More than 90% of children infected with HIV are acquired through mother-to-child transmission. Prevention of mother-to-child transmission of HIV is an important measure to protect children from HIV and reduce the incidence of AIDS. The HIV epidemic in China has moved from high-risk groups to the general population, and the proportion of women infected has increased, so the number of infants and children infected with HIV through mother-to-child transmission is bound to increase as well. According to UNAIDS, in 2011, more than 8 million pregnant women received HIV counseling and testing in China. The percentage of registered HIV-positive pregnant women on PMTCT antiretroviral treatment was 74,1%, or about 5.9 million. The estimated proportion of all HIV-positive pregnant women receiving PMTCT ART is 35,6%. Approximately 2.5 million HIV-infected women worldwide give birth each year, and 800,000 children are at risk of mother-to-child transmission. Of the 5 million additional HIV infections each year, 590,000 to 810,000 are newborns, and more than 500,000 children die from AIDS each year. Therefore, prevention of infant HIV transmission through HIV mother-to-child transmission worldwide has become an extremely urgent task at present.
1.Introduce the concept of HIV mother-to-child isolation? What is the general success rate?
Mother-to-child HIV interruption refers to the provision of a series of services for HIV-infected mothers and their infants, such as antiviral treatment, safe delivery, and artificial feeding guidance, so as to minimize the chance of vertical transmission of HIV from mother to child. Mother-to-child transmission can be reduced from 30-40% to 2-5% by implementing mother-to-child interruption.
2.How many cases of mother-to-child isolation have you been exposed to? How many cases were successful? Can you pick one successful case and one unsuccessful case to give details and the reasons for its success or failure?
Beijing Ditan Hospital has received nearly 100 cases of mother-to-child isolation, and the success rate is 100%. It may be related to the active prenatal education of the medical staff, the correct and reasonable method of PMTCT, and the good compliance of the patients.
3.What interventions should a woman who is already infected with HIV and wants to conceive and give birth, and when should the interventions start before conception?
Current guidelines recommend that ART should be administered to all HIV-positive pregnant women, regardless of viral load and CD4 levels, and that existing ART regimens should be adapted to the patient’s condition if needed. It is also recommended that antiretroviral therapy be administered during pregnancy, delivery, and lactation, regardless of the stage of the disease in HIV-infected women.
Specifically, most antiviral treatment begins at 14 weeks of gestation, and the recommended first-line antiviral regimen for pregnant women is: AZT+3TC+LPV/RTV; TDF is recommended to replace AZT if the pregnant woman is anemic or has reduced neutrophils; EFV is prohibited in the first trimester to avoid potential teratogenicity; NVP is only used for women with CD4 <250/mm3. 4.What special measures are needed at the time of conception? Generally, before conception, both men and women should undergo general routine preconception screening. In addition to the routine preconception screening, it is recommended to add some special items such as HIV viral load, CD4+ T-cell count, other sexually transmitted diseases (such as syphilis, gonorrhea, chlamydia), etc., and also ask about some nutritional status, related gynecological diseases and bad behaviors. For example, some HIV+ women have malnutrition, especially multivitamin deficiency (e.g. vitamin A deficiency), which can affect the integrity of the vaginal mucosa or placental tissue, making the maternal and fetal immunity low and facilitating the virus to enter the breast milk and fetal gastrointestinal tract, thus promoting the transmission of the virus. Then, for example, some women are combined with cervical erosion, and if the male HIV+ single positive family, the woman can easily be infected with HIV during conception and later infect the fetus through vertical transmission. Also, some poor lifestyle habits, including unprotected sex during pregnancy, smoking, alcohol abuse, and drug abuse, are associated with the occurrence of mother-to-child transmission of HIV. Among mothers with low CD4+ T-lymphocyte counts, the incidence of perinatal HIV transmission is increased threefold in smokers. Intravenous drug use during pregnancy also increases the risk of mother-to-child transmission. Unprotected sexual intercourse during pregnancy is also associated with mother-to-child transmission of HIV. It may be associated with repeated HIV infections and increased strain diversity, as well as increased inflammation or friction in the cervix and vagina. If the male partner is HIV-infected, sperm implantation after semen HIV washing is recommended in addition to routine testing of sperm viability and count. After both partners are prepared for pregnancy, ovulation detection by ovarian ultrasound in the female partner and conception by intercourse or artificial insemination under the guidance of the doctor is sufficient. For single-positive families where the woman is HIV-negative at the time of conception, it is controversial whether to give oral antiviral drugs to prevent interruption of HIV infection. However, considering the risk of infection in the female partner, we mostly recommend giving anti-blocking drugs in January during conception. 5.What is the progress of mother-to-child blockade in China and abroad? What is the level of public awareness? What are the obstacles and what are the biggest difficulties? What is the situation in the West compared to it? Every woman has the right to give birth. Therefore, if a woman with HIV is found to be pregnant or is adamant about having children, it is right that medical personnel provide her with the necessary counseling, medical examinations, and further treatment and follow-up so that she receives safe, scientific perinatal services. Many European countries, as well as the United States and Japan, have worked on the issue of assisted conception for HIV-infected couples. HIV sperm washing was performed in Italy in 1989 and in Germany in 1991, and the first preimplantation technique for HIV-positive men with HIV-negative couples was published by Semprini in 1992. By 2003, more than 1,800 couples worldwide had been treated for >4,500 cycles using a variety of assisted conception techniques. Medical centers wash and test sperm shortly before assisted conception, and no serologic changes have been reported in more than 500 children after birth.
The gradual advancement of mother-to-child interruption in China was made after 2000. With the introduction of the national “Four Free and One Care” policy, which includes free mother-to-child interruption, pregnant women with HIV are provided with free mother-to-child interruption drugs and testing reagents for their babies, which greatly reduces the probability of vertical transmission from mother to child. Some information suggests that in the absence of intervention measures, the mother-to-child transmission rate of HIV in some of China’s highly endemic areas is about 35%, similar to the situation in some developing countries, and significantly higher than the 15-25% transmission level in Western developed countries. It is close to the level of developed countries. At the same time, with national publicity and media dissemination, HIV mother-to-child interruption has become a significant concern and is gradually gaining the attention of infected patients and medical personnel, and more and more patients are being seen in outpatient clinics for counseling and treatment.
Although various approaches have been taken to interrupt mother-to-child transmission of HIV, it still cannot be completely interrupted. Although HIV testing for pregnant women has been promoted, it is still difficult to use anti-HIV testing as a routine measure in many poor developing countries where mother-to-child transmission is serious due to the cost of testing and other issues. Many HIV-infected pregnant women apply combination antiviral therapy, and their fetuses may be affected by multiple drugs and develop mitochondrial function impairment, neurological disorders, etc. In addition, although cesarean delivery can reduce mother-to-child transmission of HIV, women with HIV have a high rate of postoperative morbidity and mortality, especially in underdeveloped countries. Moreover, some mother-to-child blocking techniques, such as HIV spermicide, have not been carried out in China due to economic and ethical factors. Therefore, how to minimize the chance of mother-to-child transmission while protecting the health of pregnant women and infants as much as possible still needs to be further researched and studied.
6.What groups in China are most in need of knowledge and technology for mother-to-child isolation? Is the sale of blood for transfusion by women in remote rural areas a major route of HIV infection?
Infected women of childbearing age are the group in urgent need of mother-to-child transmission. With the promotion of national blood donation policy and blood transfusion standardization measures, sexual transmission has overtaken blood transfusion as the first of the three important transmission routes of AIDS.
7.Will children born with AIDS necessarily carry HIV if no intervention is done?
Without intervention, the mother-to-child transmission rate of HIV in high HIV prevalence areas is 30%-50%.
8. If the man is HIV positive, what is the situation if he wants to have a child?
(As mentioned above) If the male partner is HIV-infected, in addition to routine preconception screening, it is recommended to add some special items, such as HIV viral load, CD4+ T-cell count, other sexually transmitted diseases (such as syphilis, gonorrhea, chlamydia), etc., and also to ask about some nutrition, related diseases and malpractice. If necessary, sperm implantation after semen HIV washing is recommended.
9.How long can a child be born to be completely sure that it is healthy? Is there a latent period of HIV that is undetectable without symptoms?
For infants born to HIV-infected mothers, HIV nucleic acid (RNA) should be used to detect HIV infection at 4-6 weeks after birth or as early as possible thereafter to make early diagnosis and early treatment. Infants who test positive or negative for HIV-RNA should be started on antiviral therapy for 42 days immediately after intensive parental or guardian discussion and informed consent. All infants younger than 2 years of age with confirmed HIV infection should be placed on antiviral therapy as soon as possible, regardless of CD4+ T-lymphocyte count and clinical stage.