Simona Fiore

The incidence of complications after caesarean section in 156 HIV-positive women

ObjectiveTo investigate the risks of post-operative complications in HIV-positive mothers who undergo a caesarean section (CS) because the delivery cannot be safely accomplished by the vaginal route or to protect the infant from viral infection. DesignIn a multicentre study, we reviewed the incidence, and type of post-operative complications in 156 HIV-positive women who underwent a CS. These results were compared with those observed in an equal number of HIV-uninfected women who matched for the indication requiring a caesarean delivery, the stage of labour, the integrity or rupture of membranes, and the use of antibiotic prophylaxis. SettingSeven teaching hospitals providing obstetrical care for mothers infected with HIV. ResultsWe found that six HIV-infected mothers suffered a major complication (two cases of pneumonia, one pleural effusion, two severe anaemia, and one sepsis) compared with only one HIV-negative woman who required blood transfusion after surgery. Minor complications like post-operative fever, endometritis, wound, and urinary tract infections were significantly more frequent in HIV-positive women than controls. Multivariate analysis revealed that in HIV-infected women the only factor associated with a significant increase in the rate of complications was a CD4 lymphocyte count <200±106/l. ConclusionsThe results of our study indicate that HIV-positive mothers are at an increased risk of post-operative complications when delivered by CS. The risk of post-operative complications is higher in HIV-infected women who are severely immunodepressed.

HIV and reproduction.

Purpose of review Three quarters of individuals infected with HIV are in their reproductive years and can expect an almost normal life expectancy under antiretroviral treatment. Many of them want to have a child and reproductive counselling and care can offer a sharp reduction in both sexual and vertical transmission rates. Recent findings Most couples with HIV are formed by an infected man and an uninfected woman; in this setting, semen washing coupled with reproductive technology can be applied to eliminate the risk of sexual transmission of the virus. Semen washing is a processing method which reduces both HIV RNA and DNA to undetectable amounts. In couples in which only the woman is infected, self-insemination might be indicated. When both partners are carrying HIV, semen washing can be used in couples with different viral strains. HIV can be vertically transmitted and the risk of infection for the infant can be decreased to approximately 1% by reducing maternal viral load, elective caesarean section and avoidance of breastfeeding. In pregnancy the efficacy of antiretroviral treatment should be balanced against the possibility of embryonic or fetal toxicity. Caesarean section, performed electively, has proven its protective efficacy, without significant maternal morbidity. Its role should now be reassessed in mothers with undetectable viral load. Breastfeeding, discouraged to avoid postnatal transmission, might be possible in the future, with antiretroviral therapy capable of suppressing viral excretion in maternal milk. Summary Semen washing, reproductive technology, antiretroviral therapy and obstetrical care can work in sequence to allow safe reproduction in couples infected with HIV.

Hepatitis B or hepatitis C coinfection in HIV-infected pregnant women in Europe

The aim of the study was to investigate the prevalence of and risk factors for hepatitis C or B virus (HCV or HBV) coinfection among HIV‐infected pregnant women, and to investigate their immunological and virological characteristics and antiretroviral therapy use.

Reproductive experience of HIV-infected women living in Europe

BACKGROUND The aim of this study was to describe the experience of pregnant and non-pregnant HIV-infected women regarding fertility and childbearing, with a view to inform policies and practices to improve reproductive outcome. METHODS A cross-sectional survey collected information on socio-demographic and basic reproductive characteristics of HIV-infected women in Europe. A total of 403 women participated; 121 were pregnant. RESULTS The median age was 29 years and 84% (228) of women were born in Europe. Overall 68% (275 of 403) had been pregnant at some time. At the time of the survey, 59% (n = 160) of women had no HIV symptoms; severe symptoms were more frequent among non-pregnant than pregnant respondents (36% (65 of 181) versus 5% (4 of 88)). Of the women, 80% reported being in a long-standing relationship; 39% (74 of 190) reported that they became infected by their current partner and, overall, heterosexual infection was reported as the mode of acquisition in 55% (190 of 344). Maternal well-being, no previous live birth and having an uninfected partner were strongly associated with the likelihood of being pregnant. To assess the problems relating to fertility, pregnant and non-pregnant women were considered separately. Overall, 46% of pregnant women reported not using condoms to protect against infection during pregnancy. Of the 60 pregnant women who planned their pregnancies, 10 reported the need for assistance in conceiving: five monitored their ovulation period and five became pregnant through in vitro fertilization. Of 34 non-pregnant women currently trying for a baby, 15 (44%) had done so for more than 18 months. Overall 25 (27%) of 94 women who planned to become pregnant needed reproductive care. CONCLUSIONS Our results suggest that these days knowledge of HIV infection neither influences the desire for children nor the decisions regarding pregnancy in HIV-infected women living in Europe.

Characteristics and management of HIV-1-infected pregnant women enrolled in a randomised trial: differences between Europe and the USA

BackgroundRates of mother-to-child transmission of HIV-1 (MTCT) have historically been lower in European than in American cohort studies, possibly due to differences in population characteristics. The Pediatric AIDS Clinical Trials Group Protocol (PACTG) 316 trial evaluated the effectiveness of the addition of intrapartum/neonatal nevirapine in reducing MTCT in women already receiving antiretroviral prophylaxis. Participation of large numbers of pregnant HIV-infected women from the US and Western Europe enrolling in the same clinical trial provided the opportunity to identify and explore differences in their characteristics and in the use of non-study interventions to reduce MTCT.MethodsIn this secondary analysis, 1350 women were categorized according to enrollment in centres in the USA (n = 978) or in Europe (n = 372). Factors associated with receipt of highly active antiretroviral therapy and with elective caesarean delivery were identified with logistic regression.ResultsIn Europe, women enrolled were more likely to be white and those of black race were mainly born in Sub-Saharan Africa. Women in the US were younger and more likely to have previous pregnancies and miscarriages and a history of sexually transmitted infections.More than 90% of women did not report symptoms of their HIV infection; however, more women from the US had symptoms (8%), compared to women from Europe (4%). Women in the US were less likely to have HIV RNA levels <400 copies/ml at delivery than women enrolling in Europe, and more likely to receive highly active antiretroviral therapy, and to start therapy earlier in pregnancy. The elective caesarean delivery rate in Europe was 61%, significantly higher than that in the US (22%). Overall, 1.48% of infants were infected and there was no significant difference in the rate of transmission between Europe and the US despite the different approaches to treatment and delivery.ConclusionThese findings confirm that there are important historical differences between the HIV-infected pregnant populations in Western Europe and the USA, both in terms of the characteristics of the women and their obstetric and therapeutic management. Although highly active antiretroviral therapy predominates in pregnancy in both settings now, population differences are likely to remain.Trial registrationNCT00000869

Treatment of viral hepatitis in pregnancy

Viral hepatitis can be caused by the hepatitis A, B, C, D and E viruses. In the Western world, hepatitis A, B or C do not seem to influence the course of pregnancy, whereas hepatitis E infection, when contracted during the second or third trimester, seems to have a higher risk of developing into a fulminant hepatitis. Mother-to-infant transmission of hepatitis A seems to be very uncommon. The majority of HBsAg-positive and HBeAg-positive mothers can transmit the disease vertically. The timing of transmission is predominantly peripartum, and newborns of HBsAg-positive mothers should receive hepatitis B immunoglobulins within 12 h of birth, with HBV vaccine at birth and 1 and 6 months later. Hepatitis C is more often a chronic disease. Vertical transmission of hepatitis C is considered to be relatively rare but high viraemia or coinfection with HIV can increase this risk. There is currently no treatment to prevent this vertical transmission and pregnancies among HCV-positive mothers should not be discouraged. Infants should be tested for anti-HCV at 1 year and followed for the development of hepatitis. Breast feeding does not seem to play an important role in the transmission of hepatitis B and C.

Treatment with interferon for genital HPV in HIV-positive and HIV-negative women

The administration of interferons can be resorted to, either on its own or in combination with physical destruction methods, when the extent of genital HPV is widespread. Extensive genital HPV involvement is often seen in HIV-positive patients as a consequence of their immunodeficiency. The extension of these lesions may invalidate treatment by physical destruction, while an underlying immunodeficiency renders interferon therapy less efficacious. We studied HIV-positive and HIV-negative patients with a similar HPV involvement of their genital tract and compared the effectiveness of systemically administered alpha 2b and beta interferons in clearing HPV. Our results confirm that interferon therapy will cure most patients with extensive genital HPV when they are HIV-negative. HIV-positive patients with CD4 counts over 400 lymphocytes/mm3 may expect a similar cure rate, but this halves when this critical threshold is crossed. In these severely immunodeficient patients repeated courses of interferon therapy alone or in combination with physical destruction methods may be required to cure HPV infection.

Reproductive Assistance for Infected Couples with Bloodborne Viruses

During the past 15 years Assisted Reproduction has been facing a new demand from patients requiring ART: couples at risk of partner to partner, and mother to child transmission of viral infections, mainly HIV-1, HCV and HIV-HCV co-infected partners. The general conditions and life expectancy of many patients with HIV infection are very good, and three-quarters of these individuals are in their reproductive years. For these reasons, a large number of young couples are expected to make future plans to have children. This desire is not easy to realize for serodiscordant couples, if we consider that, in order to avoid HIV virus transmission, it is necessary to encourage the condom use in vaginal and anal contacts. On the other hand infertile discordant HCV couples need to be included in protocols of controlled assisted reproduction procedures to avoid any risk of HCV transmission to the partner. In this paper we consider assisted reproduction in discordant couples for HIV or HCV-positive men.

HIV and pregnancy: is the outlook for mother and baby transformed?

Purpose of review Advances in antiretroviral regimens and specific obstetrical procedures have enabled HIV-positive women to have children, with a very low risk of transmitting the infection to the infant and with improved chances of seeing their children reach adulthood. New studies have given providers of care better information on how to assist women with HIV who want to have a child in the safest possible way. Recent findings Highly active antiretroviral therapy can effectively control viral replication and reduce the risk of vertical transmission. The benefit of treatment for the mother and the infant must be balanced against any negative effects on pregnancy, the embryo and the fetus. Potential long-term consequences of prenatal exposure to potent compounds should also be considered and monitored. The evidence suggests that even in women with undetectable viral load, Caesarean section reduces vertical transmission to the same degree as documented previously for all women. Although the absolute risk reduction is very low, no study can show whether or not this is statistically significant and therefore women should be helped to make their individual choice. Mothers with HIV should not breastfeed in countries where formula milk is easily available, however highly active antiretroviral therapy administered to mothers or infants may reduce the risk of postnatal HIV transmission. Summary Counselling and assistance to conceive, modification of the therapeutic regimens and options about delivery have changed dramatically since the beginning of the HIV epidemic. Nowadays, women with HIV, similarly to uninfected women, can discuss with their doctors which therapeutic and treatment options would best fit their expectations of care.

The changing HIV epidemic in Italian pregnant women.

OBJECTIVE To describe changes in the characteristics of HIV-pregnant women in Italy and the impact of strategies for prevention of HIV vertical transmission. STUDY DESIGN Since 1985, HIV-infected women and their children are followed in 23 European centres in the European Collaborative Study (ECS), according to a standard protocol. Eight Italian Obstetric units participating in the ECS enrolled 815 patients. RESULTS Overall use of zidovudine to reduce HIV vertical transmission has increased significantly since 1994 and between 1995 and 1997, 57% of Italian women were treated. However, 27% of babies received the infant component of the 076 regimen. Over the years, age at delivery has increased and their CD4 count at delivery decreased, most likely reflecting heterosexually infected women with a longer duration of infection. The increasing rate of elective caesarean section (42%) is not related to maternal, foetal or obstetrical indications, but its use as an intervention to reduce HIV vertical transmission. CONCLUSIONS The identification of HIV-infected women during pregnancy or before delivery ensures the appropriate management of the woman and her child, and clinicians should be aware of the increasing number of women with heterosexual acquisition of HIV-infection who may be less easily identified.