Observations about casual transmission.
Jan 13, 2009
Not to beat a dead horse but some observations about the discussion of the public's concerns about "casual" HIV transmission that started when you suggested the young children of an HIV positive father and HIV (so far) negative mother get tested for HIV.
I'm an MD, and the grandfather who posted about my family's concerns about my contact with my new grandchild.
You quote an article in AIDS Research and Human Retroviruses. August 1, 2004 discussing transmission of HIV to a child in a family where the father is postivie and the mother negative, it concludes "Epidemiological and molecular data strongly suggest that horizontal transmission had occurred, probably related to the close father-to-child contact" An open ended remark with no further explanantion. Another article claims the postivie father probably trasmitted the disease throught bleeding skin lesions from atopic dermatitis, even that goes wanting because it doesn't explain how the child contracted the disease.
Thank god these kinds of articles don't find their way into the lay press or we would all find ourselves back where we started...kept at arms length from society and family members.
You know as well as I do that telling a patient that something can happen but is very RARE, many assume it will still happen to them even if one in a million.
1 - 0.6 in 10,000 is the risk of getting HIV as the negative insertive partner. Very very rare, yet here I am, postive, as an exclusive top,
My HIV provider told me I should inform my dentist and hygentist that I'm positive, even though there have been, to date, no cases of of patient to dentist transmission. They use usniversal precautions and revealing such information risks it "getting out" in my small town which could devastate my medical practice. My provider then explained that the dentist would know to check for HIV related disease. But a dentist should be checking for that anyway.
After having superficial phlebitis my vascular surgeon friend and I were considering a laser vein ablation. When I told him I was positive (after weighing whether or not I should) he switched gears and suggested I use compressoin stockings instead.
Do you get my point here?
The fear of HIV is such that telling someone that transmission through casual contact is VERY VERY VERY rare like in those articles means it can still happen. When children are the possible victims fears get even more irrational. Sometimes medical providers, innocently enough, contribute to those fears.
Response from Dr. Frascino
Sorry, but totally disagree with you. It's our job as physicians to provide our patients with accurate information, not to protect them from information that we think they can't handle or appropriately consider. Providing scientific information within context is exactly why I posted those abstracts. When people are informed and educated they respond appropriately to situations involving risk assessment. For instance, people know that when they walk in a rainstorm there is a possibility they'll be zapped dead by a bolt of lightening. However, they also know the chances of that happening are so incredibly low that the level of risk becomes acceptable. The same can be said for the risk of driving a car or flying in an airplane. The reason HIV remains so much a problem that even you are fearful of revealing your HIV-positive status to your own health care team (dentist and hygienist) is that there has been far too much misinformation, myth and stigma associated with this disease. Being less than honest about what we know won't help. In fact it only perpetuates the problem.
I do sympathize with your small town situation. However, the answer to small town mentality is education and the provision of more information, not less. I absolutely agree with your HIV provider. You should advise your dentist and hygienist that you are HIV positive. The reason to do so has nothing to do with universal precautions. I agree these must be followed on all patients. Rather, this disclosure is for your benefit. Oral/dental health is linked to immune integrity. As a physician, you should well understand how this piece of information could be critical to accurate and timely evaluation, diagnosis and treatment of various oral/dental problems.
As for your vascular surgeon friend, shame on him. There is absolutely no reason you should not have any required or recommended surgical procedure. I'd recommend you go see a more competent and compassionate vascular surgeon and have the procedure done. Then send your "friend" a copy of the operative report and use this as an opportunity to educate him. You could also have your HIV provider give him a call. Once again, it's more information, not less, that will eventually enlighten your "friend" to the true risks of operating on HIV-positive patients.
So "do I get the point?" Yes, I believe I do, but unfortunately it's obvious you do not. I urge you to reconsider. Meanwhile I will continue to provide science-based factual information, even if the information requires considerable explanation.
Re: testing the kids Jan 10, 2009
I'm sorry, I'm confused now. If the mother is testing negative now, even if she tests postive in three or six months that indicates the infection was recent or her first test would have been positive; the last child was born 7 years ago, she HAD to have been negative when they were conceived/born and couldn't transmit the virus to them since she didn't have it then. Are you saying that the pos FATHER could have transmitted HIV to a child during conception when the mother was negative?
Response from Dr. Frascino
Yours was one of several questions I received following my post concerning possible father-to-child HIV transmission. (See below.) I apologize for the confusion. I was a bit reluctant to respond to this question, because I was worried readers might misinterpret my comments. That's one of the problems with trying to provide advice over the Internet. It doesn't allow me the luxury of a conversation whereby I can address any confusion or more completely explain the rationale behind my advice.
I'll try to clear up the confusion with this more extended explanation and I'll post this same reply to others who were also confused.
OK, here we go! The questioner asked whether I would recommend testing her three children ages 11, 8 and 7, because she had just found out that her husband of 12 years was HIV positive and had a CD4 count of 193. Her initial HIV test was negative, immediately after finding out her husband was HIV infected. With this limited information, my advice was yes, she should test her children. I recommended this primarily because her husband's very low CD4 count was indicative of longstanding HIV infection. Also, since he was unaware of his HIV-positive status, he obviously was not on antiretroviral treatment and therefore probably had a high HIV plasma viral load. In addition, because he was unaware of his HIV positive status absolutely no precautions were taken to prevent possible horizontal transmission to the child.
To be more specific there are a number of reasons I recommended testing the kids even though the mother just tested HIV negative.
1. The possibility (albeit slight) that the mother's first HIV test is a false negative. (She certainly presumably had very significant and repeated exposures to her husband over many years. He was not on antiretrovirals and presumably had a high viral load.)
2. Mother-to-child transmission accounts for the vast, vast, vast majority of HIV infection in children less than 15 years of age. However, there have been a few cases of father-to-child transmission. (I'll post several abstracts from the medical literature below that discuss these very rare cases.) The evidence that fetal infection could result from integration of HIV in sperm remains controversial at best. Certainly the insemination of HIV-negative women with the processed ("washed") semen of their HIV-positive partners has resulted in uninfected babies. And there have been several studies that did not find evidence for vertical transmission in children born to HIV-positive male hemophiliacs (see below). Consequently father-to-child transmissions are most likely horizontal rather than vertical transmissions. That means they probably occurred after birth. In one case (see below) the authors of the abstract postulate a father's bleeding skin lesions from his atopic dermatitis may have been the cause. Also, it is difficult to exclude any sort of sexual contact between father and child.
3. The extremely unlikely theoretical possibility of father-to-child vertical transmission (although this has never been documented to my knowledge).
Hopefully that more clearly explains my suggestion to test the children. A simple 20-minute rapid test would give a definitive result and remove even the shadow of doubt as to whether any of the children could have contracted HIV either vertically or horizontally from there chronically infected father.
It's also extremely important to point out that I am not in any way, shape or form suggesting that HIV can be transmitted by causal contact! It cannot! These father-to-child transmissions are extremely rare occurrences and definitely not related to casual contact.
The advice I gave to the mother was to help a family that most certainly must be going through a very stressful time. Knowing definitively that their kids have not been infected will be one less worry for these parents. I believe it's extremely unlikely the children were infected, but I still would recommend testing. I hope that clears up any confusion.
Do my kids need to be tested? Jan 6, 2009
My husband of 12 years was recently diagnosed as HIV+. I was immediately tested and was negative. I will take another test in 2 months. His cd4 count was 193 which the doctor told him was statistically AIDS. Our kids are 11,8,7. Do they need to be tested? Also, is it possible that my next test will also be negative?
Response from Dr. Frascino
Your husband's CD4 count of 193 does qualify for an AIDS diagnosis (CD4 count less than 200). This low CD4 count is an indication that your husband most likely has been HIV infected for a number of years, perhaps as many as 5 to 10. Consequently I would recommend all three children get an HIV-antibody test.
That you tested negative is very encouraging. However, you will need additional HIV-antibody testing at three and six months from the time of your last potential exposure (unprotected sex). Is it possible you could continue to test HIV negative? Yes, it's possible. Luckily not every HIV exposure leads to HIV transmission. Check out the testimonials in the archives and you'll find others who found themselves in situations similar to yours and yet remained conclusively HIV negative.
Epidemiological and Molecular Evidence of Two Events of Father-to-Child HIV Type 1 Horizontal Transmission Ana Ceballos, Guadalupe Andreani, Silvia E. Gonzalez Ayala, Yamila Romer, Isabel Rimoldi, María Rosa Agosti, Liliana Martinez Peralta. AIDS Research and Human Retroviruses. August 1, 2004, 20(8): 789-793. doi:10.1089/0889222041725154.
HIV-1 infection in children less than 15 years of age is mainly due to mother-to-child transmission. The aim of this work was to investigate molecular evidence to prove father-to-child horizontal transmission in two possible events of transmission. In the first event a boy was identified as HIV infected at 23 years of age. At the same time infection was confirmed in the father, while mother and siblings were negative. In the second event a girl was negative for HIV at age 1 and identified as HIV-1 infected at age 6. The father's HIV infection was diagnosed in the same period while the mother was repeatedly negative. No evidence of sexual assault or transfusion was recorded in any case. Peripheral blood mononuclear cells were obtained from both fathers and children. After PCR amplification, the C2V3 region of the envelope gene and the region coding for amino acid 132 of p24 up to amino acid 40 of p7 of the gag gene were sequenced. Genetic distance measurements and phylogenetic tree analysis showed that in both cases the father's and child's viral sequences were closely related. They were distinct when compared to Argentine sequences including sequences from the same geographic region. Epidemiological and molecular data strongly suggest that horizontal transmission had occurred, probably related to the close father-to-child contact.
A new case of horizontal transmission in Buenos Aires Province, Argentina. Ceballos A, Ayala SG, Agosti M, Rimoldi I, Rabinovich RD, Avila MM, Peralta LM; International Conference on AIDS.
Int Conf AIDS. 2002 Jul 7-12; 14: abstract no. TuPeC4760. National Reference Centre for AIDS Facultad de Medicina Universidad de Buenos Aires, Buenos Aires, Argentina
Background Our group presented a paper in the IAS Conference, Buenos Aires 2001, showing the molecular evidence of father-child HIV-1 horizontal transmission. This is a new case of an HIV infection in a child in which the only risk factor recorded was living with his HIV infected father. The aim of this work was to analyse molecular evidences to prove father to child horizontal transmission. Methods Peripheral blood mononuclear cells were obtained from both father and child. After PCR amplification, C2V3 region of envelope gene and p24-p7 region from gene gag of HIV-1 were sequenced. Then phylogenetic and comparative sequence analyses were performed. Results The child, a girl born in 1994 in Buenos Aires province, Argentina, was negative for HIV at 2-3 years of age. She was identified as HIV-1 infected in April 2001, and had symptoms of a primoinfection (adenopathies & purulent otitis) in 2000. At present the girl is asymptomatic with normal development. No evidence of sexual assault was recorded and she did not receive a transfusion. The father was diagnosed as HIV-1 and HCV infected in 1996. The mother had no control during pregnancy, but she has been HIV and HCV negative so far. Three separate comparative genetic analysis, genetic distance measurements, phylogenetic tree and amino acid signature pattern analysis, showed that both father and child's viral sequences are closely related in both env and gag region, and were distinct from the reference sequences and those obtained from epidemiologically unlinked mother-child HIV infected pairs included in the analysis. Conclusion The epidemiological and molecular data strongly suggest that horizontal transmission has occurred. It is almost impossible though, to exclude any sort of sexual contact between father and child. Since this is the second case we observed of a possible horizontal transmission between father and child, it is very important to determine the real transmission way to prevent further cases.
Horizontal transmission of human immunodeficiency virus type 1 from father to child.Salvatori F, De Martino M, Galli L, Vierucci A, Chieco-Bianchi L, De Rossi A. Department of Oncology and Surgical Sciences, AIDS Reference Center, University of Padova, Italy.
An unusual case of human immunodeficiency virus type 1 (HIV-1) infection in a child was studied. The child, identified as HIV-1 infected at 5 years of age, lived with his parents and a 3-year-old sister. HIV-1 infection was excluded in the mother and sister, but confirmed in the father, who was unaware of his infection and was in good health, apart from an atopic dermatitis on the face and limbs. A portion of the HIV-1 proviral envelope gene was amplified from the father's and child's peripheral blood cells, and the amplified products were cloned and sequenced. Phylogenetic analysis disclosed that the father's and child's viral sequences clustered together, and were clearly distinct from the sequence sets obtained from six epidemiologically unlinked mother-child HIV-1-infected pairs included in the analysis. HIV-1 variability was lower in the child's sequence set than in the father's, and the variability between father's and child's sequences was significantly lower than that found between epidemiologically unlinked cases (p < 0.001). An uncommon APGR motif on the tip of the V3 domain was found in both the father's and child's viral clones. These data, together with the epidemiological investigations, strongly suggest that the child acquired the infection from his father, possibly by exposure to bleeding skin lesions.
No Evidence for Vertical Transmission in Children Born to HIV Seropositive Male Haemophiliacs Authors: Erik Berntorp a; Sam Schulman b; Inga Marie Nilsson a Affiliations: a Department of Coagulation Disorders, University of Lund, Malm b Department of Internal Medicine, Karolinska Hospital, Stockholm, Sweden
In order to evaluate the risk of HIV transmission during conception or pregnancy from seropositive male haemophiliacs to their children, we have investigated the families of 8 HIV antibody positive haemophilia A patients. HIV antibodies could be demonstrated in 1/9 mothers after delivery of her second child, whereas all the other mothers tested were seronegative. Of the 14 children studied at least 7 must have been conceived when the father was already seropositive. HIV antibodies were tested for in 6 of these 7 children; all were negative. All 14 children are healthy and free from clinical signs of HIV infection. We conclude that the overall risk of perinatal HIV transmission in haemophilic families should be low and this knowledge may be invaluable in family counselling.
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