Effectiveness of intensive nurse case management in decreasing vertical transmission of human immunodeficiency virus infection in Wisconsin.

BACKGROUND

During a clinical trial (ACTG Study 076), perinatal HIV transmission was reduced by two-thirds when pregnant women with HIV infection and their infants were treated with zidovudine (ZDV). A similar benefit has not been uniformly found in practice settings.

OBJECTIVES

To measure the effectiveness of a nurse case management system in supporting prenatal ZDV use in women with HIV infection and their infants and in decreasing perinatal HIV transmission.

METHODS

We performed a retrospective cohort study of all children with or at risk for HIV infection cared for in the Wisconsin HIV Primary Care Support Network. The Network uses intensive nurse case management to optimize the care of pregnant women with HIV infection and their children. For children born between January 1, 1992, and April 30, 1996, we measured the association of prenatal case management by a Network nurse with (1) ZDV use by pregnant women with HIV infection and (2) the rate of vertical HIV transmission.

RESULTS

In the 26 months after March 1, 1994 (shortly after the release date of ACTG 076 results), 5 of 39 (13%) infants born to women with HIV infection and enrolled in the Network acquired HIV perinatally compared with 12 of 30 (40%) infants in the 26 months preceding March 1, 1994 (P = 0.01). Between March 1, 1994, and April 30, 1996, 25 of 25 (100%) women whose prenatal care included intensive case management by a Network nurse were treated with prenatal orally administered ZDV, compared with 3 of 14 (21%) women whose prenatal care did not include Network case management (P < 0.0001). There were 2 of 25 (8%) infants who acquired HIV infection in the former group, compared with 3 of 14 (21%) in the latter group (P = 0.2)

CONCLUSIONS

Perinatal transmission of HIV was significantly decreased following implementation of national recommendations for ZDV treatment of pregnant women. Prenatal care that included case management by a specialized nurse was significantly more likely to result in appropriate ZDV therapy in women and showed a trend toward a lower rate of HIV infection in their infants, compared with prenatal care that did not include such personnel.