Reduction of Vertical Transmission of HIV in the Dominican Republic: Benefits of Early Presentation for Prenatal Care

Background:The impact of HIV infection on maternal and infant mortality in the Dominican Republic is unknown. The prevalence of HIV infection among pregnant women in the Dominican Republic is 1-2%, and over two-thirds of women receive prenatal care. (2,3) It is estimated that 15% of all deliveries in the Dominican Republic occur at the Hospital Maternidad Nuestra Señora de la Altagracia in Santo Domingo, making this the highest-volume maternity hospital in the country.(4) Objectives:We conducted a study to compare the impact of HIV infection on pregnant women receiving prenatal care including highly active antiretroviral therapy (HAART) versus women who were not identified as HIV positive until the time of delivery. All research took place at the Hospital Maternidad Nuestra Señora de la Altagracia, Santo Domingo, DR. Methods:We performed a retrospective chart review at the Office of Reduction of Vertical Transmission of HIV at the Hospital Maternidad Nuestra Señora de la Altagracia. All deliveries between May and September, 2009, were included. Data were compared to a record book listing monthly deliveries of HIV infected women. This database was the primary source of data on HIV positive women who delivered at the Altagracia, but who did not receive prenatal care at the PMTCT office at the Altagracia. Data points included: patient age at time of presentation to the PMTCT clinic or at the time of initial presentation for delivery; gestational age at time of presentation; gestational age at start of HAART; mode of delivery; whether a woman was less than 20 years old at time of presentation; whether she gave birth to a living child; and the type of treatment the child received after delivery. All data were collected in a de-identified manner by Ingrid Liff, a senior medical student at the University of Massachusetts Medical School. This study was approved by the IRB at the University of Massachusetts.(5) Results:Between May and September, 2009, we identified 91 HIV positive women who delivered at the Altagracia. Forty-nine women (54%) received prenatal care through the Office for Reduction of Vertical Transmission of HIV. All of these 49 women received HAART prior to delivery. Of these 49 women, 80% underwent Cesarean delivery, and 12% were adolescents (old). There was no infant mortality in this group. Forty-two women (46%) were identified as HIV infected at the time of labor, and only 7% of these women received HAART prior to delivery. Sixty-two percent of these women received no treatment for HIV infection prior to delivery. Seven percent received single dose nevirapine and 14% received Colita. (6) Of these 42 women, 48% underwent Cesarean delivery, 21% were adolescents (old), and there were 2 infant deaths. According to data collected at the time of delivery, all living newborns delivered to the HIV positive mothers in our study received treatment with a 6-week course of zidovudine (AZT) per national protocol. All of the newborns also received formula at the time of delivery and were not breastfed. Conclusions:This observational study emphasizes the need for a more aggressive approach to identify HIV infected pregnant women prior to labor. In this cohort, all HIV positive pregnant women who received prenatal care at the PMTCT clinic received HAART prior to delivery, as opposed to those who were identified during labor. Until recently, newborns born at the Altagracia were lost to follow-up. At this time there is no data on whether the infants in this study population are HIV positive. Further research is warranted to uncover the rate of vertical transmission at the Hospital Maternidad Nuestra Señora de la Altagracia in Santo Domingo. (1) Iniciativa Latinoamericana y del Caribe de Integración de la Atención Prenatal con la Detección y el Manejo Clínico del VIH y de la Sífilis (ILAP) (2) WHO, UNICEF, UNAIDS. Dominican Republic 2008 Update: Epidemiological Fact Sheet on HIV and AIDS. Published by the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, December, 2008. (3) Perez-Then E, Pena R, Tavarez-Rojas M, Pena C, Quinonez S, Buttler M, et al. Preventing Mother-to-Child HIV Transmission in a Developing Country: The Dominican Republic Experience. J Acquir Immune Defic Syndr 2003,34:506-511.; WHO, UNICEF, UNAIDS. Dominican Republic 2008 Update: Epidemiological Fact Sheet on HIV and AIDS. Published by the UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, December, 2008. (4) Secretaria de Estado de Salud Pública y Asistencia Social Subsecretaría de Planificación y Desarollo (SESPAS). Informe Estadístico, 2008. (5) IRB Exempt status, #13713 - Prenatal care and treatment for HIV positive women in the Dominican Republic (6) Colita refers to single dose nevirapine prior to delivery, followed by a tail of triple therapy for seven days after delivery. Presented as part of the Senior Scholars Program at the University of Massachusetts Medical School, May 3, 2010

Mid-trimester cervical length not associated with HIV status among pregnant women in Botswana.

ObjectiveHIV-infected women on antiretroviral therapy have a higher risk of preterm birth than HIV-uninfected women in Botswana. To better understand the mechanism for preterm birth among HIV-infected women, we evaluated whether mid-trimester cervical length differed by HIV status as cervical shortening is associated with an increased risk for preterm birth.MethodsWe conducted a prospective cohort study among pregnant women receiving care at the Scottish Livingstone Hospital in Molepolole, Botswana. Consecutive women referred for routine obstetrical ultrasound were consented and enrolled if between 22w0d and 24w6d by ultrasound biometry. Blinded to maternal HIV status, an obstetrician measured transvaginal cervical length using standardized criteria. Cervical length, as well as the proportion of women with a short cervix (ResultsBetween April 2016 and April 2017, 853 women presenting for obstetric ultrasound were screened, 187 (22%) met eligibility criteria, and 179 (96%) were enrolled. Of those enrolled, 50 (28%) were HIV-infected (86% on antiretroviral therapy), 127 (71%) were HIV-uninfected, and 2 (1%) had unknown HIV status. There was no significant difference in mean cervical length between HIV-infected and HIV-uninfected women (32mm vs 31mm, p = 0.21), or in the proportion with a short cervix (10% vs 14%, p = 0.44). Acceptability data was available for 115 women who underwent a transvaginal ultrasound exam. Of these, 112 of 115 (97%) women deemed the transvaginal scan acceptable.ConclusionsThe increased risk of preterm birth observed among HIV-infected women receiving antiretroviral therapy in Botswana is unlikely associated with mid-trimester cervical shortening. Further research is needed to understand the underlying mechanism for preterm birth among HIV-infected women