0
August 12, 1998, Vol 280, No. 6 >
From The JAMA Web Sites | August 12, 1998

Perinatal Transmission of HIV in Women Receiving Zidovudine

Lynne M. Mofenson, MD
JAMA. 1998;280(6):569-570. doi:10.1001/jama.280.6.569
Text Size: A A A
Published online
Article
References

Journal Scan Archive, June 1998
http://www.ama-assn.org/std
Posted May 4, 1998

AUTHOR INFORMATION

Medical Editor: Helene M. Cole, MD, Contributing Editor, JAMA.
Objectives

Objectives  To evaluate the impact of perinatal zidovudine use on the risk of perinatal transmission of HIV and to determine risk factors for transmission among women using perinatal zidovudine.

Design  Prospective cohort study of 1533 children born to HIV-infected women between 1985 and 1995 in four US cities.

Methods  The association of potential risk factors with perinatal HIV transmission was assessed with univariate and multivariate statistics.

Results  The overall transmission risk was 18% [95% confidence interval (CI), 16-21]. Factors associated with transmission included membrane rupture >4 h before delivery [relative risk (RR), 2.1; 95% CI, 1.6-2.7], gestational age <37 weeks (RR, 1.8; 95% CI, 1.4-2.2), maternal CD4+ lymphocyte count <500 ×106 cells/l (RR, 1.7; 95% CI, 1.3-2.2), birthweight <2500 g (RR, 1.7; 95% CI, 1.3-2.1), and antenatal and neonatal zidovudine use (RR, 0.6; 95% CI, 0.4-0.9). For infants exposed to zidovudine antenatally and neonatally, the transmission risk was 13% overall but was significantly lower following shorter duration of membrane rupture (7%) and term delivery (9%). The transmission risk declined from 22% before 1992 to 11% in 1995 (P< 0.001) in association with increasing zidovudine use and changes in other risk factors.

Conclusions  Perinatal HIV transmission risk has declined with increasing perinatal zidovudine use and changes in other factors. Further reduction in transmission for women taking zidovudine may be possible by reducing the incidence of other potentially modifiable risk factors, such as long duration of membrane rupture and prematurity.
COMMENTARY

In 1994, the Pediatric AIDS Clinical Trials Group (PACTG) protocol 076 demonstrated that a regimen of zidovudine (ZDV) administered during pregnancy, labor, and to the newborn could reduce the perinatal HIV transmission by two-thirds.1 Implementation of this regimen into general clinical practice has been associated with dramatic declines in perinatal transmission in the United States and other industrialized countries.2 - 3 The study by Simonds and colleagues4 provides further confirmation of the efficacy of this regimen. However, perinatal transmission can occur despite the use of ZDV chemoprophylaxis. It is, therefore, critical to define those factors that are associated with perinatal transmission in women who are receiving ZDV. Simonds and colleagues provide some insight into those risk factors. In a multivariate analysis, factors that were significantly associated with perinatal transmission in women receiving ZDV included prolonged duration of membrane rupture and low maternal CD4+ lymphocyte count.

Prolonged duration of membrane rupture has been associated with transmission risk in a number of studies, primarily those involving women not receiving ZDV.5 Unlike the results reported by Simonds and colleagues, duration of membrane rupture was not significantly associated with transmission risk in women receiving ZDV in either PACTG 0761 or another perinatal trial, PACTG 185. Regardless of maternal ZDV use, noninvasive obstetric methods to reduce duration of membrane rupture, such as avoiding amniotomy, seem reasonable. However, whether cesarean delivery will further reduce perinatal transmission, particularly in women already receiving ZDV, remains controversial.6 - 7 A further concern are data that indicate infected pregnant women who have cesarean delivery may have a higher risk for postoperative complications than uninfected women.8 Thus, at the present time, cesarean delivery should be restricted to those infected women who have clinical indications for operative delivery. A meta-analysis of 15 different cohort studies that includes more than 10000 infected mother-infant pairs and that evaluates the association of mode of delivery and transmission risk is ongoing, and results should be available this summer.

Low maternal CD4+ lymphocyte count may be a surrogate for high maternal viral load, a parameter not assessed by Simonds and colleagues. In PACTG 076, the effect of ZDV on maternal HIV RNA did not fully account for the observed efficacy of ZDV in reducing transmission, and preexposure prophylaxis of the fetus/infant may be a substantial component of protection.9 Further studies will be needed to define whether the use of potent combination antiretroviral regimens used for treatment of maternal HIV infection will further reduce perinatal transmission.10

REFERENCES

1 +
Connor EM, Sperling RS, Gelber R.  et al.  Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.  N Engl J Med.1994;331:1173-1180.
2 +
Cooper ER, Nugent RP, Diaz C.  et al.  After AIDS Clinical Trial 076: the changing pattern of zidovudine use during pregnancy and the subsequent reduction in vertical transmission of human immunodeficiency virus in a cohort of infected women and their infants.  J Infect Dis.1996;174:1207-1211.
3 +
Mayaux MJ, Teglas JP, Mandelbrot L.  et al.  Acceptability and impact of zidovudine for prevention of mother-to-child human immunodeficiency virus type 1 transmission in France.  J Pediatr.1997;131:857-862.
4 +
Simonds RJ, Steketee R, Nesheim S.  et al. for the Perinatal AIDS Collaborative Transmission Studies.  Impact of zidovudine use on risk and risk factors for perinatal transmission of HIV.  AIDS.1998;12:301-308.
5 +
Landesman SH, Kalish LA, Burns DN.  et al.  Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child.  N Engl J Med.1996;334:1617-1623.
6 +
Mofenson LM. A critical review of studies evaluating the relationship of mode of delivery to perinatal transmission of human immunodeficiency virus.  Pediatr Infect Dis J.1995;14:169-177.
7 +
Kind C, Rudin C, Siegrist CA.  et al.  Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis.  AIDS.1998;12:205-210.
8 +
Semprini AE, Castagna C, Ravizza M.  et al.  Incidence of complications after cesarean section in 156 HIV-positive women.  AIDS.1995;9:913-917.
9 +
Sperling RS, Shapiro DE, Coombs RW.  et al.  Maternal viral load, zidovudine treatment and the risk of transmission of human immunodeficiency virus type 1 from mother to infant.  N Engl J Med.1996;335:1621-1629.
10 +
Centers for Disease Control and Prevention.  Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States.  MMWR Morb Mortal Wkly Rep.1998;47:1-30.

Published literature selected for posting on the JAMA Web sites receives postpublication peer review. Posted abstracts may be accompanied by commentaries prepared for the Web sites and these may be selected for republishing in THE JOURNAL.

The JAMA Women's Health Sexually Transmitted Disease Information Center is made possible by grant support from Ortho-McNeil Pharmaceutical and Advanced Care Products.

First Page Preview

First page PDF preview

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Connor EM, Sperling RS, Gelber R.  et al.  Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.  N Engl J Med.1994;331:1173-1180.
2 +
Cooper ER, Nugent RP, Diaz C.  et al.  After AIDS Clinical Trial 076: the changing pattern of zidovudine use during pregnancy and the subsequent reduction in vertical transmission of human immunodeficiency virus in a cohort of infected women and their infants.  J Infect Dis.1996;174:1207-1211.
3 +
Mayaux MJ, Teglas JP, Mandelbrot L.  et al.  Acceptability and impact of zidovudine for prevention of mother-to-child human immunodeficiency virus type 1 transmission in France.  J Pediatr.1997;131:857-862.
4 +
Simonds RJ, Steketee R, Nesheim S.  et al. for the Perinatal AIDS Collaborative Transmission Studies.  Impact of zidovudine use on risk and risk factors for perinatal transmission of HIV.  AIDS.1998;12:301-308.
5 +
Landesman SH, Kalish LA, Burns DN.  et al.  Obstetrical factors and the transmission of human immunodeficiency virus type 1 from mother to child.  N Engl J Med.1996;334:1617-1623.
6 +
Mofenson LM. A critical review of studies evaluating the relationship of mode of delivery to perinatal transmission of human immunodeficiency virus.  Pediatr Infect Dis J.1995;14:169-177.
7 +
Kind C, Rudin C, Siegrist CA.  et al.  Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis.  AIDS.1998;12:205-210.
8 +
Semprini AE, Castagna C, Ravizza M.  et al.  Incidence of complications after cesarean section in 156 HIV-positive women.  AIDS.1995;9:913-917.
9 +
Sperling RS, Shapiro DE, Coombs RW.  et al.  Maternal viral load, zidovudine treatment and the risk of transmission of human immunodeficiency virus type 1 from mother to infant.  N Engl J Med.1996;335:1621-1629.
10 +
Centers for Disease Control and Prevention.  Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States.  MMWR Morb Mortal Wkly Rep.1998;47:1-30.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
A comparison of 3 regimens to prevent nevirapine resistance mutations in HIV-infected pregnant women receiving a single intrapartum dose of nevirapine.
Clin Infect Dis. 2012;54(2):285-93.
[Results of the implementation of three national guidelines for the prevention of HIV vertical transmission in Instituto Nacional Materno Perinatal. Lima, Peru].
Rev Peru Med Exp Salud Publica. 2011 Jul-Sep;28(3):492-6.
© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems