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Pregnancies in young women with vertically acquired HIV infection in Europe

2007; Lippincott Williams & Wilkins; Volume: 21; Issue: 18 Linguagem: Inglês

10.1097/qad.0b013e3282f08b5f

1473-5571

Claire Thorne, Claire L Townsend, Catherine Peckham, Marie‐Louise Newell, P Tookey,

Adolescent Sexual and Reproductive Health

Paediatric HIV infection has become a chronic childhood disease in resource-rich settings, and a small group of 'long-term survivors' of vertically acquired HIV infection born before the availability of effective treatment are now adolescents or young adults [1,2]. Pregnancies in vertically infected adolescents have been reported from the United States [3–5], Puerto Rico [6] and India [7]. We report here, for the first time to our knowledge, a small series of pregnancies in young women with vertically acquired HIV infection in Europe from the United Kingdom and Ireland's National Study of HIV in Pregnancy and Childhood and the European Collaborative Study. The full methods of both studies have been described elsewhere [8,9]. Pregnant women were classified as vertically infected if they were diagnosed before their 14th birthday, vertical infection was reported as their likely mode of acquisition and their mother was known to have HIV infection. Eleven pregnancies in nine young women have been reported (Table 1); two were terminated and nine resulted in live births. Three of these women were also reported to have been pregnant before the index pregnancy: two reported previous termination of pregnancy (cases 2 and 4) and one a previous first trimester miscarriage (case 5), but no further details about these pregnancies were available.Table 1: Maternal, delivery and infant characteristics of nine vertically infected young women.In all but two of the 11 pregnancies, the women were receiving HAART at conception, and all were heavily pretreated. The median CD4 cell count closest to delivery/termination was 190 cells/μl (range 18–642). The median HIV-RNA viral load in the eight pregnancies with detectable levels (>50 copies/ml) close to delivery/termination was 361 copies/ml (range 59–6600). Three women delivered with undetectable viral load: one had an emergency caesarean section at 32 weeks and two were among the six delivered by elective caesarean section. One woman delivered vaginally at 39 weeks, with a viral load of 282 copies/ml and one by emergency caesarean section at 33 weeks, with a viral load of 82 copies/ml. Of the nine infants, one was confirmed uninfected (negative antibody test at 18 months; case 1a), seven were presumed uninfected (repeated polymerase chain reaction tests all negative, but not confirmed with antibody test; cases 1b, 2, 4, 5, 7–9), and the most recently born is still of indeterminate infection status (case 3b). Although this corresponds to a 0% mother-to-child transmission rate, the 95% confidence limit would be 36.9%. Two infants had low birth weight adjusted for gestational age [10]: case 1b (16th centile; z-score −1.0) and case 5 (1st centile; z-score −2.2). Two had congenital abnormalities: partial malrotation of the gut; ventricular septal defect, patent foramen ovale. These women were born before the HAART era (all but two before 1988) and represent a group of 'long-term survivors' [1,2]. Throughout Europe an increasing proportion of younger vertically infected children treated with HAART will survive into young adulthood [11–13]; approximately 300 vertically infected girls and young women born between 1988 and 1996 are currently living in the United Kingdom (National Study of HIV in Pregnancy and Childhood, unpublished data). Research into the reproductive intentions and sexual behaviour of young people with vertically acquired HIV is limited [5], but access to specialized sexual health services and support is a crucial component of the complex needs of HIV-infected young people [14]. When care is based in a paediatric setting such services may be difficult to access. All these young women received HAART in pregnancy, and most had previous experience of lengthy and complex drug regimens. Two-thirds of those who delivered had detectable, but relatively low, HIV-RNA levels. Although resistance data were not available, their treatment history would predispose them to an increased risk of drug resistance. Young people may have problems adhering to HAART [15–16] and pregnancy could compound this: young infected pregnant women are likely to need additional adherence support [17]. The lack of transmissions here is reassuring, but an increased risk associated with maternal vertically acquired HIV infection cannot be excluded, although this would probably be mediated by factors including virological failure, drug resistance and advanced HIV disease. Transition of care from paediatric to adult HIV services has become increasingly important as the paediatric HIV epidemic has matured. Various models have been suggested to facilitate transition, including dedicated adolescent/youth clinics [14,18]. This series of pregnancies is an early indication of the need to develop appropriate strategies for vertically infected young people, both before and during pregnancy, and to monitor transmission rates in this group. Some of these considerations will also apply to HIV-infected pregnant women who were diagnosed many years ago and have accumulated long-term complex treatment histories. Acknowledgements National Study of HIV in Pregnancy and Childhood (NSHPC): Comprehensive surveillance of obstetric and paediatric HIV is undertaken in the UK and Ireland through the NSHPC in collaboration with the Health Protection Agency Centre for Infections, and Health Protection Scotland. The authors gratefully acknowledge the contribution of the midwives, obstetricians, genitourinary physicians, paediatricians, clinical nurse specialists and other colleagues who report to the NSHPC through the British Paediatric Surveillance Unit of the Royal College of Paediatrics and Child Health, and the obstetric reporting scheme run under the auspices of the Royal College of Obstetricians and Gynaecologists. The authors would like to thank Janet Masters and Icina Shakes from the NSHPC. They would especially like to thank K. Butler (Our Lady's Hospital for Sick Children, Dublin), J. Mok (Royal Edinburgh Hospital for Sick Children), L. Arnot (Ninewells Hospital, Dundee), M. Douglas (St Mary's Hospital, London), S. Dalton and M. Khaled (Colchester Hospital), and D. Aleksin (King's College Hospital). European Collaborative Study (ECS): The authors would like to thank the women and children who participate in the ECS. They would especially like to thank Professor I. Grosch-Woerner, Dr Thomas Schmitz and Dr C. Feiterna-Sperling (Charite Virchow-Klinikum, Berlin, Germany), Dr T. Goetghebuer, Dr P. Barlow and Dr M. Hainaut (Hopital St Pierre, Brussels, Belgium) and Dr C. Giaquinto and Dr O. Rampon (Universita degli Studi di Padova, Padua, Italy) for their assistance. The ECS collaborators are: Dr C. Giaquinto, Dr O. Rampon and Professor A. De Rossi (Universita degli Studi di Padova, Padua, Italy); Professor I. Grosch Wörner, Dr C. Feiterna-Sperling, Dr T. Schmitz, Dr S. Casteleyn (Charite Virchow-Klinikum, Berlin, Germany); Dr J. Mok (Royal Hospital for Sick Children, Edinburgh, UK); Dr I. de José, Dr I. Bates, Dr B. Larrú, Dr J. Ma Peña, Dr J. Gonzalez Garcia, Dr J.R. Arribas Lopez, Dr M.C. Garcia Rodriguez (Hospital Infantil La Paz, Madrid, Spain); Professor F. Asensi-Botet, Dr M.C. Otero, Dr D. Pérez-Tamarit (Hospital La Fe, Valencia, Spain); Dr H. Scherpbier, M. Kreyenbroek, Dr M.H. Godfried, Dr F.J. Nellen, and Dr K. Boer (Academisch Medisch Centrum, Amsterdam, the Netherlands); Dr A.B. Bohlin, Dr S. Lindgren (Karolinska University Hospital Huddinge, Stockholm, Sweden); Professor J. Levy, Dr M. Hainaut, Dr T. Goetghebuer, Dr Y. Manigart, Dr P. Barlow (Hospital St Pierre, Brussels, Belgium); Dr A. Ferrazin and Professor C. Viscoli, (Department of Infectious Diseases, University of Genoa, Genoa, Italy); Professor A. De Maria (Department of Internal Medicine, University of Genoa, Genoa, Italy); Professor G. Bentivoglio, Dr S. Ferrero, Dr C. Gotta (Department of Obstetrics and Gynecology-Neonatology Unit, University of Genoa, Genoa, Italy); Professor A. Mûr, Dr A. Payà, Dr M.A. López-Vilchez, Dr R. Carreras (Hospital del Mar, Universidad Autonoma, Barcelona, Spain); Dr N.H. Valerius, Dr V. Rosenfeldt (Hvidovre Hospital, Hvidovre, Denmark); Dr O. Coll, Dr S. Hernández, Dr J. Pascual, Dr J.M. Perez (Hospital Clínic, Barcelona, Spain); Dr V. Savasi, Dr S. Fiore, Professor E. Ferrazzi (Department of Obstetrics, L. Sacco Hospital, Milan, Italy); Professor A. Viganò, Dr V. Giacomet (Department of Paediatrics, L. Sacco Hospital, University of Milan, Milan, Italy); Dr S. Alberico, Dr M. Zanette, Dr V. Soini, Dr C. Businelli (IRCCS Burlo Garofolo, Trieste, Italy); Dr G.P. Taylor, Dr E.G.H. Lyall (St Mary's Hospital, London, UK); Ms Z. Penn (Chelsea and Westminster Hospital, London, UK); Drssa W. Buffolano, Dr R. Tiseo, (Pediatric Department, Federico II University, Naples, Italy); Professor P. Martinelli, Drssa M. Sansone, Dr A. Agangi (Obstetric Department, Federico II University, Naples, Italy); Dr C. Tibaldi, Dr S. Marini, Dr G. Masuelli, Professor C. Benedetto (University di Torino, Turin, Italy); Dr T. Niemieç (National Research Institute of Mother and Child, Warsaw, Poland); Professor M. Marczynska, Dr A. Oldakowska, M. Kaflik (Medical University of Warsaw, Warsaw, Poland); Dr R. Malyuta (Odessa, Ukraine); Dr I. Semenenko, T. Pilipenko (Kiev, Ukraine); Dr S. Posokhova, Dr T. Kaleeva, (Regional Hospital, Odessa, Ukraine); Dr A. Stelmah, Dr G. Kiseleva (Simferopol, Ukraine). For a list of acknowledgements, please see a recent publication of the ECS. Sponsorship: The NSHPC receives funding from the Department of Health and the Health Protection Agency. The ECS is a coordination action of the European Commission (PENTA/ECS 018865). The Medical Research Council (UK) Sexual Health and HIV Research Strategy Committee provided support to the ECS coordinating centre. Research at the Institute of Child Health benefits from research and development funding received from the Department of Health.