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Kenneth Dominguez, MD, MPH
Mother-Child Transmission Pediatric and Adolescent Studies Section,
Epidemiology Branch, Division of HIV/AIDS Prevention,
National Center for HIV, STD, TB Prevention,
Centers for Disease Control and Prevention,
Atlanta, GA 30333
Toni Frederick, PhD, MSPH
Los Angeles County Department of Health Services,
Los Angeles, CA 90012
Sharon K. Melville, MD, MPH
Bureau of HIV and STD Prevention,
Texas Department of Health,
Austin, TX 78756
Ho-Wen Hsu, MD
State Laboratories Institute,
Jamaica Plain, MA 02130
Idith Ortiz, MD, MPH
AIDS Surveillance Office,
Puerto Rico Department of Health,
San Juan, Puerto Rico 00921
Tamara Rakusan, MD, PhD
Infectious Disease Division,
George Washington University School of Medicine,
Children’s National Medical Center,
Washington, DC 20010
and the PSD Consortium
The PSD Project,
Atlanta, GA 30333
To the Editor.—
We appreciate Dr Hyslop’s comparison of missed opportunities for perinatal human immunodeficiency virus (HIV) prevention in resource-poor countries and the United States.1 We recognize the tremendous burden of HIV infection in sub-Saharan Africa and the challenges that face countries with limited resources.2 The success of the programs in the United States requires significant amounts of resources, which include perinatal HIV-prevention programs that can provide combination antiretrovirals and obstetrical interventions for perinatal HIV prevention, access to specialist medical care for the mother and child, and monitoring through local, state, and national surveillance systems. The success is demonstrated by the dramatic (>90%) declines in new perinatal HIV infections since the peak in the early 1990s.3
Since breastfeeding was first recognized in 1985 to be associated with perinatal HIV transmission, the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics have recommended that HIV-infected mothers in the United States receive counseling regarding the avoidance of breastfeeding, which led to the practice of exclusive formula feeding among perinatally HIV-exposed infants.4 Although exclusive formula feeding is feasible and deliverable in resource-rich settings such as the United States, it is not a realistic option for many HIV-infected women in resource-limited settings in which safe, sustainable alternatives to breastfeeding are not available and breastfeeding is the cultural norm. Hence, breastfeeding remains an important factor in mother-to-child transmission of HIV infection in these settings.4 A number of trials are in process to test strategies to reduce the risk of transmission during lactation for the majority of HIV-infected women who do choose to breastfeed in these settings.5
In 1994, the results of AIDS Clinical Trials Group 076 demonstrated that antiretroviral therapy could prevent HIV transmission, and other studies showed that combination antiretroviral therapies and delivery by cesarean section in select circumstances could reduce perinatal HIV transmission further.6 These findings facilitated establishment of state- and nationally funded perinatal HIV-prevention programs. Data from CDC’s HIV/AIDS Surveillance System and local and state health departments have monitored the success of the programs.7,8 After the trial results, the US Public Health Service first issued guidelines for universal counseling and offering voluntary HIV testing of pregnant women in 1995 and in 2001 revised the guidelines to further reduce barriers to universal HIV testing of pregnant women.3 In 2003, the CDC reiterated its goal of universal HIV testing of all pregnant women and recommended the "opt-out approach" to prenatal HIV screening as a useful strategy to achieve high levels of prenatal HIV testing to achieve additional reductions in perinatal HIV transmission.9 With the opt-out approach, pregnant women are notified about perinatal HIV and its prevention and advised that an HIV test will be included in the standard battery of prenatal tests unless a woman refuses.9 The CDC also recommends routine rapid testing at labor for those women whose HIV status is still unknown. In New York, there is mandatory expedited HIV testing of mothers or newborns at the time of delivery when the results of prenatal HIV testing are not known. The results of the expedited testing must be available within 12 hours of birth.10 Additionally, in New York all newborns are tested for perinatal HIV exposure through the Comprehensive Newborn Screening program.10
Despite the successes and the dramatic decline in perinatal HIV transmission rates in the United States, missed opportunities and failures of perinatal HIV prevention continue to occur. Hard-to-reach pregnant women include illicit drug users, adolescents, non-English-speaking women, and unregistered immigrants. In the Pediatric Spectrum of HIV Disease study, illicit-drug-using women were significantly more likely to lack prenatal care than non-drug-using women. Immigrants may be reluctant to agree to HIV testing or choose to breastfeed for cultural reasons. CDC-funded perinatal HIV prevention programs target these hard-to-reach populations in the United States to offer needed services and support.9 In parallel, CDC’s Global AIDS Program and other organizations are helping to develop and implement programs to reduce perinatal transmission in resource-limited international settings with high HIV seroprevalence. Although fewer women in resource-poor countries compared to the United States have access to prenatal care and hospital-based deliveries, it has been suggested that traditional birth attendants may be able to play a role in preventing perinatal transmission of HIV.11 Pilot studies in several African countries are investigating the use of trained traditional birth attendants to provide HIV counseling and testing and assistance with administering antiretroviral prophylaxis at delivery in rural settings without hospitals.
We remain hopeful that the strategies currently being piloted that take into account the unique sociocultural aspects of resource-constrained countries, such as the use of antiretrovirals during the breastfeeding period and use of traditional birth attendants in administering perinatal HIV prevention activities, may eventually play a major role in reducing perinatal HIV transmission in these settings.
ACKNOWLEDGMENTS
We thank Dr Mary Glenn Fowler and Dr Marc Bulterys of the Centers for Disease Control and Prevention for assistance in preparing this response.
REFERENCES
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