Ethnic Disparity in HIV Prevalence and Zidovudine Treatment Among Childbearing Women and Pediatric AIDS Cases in California

Almost all HIV infections in children under 14 years old, and 90 percent of pediatric AIDS cases, are attributed to mother-to-child transmission. In 1994, this study reports, the AIDS Clinical Trials Group Protocol 076 showed that multi-course zidovudine treatment for the mother and neonate resulted in a dramatic reduction of MTC HIV transmission. The protocol formed the basis for the California Public Health Service's guidelines, established in 1995, calling for routine HIV counseling and voluntary testing for all pregnant women, and for the use of zidovudine to reduce the risk of MTC transmission.

Significant progress in reducing MTC HIV transmission has been made in the United States, but pediatric HIV infection is still a concern. The authors noted that women of childbearing age comprise the fastest-growing group of newly reported AIDS cases in this country. The authors compared the prevalence of HIV and zidovudine treatment by ethnicity among a cross-sectional survey of childbearing women in California in 1998, and the number of pediatric AIDS cases from 1998 to 2001.

During the third quarter of 1998, public health officials collected 119,108 dried-blood samples, collected via infant heel-stick for metabolic screening, and anonymously tested them for HIV antibody. For each specimen, the Genetic Disease Branch furnished information about the mother's race and ethnicity. Researchers sent the HIV-positive specimens to the CDC Newborn Screening Quality Assurance Program, where investigators measured levels of zidovudine in the specimens.

Of the 119,108 blood samples tested, 77 were HIV antibody positive, for an HIV seroprevalence rate of 0.65 per 1,000 women giving birth in California, the authors report. African-American mothers accounted for 37.7 percent of the 77, followed by Latina mothers at 35.1 percent, and white mothers at 20.8 percent. The investigators found a 76.6 percent prevalence of zidovudine among HIV-infected childbearing women. They found the absence of zidovudine therapy among 23.4 percent of the HIV-positive mothers. Absence of therapy was highest for African-American mothers (29.6 percent) and Latina mothers (24.1 percent).

Between 1998 and 2001, 41 pediatric AIDS cases were reported. Eighteen cases among Latino children and 15 cases among African-American children accounted for most of the pediatric AIDS cases diagnosed during that period.

Ruiz and colleagues report that although Latina and African-American mothers were more likely to have AIDS in 1998, they were less likely to receive zidovudine therapy. "The ethnic disparity of HIV cases and zidovudine therapy among childbearing women may have played a role in the disproportionate number of Latino and African-American children subsequently diagnosed with AIDS," they wrote.

The authors suggest that inequity in therapy may reflect the fact that Latina and African-American women receive inadequate prenatal care. Late or no prenatal care, they speculate, can reduce the chance of pregnant women receiving HIV testing or counseling. Or, they hypothesize, prenatal care providers may spend insufficient time discussing HIV with patients, or may do so in a culturally inappropriate way.

Ruiz and coauthors refer to the CDC-funded rapid testing program MIRIAD (Mother Infant Rapid Intervention at Delivery), which focuses on five minority communities and gives women the chance to be tested for HIV before labor. Those who test positive receive counseling and information about zidovudine therapy. "This rapid intervention before labor may prevent several pediatric AIDS cases each year," they wrote. They stressed "the need for the detection of childbearing women who do not receive HIV testing or zidovudine prophylaxis, and the development of effective community-based interventions and outreach programs," concluding that "The successful implementation of these programs may dramatically reduce the number of pediatric AIDS cases in California."

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