March 12, 2002
"This has been the leading edge of success in HIV prevention," said Robert Janssen, M.D., director of the CDC's Division of HIV Prevention. "The real goal now is elimination."
Since the breakthrough of the 076 trial, transmission rates in the US have declined from 15 to 20 percent to as low as 1 to 3 percent. That translates to less than 250 HIV-positive infants born a year. In North Carolina, where more than 1,000 babies had been exposed to HIV over a six-year period, only one to three infants per year become infected now. "Recognizing and trying to find the unique situations where the infant doesn't receive benefits of prevention is increasingly difficult," said Catherine Wilfert, M.D., scientific director of the Elizabeth Glazer Pediatric AIDS Foundation and a leading researcher in pediatric HIV.
At the foundation of the elimination quest has been the remarkable success of antiretroviral therapy for infected mothers. New research shows that transmission is virtually halted in women with an undetectable viral load. "If we can get them down to undetectable levels, we can virtually eliminate transmission, so that is what we are trying to do in the elimination process," said Martha Rogers, M.D., a former CDC researcher and now director of the Collaborative Center for Child Wellbeing.
While all infections can be prevented with prophylaxis and treatment, elimination, experts say, is a reasonable goal but one that will require sustained resources and effort. The CDC has chosen to continue dedicating the $10 million annual outlay set aside for perinatal prevention, even though Congress no longer earmarks it. "When you move toward elimination it actually requires more, not less, money because you are trying to get at the hardest to reach people," Janssen said. "So, it didn't take long to say, 'No, we are going to keep using this for perinatal prevention.'"
The Office of the Inspector General is expected soon to release a report evaluating how well obstetricians have been screening pregnant women for HIV. And in April, Secretary of Health and Human Services Tommy Thompson will provide recommendations for each state on how they can further reduce perinatal transmission.
At the same time, providers are implementing recent revisions to the CDC's updated guidelines for perinatal HIV prevention and HIV testing in pregnant women. The guidelines include simpler, more flexible pre-test counseling and emphasize the need to question women if they refuse testing. Guiding where efforts need to be improved are 25 enhanced perinatal surveillance project areas created by the CDC to provide more mother and child data. "Surveillance data are critical for planning, prevention, targeting activities and assessing missed opportunities," said Teresa Hammett, MPH, a researcher in the CDC's HIV surveillance branch.
Preliminary results from 17 project areas reporting between 1999 and 2001 include data from 1,879 exposed infants. Among the findings that highlight areas for improvement are: *25% of drug-using women didn't receive prenatal care; *30% of mothers were diagnosed with at least one STD during pregnancy. The most common STDs were trichomoniasis (42%), chlamydia (41%), syphilis (17%), and genital herpes (17%); *HIV status of women was documented in only 90% of medical charts.
Various programs have used creative strategies to reach women. Some have been crucial in getting substance-abusing women into prenatal care. These include seeking patients in parks, laundromats and bars, providing emotional and survival needs, and taking women to clinics. The Baltimore Pediatric AIDS Program, for instance, has reduced transmission to just one of 48 babies born to infected mothers at the University of Maryland facility in the past two years. Part of their success is attributed to non-clinical services, including counseling on completing therapy and providing transportation.
A recent trend of concern to health officials is the increasing number of HIV-positive women choosing to become pregnant. Officials recommend that providers not just take no for an answer. If a woman refuses testing, counselors should find out why in the hopes that once a woman's issues are addressed she may accept testing. New guidelines also provide more flexibility to allow different types of consent such as "opt-in, opt-out," so long as this doesn't conflict with state laws and hospital policies.