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Approximately half of HIV-discordant heterosexual couples in the United States want children. Oral antiretroviral preexposure prophylaxis, if effective in reducing heterosexual HIV transmission, might be an option for discordant couples wanting to conceive. Couples should receive services to ensure they enter pregnancy in optimal health and receive education about all conception methods that reduce the risk of HIV transmission. In considering whether preexposure prophylaxis is indicated, the question is whether it contributes to lowering risk in couples who have decided to conceive despite known risks. If preexposure prophylaxis is used, precautions similar to those in the current heterosexual preexposure prophylaxis trials would be recommended, and the unknown risks of preexposure prophylaxis used during conception and early fetal development should be considered. Anecdotal reports suggest that oral preexposure prophylaxis use is already occurring. It is time to have open discussions of when and how preexposure prophylaxis might be indicated for HIV-discordant couples attempting conception., (Published by Mosby, Inc.)

Two studies that were published in 1999 demonstrated that cesarean delivery before labor and before the rupture of membranes (elective cesarean delivery) reduces the risk of mother-to-child transmission of the human immunodeficiency virus (HIV). On the basis of these results, the American College of Obstetricians and Gynecologists and the US Public Health Service recommend that HIV-infected pregnant women with plasma viral loads of >1000 copies per milliliter be counseled regarding the benefits of elective cesarean delivery. Since the release of these guidelines, the cesarean delivery rate among HIV-infected women in the United States has increased dramatically. Major postpartum morbidity is uncommon, and cesarean delivery among HIV-infected women is relatively safe and cost-effective. However, a number of important questions remain unanswered, including whether cesarean delivery has a role among HIV-infected women with low plasma viral loads or who receive combination antiretroviral regimens.

Objective: Significant reductions in perinatal human immunodeficiency virus (HIV) transmission have been demonstrated in which the HIV-infected mothers and their HIV-exposed infants receive prenatal, intrapartum, and neonatal antiretroviral therapy., Study Design: We used data that were collected through the Enhanced Perinatal Surveillance system for HIV-exposed singleton births that occurred 1999-2001 in 24 sites., Results: The overall infant infection rate for the 3 years was 4.7%. Compared with zidovudine monotherapy, those patients who received zidovudine with other drugs that included a protease inhibitor and those who received zidovudine and other drugs with no protease inhibitor were less likely to have an infected infant (adjusted odds ratio, 0.4 [95% CI, 0.3-0.07]; adjusted odds ratio, 0.5 [95% CI, 0.3-0.8], respectively)., Conclusion: These data support the current treatment recommendations and show that infants were less likely to be infected when the mothers were given a prenatal antiretroviral therapy regimen that contained zidovudine with additional antiretroviral drugs with or without a protease inhibitor in addition to receiving antiretrovirals during delivery and neonatally.

In the United States, current human immunodeficiency virus (HIV) testing guidelines recommend an opt-out approach for pregnant women, whereby HIV testing is incorporated routinely into the standard panel of prenatal tests with the option to decline. Current recommendations for the initiation of treatment of HIV infection in pregnant women are the same as those for nonpregnant women. However, the special circumstances of pregnancy raise additional issues that are related to potential drug toxicity to the mother and fetus, which affect the choice of antiretroviral drugs to be used. For HIV-infected pregnant women who do not require therapy for their own health, antiretroviral drugs are recommended for prevention of mother-to-child transmission. Highly active antiretroviral therapy is recommended for all women with HIV RNA levels of > or = 1000 copies/mL, along with consideration of elective cesarean delivery. For women with HIV RNA levels of < 1000 copies/mL, a 3-part zidovudine prophylaxis regimen (prenatal, intrapartum, and neonatal) should be used alone or in combination with other antiretroviral drugs.

The objective of the study was to evaluate the feasibility, acceptability, and accuracy of rapid human immunodeficiency virus (HIV) testing during labor. The Mother-Infant Rapid Intervention at Delivery (MIRIAD) study was a prospective, multicenter study that offered voluntary, rapid HIV testing to women with undocumented HIV status at 17 hospitals in 6 cities. Of 12,481 eligible women, 74% were approached for participation and 85.5% of those approached accepted rapid HIV testing. Among 7753 women tested, MIRIAD identified 52 (0.7%) HIV-infected women. The time between obtaining the blood sample for the rapid test and reporting the results to the health care provider was shorter for hospitals utilizing point-of-care testing than in hospitals utilizing laboratory-based testing (30 minutes vs 68 minutes; P < .0001), and point-of-care testing strategies were 14 times more likely to have a short turnaround as laboratory testing strategies. Routine rapid testing during labor provides a feasible, acceptable, and accurate way to identify HIV-infected women before delivery.

Prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) in the United States and Europe has been a tremendous success, such that transmission rates of less than 2% have been achieved. Some key successes have also been demonstrated in resource-poor countries; however, the translation of successful interventions into public health policy has been slow because of a variety of factors such as inadequate funding and cultural, social, and institutional barriers. The issue of HIV and infant feeding in settings that lack culturally acceptable, feasible, affordable, safe, and sustainable nutritional substitutes for breast milk is a continuing dilemma. An effective preventive infant HIV vaccine would be an optimal approach to reduce HIV acquisition in the first year of life among breast-feeding infants. The challenges to eliminate new perinatal HIV infections worldwide will depend on both sustaining and expanding PMTCT interventions and effective primary HIV prevention for women, adolescents, and young adults.

The objective of the study was to assess the effectiveness of federal funds in preventing perinatal human immunodeficiency virus (HIV) transmission in the United States. We used surveillance data from 1999 and 2001 in 6 funded areas to estimate the proportion of HIV-infected women prescribed perinatal prophylaxis and whose infants were HIV infected. We compared outcomes with 5 unfunded areas in which surveillance data were available. The proportion of funded-area women prescribed prophylaxis increased from 80.1% to 85.9% (P < .01), compared with a decline in unfunded areas from 95.1% to 86.7% (P < .01); the difference in trends between groups was P < .01. The perinatal HIV transmission rate for funded areas declined from 6.5% (105 cases) in 1999 to 3.4% (46 cases) in 2001 (P < .01), compared with a decline in unfunded areas from 4.3% (19 cases) to 3.4% (13 cases) (P = .59); the difference in trends between groups was P = .24). The number of perinatal HIV infections in the funded areas decreased by 56%, achieving the Centers for Disease Control and Prevention's goal of a 50% reduction in incidence by 2005.