Herpes simplex and HIV infections and preterm PROM

Maternal human immunodeficiency virus (HIV) and genital herpes simplex virus (HSV) infection in pregnancy have potential for vertical transmission that may result in death or morbidity. The risk increases with preterm delivery and prolonged ruptured membranes. When managing preterm premature rupture of membranes, the risk of transmission must be weighed against the risk of prematurity. Before 32 to 34 weeks, expectant management is preferred for patients with well controlled HIV or recurrent active genital HSV infection. For patients with advanced HIV disease or primary genital HSV infection, the risk of vertical transmission is higher and many clinical factors need to be considered.     

Sexually transmitted infection/HIV risk reduction interventions in clinical practice settings

African American women, particularly those who live in inner-city areas, experience disproportionately high rates of sexually transmitted infections including HIV. As there are currently no preventive vaccines for HIV and most sexually transmitted infections, prevention efforts must focus on behavioral risk reduction. Thus, culturally tailored interventions for African American women are needed to reduce their incidence of sexually transmitted infections including HIV. One place to intervene with inner-city African American women is in primary care settings. Primary care settings have the potential to reach a wide range of women, including those who may not proactively seek sexually transmitted infection/HIV prevention services. However, in order to be feasible for use in clinical settings, sexually transmitted infection/HIV risk reduction interventions must be brief and easily adapted for use with diverse clients in varied practice environments. To date, few brief sexually transmitted infection/HIV prevention interventions have been designed for use with African American women in primary care settings. Only one of these, the "Sister to Sister: Respect Yourself! Protect Yourself! Because You Are Worth It!" intervention, has demonstrated effectiveness in reducing sexual risk behaviors and sexually transmitted infection incidence. This article describes this 20-minute, one-on-one nurse-led intervention for African American women and discusses considerations for its implementation in primary care and other clinical settings.     

Acquired immunodeficiency syndrome (AIDS): a commentary on the international aspects of the disease

By the beginning of 1987 there were 1100 heterosexual cases of AIDS in the US, and by 1991 an estimated 1/4 million US citizens will have AIDS, or will have already died from it. The situation in the 3rd World is even more grim. In parts of Africa the annual incidence of HIV infection is approaching 1%. Up to 12% of pregnant women in urban hospitals in Zaire carry the virus, and 25-88% of the prostitutes in some of the large cities in sub-Sahara Africa have the disease. Already, 5-10 million people around the world may be carrying HIV. Like the influenza virus, HIV can change its protein coat rapidly. The victim can appear perfectly healthy and still spread the disease. In countries with low maternal mortality, it could become the most common cause of maternal death. If people are to adopt safe sex practices, they must be convinced that they are at risk, that a lethal disease can be asymptomatic but ineffective for many years. They must know that safety practices--including the use of condoms, and perhaps especially spermicidally lubricated condoms--offer worthwhile protection. If any link in this chain is broken, individuals will not adopt such voluntary practices. There are no known political or geographical barriers to human copulation; now is the time to act, particularly in countries with a low or no prevalence of AIDS. Obstetricians must fight AIDS with the same commitment to preventative medicine that they bring to good obstetrics and good family planning.     

Obstetric and perinatal consequences of human immunodeficiency virus (HIV) infection: a review

Pediatric acquired immune deficiency syndrome (AIDS) was known to be a new disease that could be acquired from the mother even before human immunodeficiency virus (HIV) was identified. The suggested routes of transmission of infection are intrauterine, perinatal--from contact with infected maternal genital secretions, or through breastfeeding. At this time the problem in Europe concerns primarily women in high-risk groups: intravenous drug abusers, prostitutes, women from countries where the prevalence of HIV is high, and women whose sexual partners are in a high-risk group. In the future, the infection may extend beyond women in high-risk groups as the disease becomes more prevalent in the community. It has been claimed that pregnancy accelerates symptoms in women who are HIV positive, yet this is based on only a series of case reports of severe infection in pregnancy and on the development of AIDS in asymptomatic women in pregnancy subsequent to the birth of an AIDS child. The only data capable of shedding some light on this issue would be a prospective followup of both pregnant and nonpregnant HIV-positive women from similar high-risk groups. Such a study is ongoing in the US. An increasing number of case reports suggest intrauterine transmission of infection. The following 3 case reports provide clear evidence of intrauterine transmission. Sprecher et al. (1986) detected HIV antigen in amniotic fluid and fetal tissues from a pregnancy termination at 15 weeks gestation in a woman with stage IV AIDS and Kaposi sarcoma. Lapointe et al. (1985) reported an infant born by cesarean section at 28 weeks gestation to a mother with terminal aids. A new dysmorphic syndrome recently has been described in children with symptomatic HIV infection (Marion et al., 1986). HIV has been isolated from cervical secretions (Fogt et al., 1986; Wofsy et al., 1986), which suggests that this cold be another source of infection. There is 1 report of isolation of HIV from the noncellular fraction of breast milk (Thirty et al., 1985). Several case reports have described acquired immunodeficiency in infants for whom the only known risk factor was neonatal transfusion from an individual later found to be suffering from AIDS. The risk of transmission from an infected mother to her infant is unknown, but the best available evidence comes from a study of children born to women who had previously given birth to a child with AIDS (Scott et al, 1985). Of 12 children, 4 developed AIDS or Aids-related complex. Clinical problems among children with AIDS or AIDS-related complex have been fully described. The fatality rate of children with AIDS is high, but the ultimate progress of children with less severe disease or who have asymptomatic infection is known.     

Depoliticize human immunodeficiency virus infection: a commentary

Public-health policy is inconsistent in its approach to the sexually transmitted disease human immunodeficiency virus (HIV). Nearly every health agency has politicized the reporting, finding, and contacting of HIV cases. There is also no consistency among the various state health departments and the various federal health agencies. Until we have a uniform health policy that treats HIV infection as every other reportable sexually transmitted disease, we will make little progress toward controlling its inevitable increase in both cases and costs.     

Breast-feeding and the potential for human immunodeficiency virus transmission

There is evidence to suggest that the human immunodeficiency virus (HIV) can be transmitted from mothers to their uninfected offspring via infected breast milk. The quantitative risk of transmission by this route is unknown. We must urge all individuals at risk for HIV infection to be tested. In the United States, it is recommended that women who are known to be HIV-positive be discouraged from breast-feeding. In certain regions of the United States, such as high-risk areas of New York City, HIV infection may be present in more than 3% of reproductive-age women, most of whom do not know they are infected. Women who either live in areas of the United States in which acquired immunodeficiency syndrome (AIDS) is endemic or are living in other parts of the country and are at high risk for AIDS, yet refuse to be tested, should be counseled regarding the potential for transmission of the virus to uninfected offspring via breast-feeding.     

ACOG Committee Opinion No. 389, December 2007. Human immunodeficiency virus

Because human immunodeficiency virus (HIV) infection often is detected through prenatal and sexually transmitted disease testing, an obstetrician-gynecologist may be the first health professional to provide care for a woman infected with HIV. Universal testing with patient notification and right of refusal ("opt-out" testing) is recommended by most national organizations and federal agencies . Although opt-out and opt-in testing (but not mandatory testing) are both ethically acceptable, the former approach may identify more women who are eligible for therapy and may have public health advantages . It is unethical for an obstetrician-gynecologist to refuse to continue providing health care for a patient solely because she is , or is thought to be, seropositive for HIV. Health care professionals who are infected with HIV should adhere to the fundamental professional obligation to avoid harm to patients. Physicians who believe that they have been at significant risk of being infected should be tested voluntarily for HIV.     

AIDS. Natural history and prognosis

Infection with HIV results in a chronic, persistent infection that usually progresses slowly from an asymptomatic state to full-blown AIDS. AIDS remains a lethal disease with no effective cure. A great deal of information has been learned in the past decade, yet many questions remain unresolved. Much more research is needed into the conditions surrounding the perinatal transmission of HIV. Many women who give birth to a child with AIDS are themselves asymptomatic for HIV infection during pregnancy and at delivery; thus, routine voluntary prenatal HIV screening programs must be instituted in areas of high seroprevalence. Such screening programs must provide pretest and post-test counseling with consent and confidentiality. Seroprevalence studies conducted during the perinatal period or at birth using newborn blood samples will provide important epidemiologic data for further research investigations as well as continued estimates of the prevalence of HIV infection. Currently, there is no formal reporting system for HIV infection, only for the clinical expression of AIDS. There may be a need to develop a centralized reporting unit for HIV infection. As the epidemic continues and the true prevalence rates are determined, additional resources for public health care, housing, insurance, and foster care for children will be needed. The number of women who are infected is increasing at an alarming rate. Every opportunity to increase public awareness about the AIDS epidemic and modes of transmission must be exploited if we are to impact on the spread of HIV infection. Prospective studies of pregnant HIV-positive women and pediatric follow-up can provide a wealth of data about AIDS and disease progression in both the mother and the infant. Even if some children do not develop AIDS, the possibility of permanent effects of in utero exposure to the virus still exists. At what exact point in gestation does infection occur? Can infection be prevented or delayed with current chemotherapeutic protocols? Even if a cure or vaccine is developed in the near future, the impact of this deadly virus will have repercussions for many years to come.     

AIDS and reproductive health

Over 24 million adults worldwide have been infected with HIV. Primarily a sexually transmitted disease, AIDS is inexorably linked to reproductive health and care. Because HIV tends to infect those who are in their reproductive years, the impact of this disease on population growth and life expectancy is projected to be immense in some parts of the world, especially in sub-Saharan Africa. Not least is the challenge to individual families and infant care programs to care for AIDS babies. Estimates of the rate of vertical transmission of HIV range from < 10 to 46%. Transmission through sexual contact accounts for 75-85% of HIV infection worldwide, and today, nearly 20 years into the epidemic, the main tool to stall the spread is advocating change in sexual conduct. Numerous studies leave no doubt that the attributable risk of co-infection with other STDs--both ulcerative and non-ulcerative--in heterosexual transmission is substantial. The only known contraceptive method proven to reduce both infectiousness and susceptibility to HIV is barrier contraception. Spermicidal agents currently available have not been shown to reduce HIV concentrations in genital secretions, or to reduce transmission of the virus. The challenges that lie ahead are tremendous: we must continue to focus on development of affordable preventive measures; urge policy-makers to back further research in prevention to complement condom use; and advocate for continued support of basic research to learn more about fundamental mechanisms of HIV transmission.     

Pleasure and prevention: when good sex is safer sex

Most sexual health education programmes use fear and risk of disease to try to motivate people to practise safer sex. This gives the impression that safer sex and pleasurable sex are mutually exclusive. Yet there is growing evidence that promoting pleasure alongside safer sex messaging can increase the consistent use of condoms and other forms of safer sex. To this end, the Pleasure Project created The Global Mapping of Pleasure, a document that identifies projects and organisations worldwide that put pleasure first in HIV prevention and sexual health promotion, and sexually provocative media that include safer sex. This article summarises some of the findings of this mapping exercise and what we learned about incorporating pleasure from it. We found that there are a variety of organisations, including religious and youth groups, and HIV/AIDS organisations and NGOs, promoting pleasurable safer sex. The techniques they use include promoting sexual techniques and dialogue about sex, teaching married couples how to have better sex and putting images of desire in sexual education materials. This paper focuses on ways of eroticising female and male condoms as examples of effective ways of using pleasure in HIV prevention and sexual health promotion.     

The Dilemma of Postnatal Mother‐to‐Child Transmission of HIV: To Breastfeed or Not?

The promotion of nearly universal breastfeeding has played an important role in improving child health by providing optimum nutrition and protection against common childhood infections, and by promoting child spacing. Unfortunately, it has become clear that breastfeeding is responsible also for much of the increasing burden of worldwide pediatric human immunodeficiency virus (HIV) infection, especially in the developing nations (12–14% additional risk of HIV infection transmitted by breastfeeding; 35% total proportion of all HIV‐infected children in an area infected through breastfeeding). Several factors influence the transmission of HIV by breastfeeding, including whether a woman acquires her infection during breastfeeding (29% risk of transmission) or before pregnancy (7–10% risk of breastfeeding transmission),the degree of maternal plasma and breastmilk viral load, and the presence of mastitis. In areas of the world where adequate sanitary replacement feeding is not available, the decision to withhold breastfeeding so as to decrease HIV transmission may lead to increased rates of child morbidity and mortality from diarrheal and respiratory diseases, and malnutrition. This review summarizes current data on the pathophysiology of breastfeeding transmission of HIV infection, the risk factors for and incidence rates of transmission, and the feasibility of possible alternatives to exclusive breastfeeding in the setting of maternal HIV infection. Clearly, women must be fully informed about the risks of breastfeeding transmission of HIV, the risks of morbidity and mortality among nonbreastfed infants, and the expense and availability of procuring adequate replacement formula. If an uninterrupted access to a nutritionally adequate breastmilk substitute that can be safely prepared is ensured (as is possible in industrialized countries), HIV‐infected women should be counseled not to breastfeed their infants.     

HIV Risk Status and Preventive Behaviors Among 17,619 Women

Objectives : To document the percentage of women at high risk for human immunodeficiency virus (HIV) infection among primary care clients, identify their most prevalent risk factors for HIV infection, and examine the relationships between risk status and preventive behaviors for HIV infection.
Design : Cross-sectional.
Setting : Urban and nonurban primary care clinics.
Participants : Female clients (N = 17,619) who voluntarily completed an HIV risk-assessment form.
Main outcome measures : HIV risk status, condom use, and previous HIV testing.
Results : Using criteria from the Centers for Disease Control, the study found 14% of the sample to be at high risk for HIV infection. Prevalent risk factors were having sex with persons at high risk for AIDS, having sex with more than six persons in a year, and having more than two sexually transmitted diseases. Women at high risk were more likely to be older, urban, and black. Overall, rates of consistent condom use and HIV testing were low, 12% and 7%, respectively. Older women, coupled women, and women of color were least likely to use condoms consistently. Women at low risk were less likely to have had HIV tests.
Conclusions : To prevent HIV infection, nursing interventions can target women of all ages, especially urban and black women. Nurses should use strategies and skills to promote condom use that are different from those they use to encourage HIV testing.     

Pregnant or positive: adolescent childbearing and HIV risk in KwaZulu Natal, South Africa

In communities where early age of childbearing is common and HIV prevalence is high, adolescents may place themselves at risk of HIV because positive or ambivalent attitudes towards pregnancy reduce their motivation to abstain from sex, have sex less often or use condoms. In this study, we analyse cross-sectional survey data from KwaZulu Natal, South Africa, to explore whether an association exists between the desire for pregnancy and perceptions of HIV risk among 1,426 adolescents in 110 local communities. Our findings suggest that some adolescents, girls more than boys, were more concerned about a pregnancy if they lived in environments where youth were perceived to be at high risk of HIV infection. The probability that pregnancy was considered a problem by boys was positively correlated with the proportion of adult community members who thought youth were at risk of acquiring HIV, and for girls by the proportion of peers in the community who thought youth were at risk of HIV. We also found that becoming pregnant would be a bigger problem for the African girls than the white and Indian girls. The analysis suggests that for some adolescents, in addition to effects on educational and employment opportunities, the danger of HIV infection is becoming part of the calculus of the desirability of a pregnancy.     

Human immunodeficiency virus testing and the risk to the surgeon of acquiring HIV

Physicians and other health care workers risk infection with human immunodeficiency virus (HIV), hepatitis B virus and other infectious agents. Most authorities have argued against routine testing of patients preoperatively for HIV infection because it would not prevent or reduce the risk of infection to health care workers. They agree with the policy of the Centers for Disease Control that advocates universal precautions for all patients. Surgeons have not been reassured by these arguments. They claim that their exposure to blood during operation exposes them to increased risk of infection. The risk of acquiring HIV from a single needle-stick injury is low. However, most surgeons are interested in their lifetime risk of infection. In this study, a mathematical model for predicting the risk of acquiring HIV in patients in a given hospital and the total number of needle-stick injuries are given. Using minimal likely HIV seroprevalence, this model predicts that at least 47 of the approximately 18,000 Fellows of the American College of Surgeons would become infected. New data showing early treatment can lead to increased longevity in infected patients with HIV, the fact that many health care workers do not follow universal precautions and other arguments are put forward to support a suggested routine--voluntary testing of all surgical patients for antibody to HIV.     

Summary of the updated recommendations from the Public Health Service Task Force to reduce perinatal human immunodeficiency virus-1 transmission in the United States

Within the last decade, substantial advances have been made in the treatment of human immunodeficiency virus (HIV)-infected pregnant women and in the prevention of perinatal HIV-1 transmission, and recommendations for care continually change. Within this rapidly evolving field, the Public Health Service Task Force Perinatal HIV Guidelines Working Group, which is composed of pediatric and obstetric experts in HIV infection, community representatives, and federal agency representatives, currently meets by monthly conference calls to review new data related to prevention of mother-to-child HIV transmission and management of women with HIV infection. This group periodically issues updates to their guidelines, "Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States," which are available on the HIV/AIDS Treatment Information Service Web site (http://www.hivatis.org).     

Cervical Cancer Screening and the Immunosuppressed Patient: the Issues in Screening High-Risk Populations

Purpose of Review

While evidence-based guidelines are available for cervical cancer screening in the general population, women at higher risk of persistent HPV infection and cervical cancer are excluded. There is limited evidence to guide screening practices for “high-risk” women, in particular, those who are immunosuppressed.

Recent Findings

Women with immunosuppression demonstrate an increased risk of cervical dysplasia and invasive cervical cancer (ICC) compared to the baseline population. Women with HIV were found to have increased rates of ICC and recurrent dysplasia, compounded by lower CD4 counts. Women with other forms of immune suppression demonstrated variable risk of dysplasia and cancer with the highest risk in transplant recipients and variable risk of dysplasia reported in autoimmune diseases. Data support updated screening guidelines for women with HIV: annual cytology for 3 years, and if screening is negative, increased screening intervals to every 3 years. However, women with HIV and other forms of immunosuppression have been reported to be less compliant with screening guidelines.

Summary

While there is high-quality data to support screening intervals for women with HIV, we were not able to identify data to guide modality and interval of screening in other types of immune compromise. Compliance with screening is lower both in women with HIV and other immune-mediated disease. Improving screening compliance in this high-risk population with a simplified screening strategy is likely the most important factor for reducing the risk of cervical cancer and further research is needed.

     

Disseminated herpes simplex infection in a twin: the role of the "stat" autopsy in immediate therapeutic intervention for survival of multiple birth neonates.

Multiple birth neonates are unique in sharing similar intrauterine, and commonly the extrauterine, environments. The development of an infectious disease in one infant during the perinatal period assumes special significance in this setting, and the other siblings are often at high risk for a similar disease. Under these circumstances it is important to make a rapid etiologic diagnosis to provide appropriate therapeutic intervention. The immediate, or "stat", autopsy is a diagnostic modality involving the use of multiple procedures for the rapid diagnosis of perinatal infection which may be lifesaving in the setting of multiple birth neonates. This report describes the use of the "stat" autopsy to diagnose a fatal case of disseminated herpes simplex infection in a twin, which lead to the immediate treatment of the surviving sibling with appropriate antiviral medication.     

Cervical-vaginal disease in HIV immunosuppressed patients: management and present screening programme

The aim of this study was to evaluate the rate of the cervical intraepithelial neoplasia (L-SIL and H-SIL) in HIV-positive patients using cytological, colposcopic and histological examinations. The correlations between these cervical lesions, the role of HPV and the clinical and immunological aspects of HIV infection and inflammatory cervical-vaginal disease were studied. We believe that HPV infection and preneoplastic and/or neoplastic lesions occur more often in immunodepressed HIV-positive patients, and that on the grounds of the high risk of precancerous lesions in this population and the low sensibility of the Pap test, it is advisable to perform a colposcopic examination to discover early lesions that must undergo a specific biopsy.     

Inverted T helper/T suppressor lymphocyte ratio is not a reliable indicator of coexistent HIV infection in the presence of carcinoma: report of a patient with ovarian carcinoma and inverted TH/TS ratio

Patients with non-HIV (Human Immunodeficiency Virus) related cancers may also have HIV infection. Inverted peripheral blood lymphocyte T helper/T suppressor ratios with selective loss of T helper cells may be used as a clinical screening test for HIV infection in these patients since they may be seronegative for retrovirus infection early in the course of infection. We describe a case in which carcinoma alone appeared to induce systemic changes that resembled coexistent HIV infection. Many of these abnormalities, including inverted TH/TS ratio with selective loss of T helper cells, improved in the immediate postoperative period, indicating that HIV infection was not present. We conclude then, that diagnosis of HIV infection should not be made without more definitive evidence of its presence than an inverted TH/TS ratio in a patient with carcinoma.     

Pregnancy and infection with human immunodeficiency virus

During the past decade, there has been a dramatic increase in the number of women infected with HIV and the number of women with clinical AIDS. One of the most prominent features of HIV infection is that it is usually diagnosed during the peak reproductive years, and in 1998, HIV/AIDS was the fourth leading cause of death among women between the ages of 25 and 44 years. For this reason, there has been long-standing concern regarding the obstetric implications of HIV infection: both the impact of pregnancy on possibly accelerating the course of HIV disease and the impact of HIV infection on the course of pregnancy. There appears to be some immunologic changes associated with pregnancy, but they are not dramatic, and immune markers generally resume their prepregnancy values after delivery. With regard to long-term effects of pregnancy on HIV disease progression, no study to date has shown significant increases in mortality or in AIDS incidence associated with pregnancy. Studies have generally been small, however, and none have accounted for antiretroviral therapy usage. Many studies have shown that certain adverse outcomes are more common in HIV-positive pregnant women as compared with HIV-negative pregnant women, and concerns have been raised that spontaneous abortions may be more common among HIV-infected women and that this may impact fertility rates. Although important understanding has been acquired regarding the associations between pregnancy and the course of HIV infection, much remains to be understood. Additional, well-designed studies are clearly needed to rigorously address the many remaining questions that exist. We can anticipate that the resolution of these questions will continue to be of broad public health interest as the epidemic impacts increasing numbers of women, a large fraction of whom will be adolescents.