Mother-To-Child Transmission of the HIV Virus

Problem

Throughout pregnancy, during delivery and even postpartum, there are several pathways by which an HIV-infected mother can infect her child. This mother-to-child transmission of the virus, also referred to as vertical transmission is a public health issue that begs mitigation. Health care researchers have worked towards the goal of fully suppressing the incidence of transmission pathways by: addressing the gestational, delivery and postpartum viral loads of the mother; and administering post-prophylaxis treatment to the infant postpartum. While mother-to-child transmission rates have been significantly reduced to-date, they have not yet been reduced to zero or statistically zero.

History

According to the World Health Organization (WHO), approximately 10 million infants had been born infected with HIV by the year 2000, with an estimated 600,000 of those cases occurring in 1999 alone, mostly in developing nations [10]. These dismal statistics improved drastically with zidovudine monotherapy becoming widespread; zidovudine monotherapy has been associated with a decrease in perinatal HIV transmission from 25.5 percent to 8.3 percent [5]; 3.8% for women receiving dual antiretroviral therapy with no or one highly active drug (Multi-ART); and 1.2% for women receiving highly active antiretroviral therapy (HAART) [6].

Current State

Current research/estimates has found that (what are the current mother-to-child transmission rates) the majority (50 to 80 percent) of vertical transmissions occur around time of birth, with the chances of vertical transmission increased with the decreased complexity of the antiretroviral therapy received by the mother and with the mother's increased viral load [10]. Considering the chance of postpartum vertical transmission during breastfeeding, however, research recommends that mothers undergo repeat testing through twelve months postpartum to verify their HIV statuses. It is not apparent that this follow-up testing is currently being done in the United States, or if it is being done it is not being documented [10]. Risk of vertical transmission was 2.8 times higher (22.7 percent) among women with incident HIV infection in the postpartum period compared to women with chronic HIV [7].

While academics generally agree that compared to other antiretroviral therapies, HAART (the most complex) is the most effective at reducing the risk of vertical transmission. However, the treatment remains inaccessible in the United States, with costs ranging from $10,000-$20,000 per patient per year [4]. This is a highly inaccessible cost, considering that the average median household income was $61,372 in 2017 [8].

Viewpoints

Schools of thought appear to be unanimous on topics pertaining to vertical transmission of the HIV virus. Since there are no known ethnic differences in virologic, immunologic, or clinical outcomes to HAART [2], there is an apparent consensus agreement that more complex antiretroviral therapies are universally more effective at minimizing risk of vertical transmission [6, 16]; and that mothers who began antiretroviral therapy prior to conception are more likely to experience adverse pregnancy outcomes such as preterm birth and low birthweight [9, 17]. Academics agree that due to pregnant and postpartum women being similarly susceptible to HIV-1 acquisition, mothers should be screened for infection status both during gestation and post-partum. [7, 11]

Possible Solutions

Public health policy makers can use these findings to support any legislation they may propose incentivizing HIV screening for women that are trying to conceive. This will improve quality of care for HIV-1 infected mothers: if mother HIV-status is known before conception, health care providers might recommend that other antiretroviral therapies are used prior to conception, but that the specific prescription cocktail characteristic of ART is started after conception to reduce the risk of adverse pregnancy outcomes. Policy makers can also use these findings to support any legislation they may propose requiring that highly active antiretroviral therapy should be made affordable.

REFERENCES

1. Achievements in Public Health: Reduction in Perinatal Transmission of HIV Infection United States, 1985--2005. (n.d.). Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a3.htm
2. Anastos, K., Schneider, M. F., Gange, S. J., Minkoff, H., Greenblatt, R. M., Feldman, J., Cohen, M. (2005). The Association of Race, Sociodemographic, and Behavioral Characteristics With Response to Highly Active Antiretroviral Therapy in Women.Journal of Acquired Immune Deficiency Syndromes,39(5).
3. Aschengrau, A., & Seage, G. R. (2010).Essentials of epidemiology in public health(2nd ed.). Sudbury, MA: Jones and Bartlett Publ.
4. Bartlett C, Doyal L, Ebrahim S et al. The causes and effects of socio-demographic exclusions from clinical trials.Health Technol Assess.2005;9(38)
5. Connor, E.M., Sperling, R.S., Gelber, R., Kiselev, P., Scott, G., O'Sullivan, M.J. et al. (1994). Reduction of maternal- infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. New England Journal of Medicine, 331, 1173-80.
6. Cooper, E. R., Charurat, M., Mofenson, L., Hanson, I. C., Pitt, J., Diaz, C.,  Blattner, W. (2002). Combination Antiretroviral Strategies for the Treatment of Pregnant HIV-1 Infected Women and Prevention of Perinatal HIV-1 Transmission.JAIDS Journal of Acquired Immune Deficiency Syndromes,29(5), 484-494. doi:10.1097/00042560-200204150-00009
7. Drake, A. L., Wagner, A., Richardson, B., & John-Stewart, G. (2014). Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis.PLoS Medicine,11(2). doi:10.1371/journal.pmed.1001608
8. Kurt, D. (2018, October 9). What Is the Average Income in the U.S.Retrieved from https://www.investopedia.com/personal-finance/what-average-income-us/
9. Machado, E. S., Hofer, C. B., Costa, T. T., Nogueira, S. A., Oliveira, R. H., Abreu, T. F., Lambert, J. S. (2008). Pregnancy outcome in women infected with HIV-1 receiving combination antiretroviral therapy before versus after conception.Sexually Transmitted Infections,85(2), 82-87. doi:10.1136/sti.2008.032300
10. Mcgowan, J. P., & Shah, S. S. (2000). Prevention of perinatal HIV transmission during pregnancy.Journal of Antimicrobial Chemotherapy,46(5), 657-668. doi:10.1093/jac/46.5.657
11. Mercey, D. (1998). Antenatal HIV testing.Bmj,316(7127), 241-242. doi:10.1136/bmj.316.7127.241
12. Ranganathan M, Bhopal R. Exclusion and inclusion of nonwhite ethnic minority groups in 72 North American and European cardiovascular cohort studies.PLoS Med.2006;3(3):e44.
13. Rogers, W., & Lange, M. M. (2013). Rethinking the Vulnerability of Minority Populations in Research.AM J Public Health. doi:10.2105/AJPH.2012.301200
14. Sheon, A. R., Fox, H. E., Rich, K. C., Stratton, P., Diaz, C., Tuomala, R., .Alexander, G. (1996). The Women and Infants Transmission Study (WITS) of Maternal-Infant HIV Transmission: Study Design, Methods, and Baseline Data.Journal of Womens Health,5(1), 69-78. doi:10.1089/jwh.1996.5.69
15. Towers, C. V., Deveikis, A., Asrat, T., Major, C., & Nageotte, M. P. (1998). A bloodless cesarean section and perinatal transmission of the human immunodeficiency virus.American Journal of Obstetrics and Gynecology,179(3), 708-714. doi:10.1016/s0002-9378(98)70069-9
16. Townsend, C. L., Cortina-Borja, M., Peckham, C. S., Ruiter, A. D., Lyall, H., & Tookey, P. A. (2008). Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000-2006.Aids,22(8), 973-981. doi:10.1097/qad.0b013e3282f9b67a
17. Uthman, O. A., Nachega, J. B., Anderson, J., Kanters, S., Mills, E. J., Renaud, F., Mofenson, L. M. (2017). Timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: A systematic review and meta-analysis.The Lancet HIV,4(1). doi:10.1016/s2352-3018(16)30195-3

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