmissions in the U.S., given our longstanding public health approach to prenatal testing of all pregnant women.
The extremely low ART coverage rates among HIV–infected women and their newborns highlight a failure to effectively identify and treat HIV–infected pregnant women in the U.S. Health care providers need to establish rigor in identifying HIV infection and exposure in pregnant women and their newborns to provide optimal treatment and preventive strategies for this vulnerable population.
Perinatal HIV infection is a preventable disease, but prevention requires ongoing vigilance on the part of obstetricians, pediatricians and pediatric infectious disease specialists to identify women infected with HIV and to treat pregnant women with ART drugs to control HIV replication, as it is important to provide timely post-exposure ART prophylaxis to the infant. It is critical to ensure ongoing financial support for the services needed to sustain care and HIV testing of pregnant women.
The numbers are appalling: In the U.S., nearly half of women (51.5%) who transmitted HIV knew they were infected before the pregnancy, which means that the necessary care and treatment of HIV were ineffective. The extremely low proportion of HIV–infected women and their newborns receiving ART for prevention of mother-to-child transmission was also abysmally low, at 31.8%. Additionally, the high proportion of C-sections among HIV–infected women (55%) in this study may have aided with prevention of mother-to-child transmission, given the low rates of ART coverage.
Further studies are needed to examine how can we can achieve the UNAIDS 90-90-90 goals among HIV–infected women of childbearing age in the U.S. The high proportion of women with missing data on basic health care information highlights the need for improvement in our health care systems for the populations affected by HIV in the U.S. That will require improved collection of the data to better assess progress in prevention of mother-to-child transmission in the U.S.
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