Peters Vicki, Liu Kai-Lih, Dominguez Kenneth, Frederick Toni, Melville Sharon, Hsu Ho-Wen, Ortiz Idith, Rakusan Tamara, Gill Balwant, Thomas Pauline
New York City Department of Health and Mental Hygiene, New York, New York. Centers for Disease Control and Prevention, Atlanta, Georgia 10013, USA.
Pediatrics. 2003 May;111(5 Pt 2):1186-91.
Despite dramatic reductions in perinatal human immunodeficiency virus (HIV) transmission in the United States, obstacles to perinatal HIV prevention that include lack of prenatal care; failure to test pregnant women for HIV before delivery; and lack of prenatal, intrapartum, or neonatal antiretroviral (ARV) use remain. The objective of this study was to describe trends in perinatal HIV prevention methods, perinatal transmission rates, and the contribution of missed opportunities for perinatal HIV prevention to perinatal HIV infection.
We analyzed data obtained from infant medical records on 4755 HIV-exposed singleton deliveries in 1996-2000, from 6 US sites that participate in the Centers for Disease Control and Prevention's Pediatric Spectrum of HIV Disease Project. HIV-exposed deliveries refer to deliveries in which the mother was known to have HIV infection during the pregnancy.
Of the 4287 women with data on prenatal care, 92% had prenatal care. From 1996 to 2000, among the 3925 women with prenatal care, 92% had an HIV test before delivery; the use of prenatal zidovudine (ZDV) alone decreased from 71% to 9%, and the use of prenatal ZDV with other ARVs increased from 6% to 70%. Complete data on maternal and neonatal ARVs were available for 3284 deliveries. Perinatal HIV transmission was 3% in 1651 deliveries with prenatal ZDV in combination with other ARVs, intrapartum ZDV, and neonatal ZDV; 6% in 1111 deliveries with prenatal, intrapartum, and neonatal ZDV alone; 8% in 152 deliveries with intrapartum and neonatal ZDV alone; 14% of 73 deliveries with neonatal ZDV only started within 24 hours of birth; and 20% in 297 deliveries with no prenatal, intrapartum, and neonatal ARVs. Complete data on prenatal events were available in 328 HIV-infected and 3258 HIV-uninfected infants. A total of 56% of mothers of HIV-infected infants had missed opportunities for perinatal HIV prevention versus 16% of mothers of HIV-uninfected infants. Forty-four percent of the infected infants were born to mothers who had prenatal care, a prenatal HIV diagnosis, and documented prenatal ARV therapy. Seventeen percent of women with reported illicit drug use had no prenatal care versus 3% of women with no reported drug use. In a multivariate analysis, maternal illicit drug use was significantly associated with lack of prenatal care. In a multivariate analysis, year of infant birth and the combination of lack of maternal HIV testing before delivery and lack of prenatal antiretroviral therapies were significantly associated with perinatal HIV transmission.
Missed opportunities for perinatal HIV prevention contributed to more than half of the cases of HIV-infected infants. Prenatal care and HIV testing before delivery are major opportunities for perinatal HIV prevention. Illicit drug use was highly associated with lack of prenatal care, and lack of HIV testing before delivery was highly associated with perinatal HIV transmission.
尽管美国围产期人类免疫缺陷病毒（HIV）传播率大幅下降，但围产期HIV预防仍存在障碍，包括缺乏产前护理；分娩前未对孕妇进行HIV检测；以及缺乏产前、产时或新生儿抗逆转录病毒（ARV）治疗。本研究的目的是描述围产期HIV预防方法的趋势、围产期传播率，以及围产期HIV预防错失机会对围产期HIV感染的影响。
我们分析了1996 - 2000年期间从美国6个参与疾病控制和预防中心儿科HIV疾病谱项目的地点获取的4755例暴露于HIV的单胎分娩婴儿的医疗记录数据。暴露于HIV的分娩是指已知母亲在怀孕期间感染HIV的分娩。
在4287名有产前护理数据的女性中，92%接受了产前护理。1996年至2000年期间，在3925名接受产前护理的女性中，92%在分娩前进行了HIV检测；仅使用产前齐多夫定（ZDV）的比例从71%降至9%，产前ZDV与其他ARV联合使用的比例从6%增至70%。3284例分娩有完整的母婴ARV数据。在1651例分娩中，产前ZDV与其他ARV联合使用、产时ZDV和新生儿ZDV，围产期HIV传播率为3%；在1111例仅使用产前、产时和新生儿ZDV的分娩中，传播率为6%；在152例仅使用产时和新生儿ZDV的分娩中，传播率为8%；在73例仅在出生后24小时内开始使用新生儿ZDV的分娩中，传播率为14%；在297例未使用产前、产时和新生儿ARV的分娩中，传播率为20%。328例HIV感染婴儿和3258例未感染HIV婴儿有完整的产前事件数据。感染HIV婴儿的母亲中，共有56%错失了围产期HIV预防机会，而未感染HIV婴儿的母亲中这一比例为16%。44%的感染婴儿母亲接受了产前护理、产前HIV诊断并有记录的产前ARV治疗。报告有非法药物使用的女性中，17%未接受产前护理，而未报告有药物使用的女性中这一比例为3%。在多变量分析中，母亲非法药物使用与缺乏产前护理显著相关。在多变量分析中，婴儿出生年份以及分娩前母亲未进行HIV检测和缺乏产前抗逆转录病毒治疗的组合与围产期HIV传播显著相关。
围产期HIV预防错失机会导致超过一半的HIV感染婴儿病例。产前护理和分娩前HIV检测是围产期HIV预防的主要机会。非法药物使用与缺乏产前护理高度相关，分娩前未进行HIV检测与围产期HIV传播高度相关。
