SAN DIEGO, CA — A trio of presentations on HIV, Women and Child Health this morning told a story of success in preventing transmission of HIV from parents to children in the United States that has yet to be duplicated in developing countries, of options that could make a difference, and, in a look at the burdens children born with HIV will carry into adulthood, of some of the relatively rarely discussed consequences of gaps in efforts so far.
Dr. Elaine J. Abrams of Columbia University’s Mailman School of Public Health and the International Center for HIV Care and Treatment Programs began with a cheering review of a now familiar graph showing the steep drop in parent to child HIV transmissions in the United States following the development of treatment for pregnant HIV-positive became in the 1990s here.
“We haven’t seen the same success globally,” she added. While the number dropped close to zero here, more than 330,000 children are born with the virus worldwide every year. In the course of efforts to provide HIV-positive pregnant women with the treatment they need to prevent transmitting the virus to their infants, it’s estimated that about 600,000 transmissions to babies have been averted — “rather modest in the overall picture of things,” Abrams said.
Obstacles strew the fragile healthcare systems where the needs to reach women with preventive treatment are highest, Abrams showed, in gaps in prenatal care access, failures to screen, treat, retain women, in shortages of staff who can prescribe antiretroviral regimens and in shortages of equipment to carry out necessary testing.
The World Health Organization’s “Option B +” guidelines for lifelong treatment of all HIV-positive pregnant women offer an answer to many of the obstacles, simplifying screening in countries where equipment to determine women’s immune cell count remains a luxury, while preventing transmission to future children and HIV-negative partners. The cost of medicine, though has daunted most countries, while at the same time, some countries with fewer resources than most, including Malawi have embraced the option.
Another set of options followed, in the presentation by Dr. Jean R. Anderson, director of Johns Hopkins HIV Women’s Health Program, who gave updates on advances in ways to help women prevent some of the 50 percent of all pregnancies that are unintended, and to help those who do want to conceive to plan their pregnancies safely.
In developing countries where unintended pregnancies are common, effective contraception methods remain underused in HIV care settings, she said, and women frequently get pregnant while using ineffective contraception.
Hormonal methods are by far most effective reversible method, she said, male and female condoms the least.
Alternate ways to deliver hormonal contraception — including transdermal patches, vaginal rings, implants under the skin, and intrauterine devices, are overcoming some of the problems to effective use, in settings where taking a daily pill, re-visiting a clinic or pharmacy pose problems. In addition, hormonal contraception can bring noncontraceptive benefits, including decreased menstrual bleeding and drops in incidence of ovarian, endometrial and colorectal cancers. They come with some precautions, too, for women with high blood pressure, liver disease, diabetes, or who have had breast cancer. In addition, drug interactions with some antiretroviral drugs can make contraception less effective, and use of contraception can increase side effects.
That doesn’t necessarily mean they shouldn’t be used, Anderson said, “All of this must be balanced against the critical need for safe pregnancy prevention,” she added.
At the same time, with HIV-positive women facing longer life expectancies than in years past, and having the means to prevent transmitting the virus to their infants have changed views on the the rights of HIV-positive women to bear children, Anderson said.
“Women with HIV should not be discriminated against in their desire to get pregnant and have a genetically related child,” she said.
Among the ways to more safely conceive, she said, “the turkey baster method” (non-intercourse conception) is best, male circumcision reduces odds of transmission to an HIV-negative male partner by 66 percent, and, if the man is HIV-positive “sperm-washing” is safest, but expensive and not an option in lo resource settings.
Her conclusions: “All HIV-positive women of childbearing age should receive comprehensive family planning and preconception counseling and prevention of unintended pregnancy should be a priority.”
She was followed by Dr. Ellen Cooper of the Boston University School of Medicine, who spelled out the challenges that the generations of children born so far with HIV face — and, in time, present. Born frequently into families already torn by death and illness, often grappling with grief, loss, secrecy and stigma, they tend to grow up with cognitive and physical problems — some perhaps a product of the virus, some of the medicine that treats it, some perhaps from the challenges that surround them. Raised often in ignorance of their own illness, a staggering 46 percent do not know they have and can transmit HIV when they first have sex.
And with obstacles to sticking to a drug regimen including all of the above — as well as predictable adolescent issues, they tend to be resistant to multiple lines of treatment by the time they are of reproductive age, with the result that a “very resistant virus” is transmitted to the next generation.