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Risk factors for in utero and intrapartum transmission of HIV.
Magder LS, Mofenson L, Paul ME, Zorrilla CD, Blattner WA, Tuomala RE, LaRussa P, Landesman S, Rich KC.
J Acquir Immune Defic Syndr
2005 Jan 1;38(1):87-95.
Abstract
OBJECTIVE: To identify predictors of in utero and intrapartum HIV-1 transmission in infants born in the Women and Infants Transmission Study between 1990 and 2000. METHODS: In utero HIV-1 infection was defined as an infant with the first positive HIV-1 peripheral blood mononuclear cell culture and/or DNA polymerase chain reaction assay at 7 days of age or younger; intrapartum infection was defined as having a negative HIV-1 culture and/or DNA polymerase chain reaction assay at 7 days of age or younger and the first positive assay after 7 days of age. RESULTS: Of 1709 first-born singleton children with defined HIV-1 infection status, 166 (9.7%) were found to be HIV-1 infected; transmission decreased from 18.1% in 1990-1992 to 1.6% in 1999-2000. Presumed in utero infection was observed in 34% of infected children, and presumed intrapartum infection, in 66%. Among infected children, the proportion with in utero infection increased over time from 27% in 1990-1992 to 80% (4 of 5) in 1999-2000 (P = 0.072). Maternal antenatal viral load and antiretroviral therapy were associated with risk of both in utero and intrapartum transmission. Controlling for maternal antenatal viral load and antiretroviral therapy, low birth weight was significantly associated with in utero transmission, while age, antenatal CD4 cell percentage, year, birth weight, and duration of membrane rupture were associated with intrapartum transmission. CONCLUSION: Although there have been significant declines in perinatal HIV-1 infection over time, there has been an increase in the proportion of infections transmitted in utero.
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Reviewed by
Arthur Ammann, MD
Comment
Most vertical HIV infection in non-breast-feeding populations occurs during the intrapartum period. This study finds that, over a 10-year period in the United States, the proportion of HIV-infected infants who were infected in utero increased whereas the proportion who were infected during the intrapartum period decreased.
This shift may be explained by the fact that the factors influencing intrapartum mother-to-child transmission of HIV are more controllable by clinicians than are the factors that influence in utero transmission. Examples of interventions that can dramatically reduce intrapartum transmission include more aggressive intrapartum antiretroviral prophylaxis, including intravenous zidovudine, the use of elective cesarean section, and the reduction of premature rupture of membranes. In contrast, in utero transmission is associated with factors that are more difficult to control, including maternal viral load and the type and the timing of antiretroviral therapy in pregnancy. These factors could be addressed by earlier prenatal HIV testing, improved prenatal care, and earlier and more potent combination antiretroviral treatment of HIV-infected pregnant women for their own infection.
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