Follow up of HIV perinatal exposure and accomplishment of strategies to reduce the risk of viral transmission, experience in a reference hospital in Medellín / Calidad del seguimiento a la exposición perinatal al HIV y observancia de las estrategias reconocidas para disminuir su transmisión en un centro de referencia de Medellín

Introduction: Prevention of mother-to-child transmission of the human immunodeficiency virus (HIV) is essential to limit the spread of the disease. Colombian data about HIV infection in pregnancy are scarce, as well as on the results of the strategies used worldwide to reduce perinatal transmission. Objective: To describe the characteristics and outcomes of pregnant women infected with HIV and their children in a reference center in Medellín. Materials and methods: We conducted a retrospective observational study for the 2012-2015 period by studying the clinical records of newborns exposed to HIV and their mothers. We evaluated the characteristics of prenatal care, deliveries, and infant postnatal care, as well as the follow-up data to confirm or exclude HIV transmission. Results: We included 106 infants and their mothers. We found that 39,6% of mothers knew about the HIV diagnosis before pregnancy and 58,5% were diagnosed during pregnancy; 95.3% of them attended prenatal controls, but only 46.5% as of the first trimester; 95% of them received antiretrovirals, but 23.9% started therapy just during the third trimester. Only 63% of women had a viral load for HIV after 34 weeks of gestation. None of the 103 children with follow up had confirmed presence for HIV and in 88% of them, it was discarded. Conclusions: No cases of perinatal HIV transmission were found in the study. However, difficulties and delays persist in prenatal care, in timely maternal follow-up to confirm or discard HIV, and for early detection of maternal co-infections and their effects on newborns.

Introducción. La prevención de la transmisión materno-infantil del virus de la inmunodeficiencia humana (Human Immunodeficiency Virus, HIV) es una estrategia fundamental para evitar la infección en niños. A nivel local, se desconoce la situación de las mujeres gestantes infectadas por HIV y el grado de observancia de las estrategias reconocidas mundialmente para disminuir la transmisión perinatal. Objetivo. Describir las características sociodemográficas y clínicas de las mujeres gestantes con HIV y de sus hijos en un centro de referencia de Medellín. Materiales y métodos. Se hizo un estudio descriptivo retrospectivo entre 2012 y 2015 mediante la revisión de las historias clínicas de las mujeres gestantes con HIV y de sus neonatos habidos en partos atendidos en el Hospital San Vicente Fundación. Se describieron las variables de atención prenatal, parto, recién nacido y seguimiento de los neonatos. Resultados. Se analizaron 106 madres y sus hijos expuestos al HIV. El 39,6 % de las mujeres gestantes conocía el diagnóstico antes del embarazo y al 58,5 % se le diagnosticó durante este. El 95,3 % de las mujeres gestantes asistió a control prenatal, 46,5 % de ellas a partir del primer trimestre. Si bien el 95 % recibió antirretrovirales, el 23,9 % comenzó a tomarlos tardíamente en el tercer trimestre. Solo el 63 % de las mujeres registró carga viral para el HIV después de la semana 34 de gestación. El 90,6 % de los partos fueron por cesárea, y el virus del papiloma humano y la sífilis fueron las principales infecciones concomitantes. Se hizo seguimiento de 103 niños (no fue posible localizar a tres de ellos para el seguimiento), a ninguno se le confirmó la presencia del HIV y, en el 88 %, se descartó. Conclusiones. En este estudio, no se registraron casos de transmisión perinatal. Sin embargo, siguen presentándose fallas y retrasos en la atención prenatal y en la oportunidad del seguimiento materno para confirmar oportunamente el HIV y para detectar tempranamente infecciones maternas concomitantes que eviten la morbilidad y las secuelas en los neonatos.

Calidad del seguimiento a la exposición perinatal al HIV y observancia de las estrategias reconocidas para disminuir su transmisión en un centro de referencia de Medellín / Follow up of HIV perinatal exposure and accomplishment of strategies to reduce the risk of viral transmission, experience in a reference hospital in Medellín

Resumen Introducción. La prevención de la transmisión materno-infantil del virus de la inmunodeficiencia humana (Human Immunodeficiency Virus, HIV) es una estrategia fundamental para evitar la infección en niños. A nivel local, se desconoce la situación de las mujeres gestantes infectadas por HIV y el grado de observancia de las estrategias reconocidas mundialmente para disminuir la transmisión perinatal. Objetivo. Describir las características sociodemográficas y clínicas de las mujeres gestantes con HIV y de sus hijos en un centro de referencia de Medellín. Materiales y métodos. Se hizo un estudio descriptivo retrospectivo entre 2012 y 2015 mediante la revisión de las historias clínicas de las mujeres gestantes con HIV y de sus neonatos habidos en partos atendidos en el Hospital San Vicente Fundación. Se describieron las variables de atención prenatal, parto, recién nacido y seguimiento de los neonatos. Resultados. Se analizaron 106 madres y sus hijos expuestos al HIV. El 39,6 % de las mujeres gestantes conocía el diagnóstico antes del embarazo y al 58,5 % se le diagnosticó durante este. El 95,3 % de las mujeres gestantes asistió a control prenatal, 46,5 % de ellas a partir del primer trimestre. Si bien el 95 % recibió antirretrovirales, el 23,9 % comenzó a tomarlos tardíamente en el tercer trimestre. Solo el 63 % de las mujeres registró carga viral para el HIV después de la semana 34 de gestación. El 90,6 % de los partos fueron por cesárea, y el virus del papiloma humano y la sífilis fueron las principales infecciones concomitantes. Se hizo seguimiento de 103 niños (no fue posible localizar a tres de ellos para el seguimiento), a ninguno se le confirmó la presencia del HIV y, en el 88 %, se descartó. Conclusiones. En este estudio, no se registraron casos de transmisión perinatal. Sin embargo, siguen presentándose fallas y retrasos en la atención prenatal y en la oportunidad del seguimiento materno para confirmar oportunamente el HIV y para detectar tempranamente infecciones maternas concomitantes que eviten la morbilidad y las secuelas en los neonatos.

Abstract Introduction: Prevention of mother-to-child transmission of the human immunodeficiency virus (HIV) is essential to limit the spread of the disease. Colombian data about HIV infection in pregnancy are scarce, as well as on the results of the strategies used worldwide to reduce perinatal transmission. Objective: To describe the characteristics and outcomes of pregnant women infected with HIV and their children in a reference center in Medellín. Materials and methods: We conducted a retrospective observational study for the 2012- 2015 period by studying the clinical records of newborns exposed to HIV and their mothers. We evaluated the characteristics of prenatal care, deliveries, and infant postnatal care, as well as the follow-up data to confirm or exclude HIV transmission. Results: We included 106 infants and their mothers. We found that 39,6% of mothers knew about the HIV diagnosis before pregnancy and 58,5% were diagnosed during pregnancy; 95.3% of them attended prenatal controls, but only 46.5% as of the first trimester; 95% of them received antiretrovirals, but 23.9% started therapy just during the third trimester. Only 63% of women had a viral load for HIV after 34 weeks of gestation. None of the 103 children with follow up had confirmed presence for HIV and in 88% of them, it was discarded. Conclusions: No cases of perinatal HIV transmission were found in the study. However, difficulties and delays persist in prenatal care, in timely maternal follow-up to confirm or discard HIV, and for early detection of maternal co-infections and their effects on newborns.

[Demands of home care of children born exposed to HIV in the perspective of the environmental theory]. / Demandas de cuidado domiciliar da criança nascida exposta ao HIV na ótica da teoria ambientalista.

The purpose of this study was to identify the demands of home care of children born exposed to HIV in the perspective of the environmental theory. It consists of an exploratory descriptive qualitative study, developed between January and April of 2011. Study participants were ten HIV-infected mothers with infants exposed to the virus, living in Fortaleza, Ceará. The data collection instruments included a disposable digital camera and forms to obtain information on health associated with the home environment. Results were contextualized according to the theory and organized into the following categories: vulnerabilities associated with the physical structure of the house; contaminated intra and peridomestic air; unclean water used for drinking; sanitation and sewerage system; lighting and ventilation of the house. In conclusion, the home environment offers unfavorable environmental conditions for the child. Targeted interventions in the home environment are necessary so as to promote the health of children born exposed to HIV.

Demandas de cuidado domiciliar da criança nascida exposta ao HIV na ótica da teoria ambientalista / Demandas de cuidados en casa del niño nacido expuesto al VIH en la óptica de la teoría ambientalista / Demands of home care of children born exposed to HIV in the perspective of the environmental theory

Objetivou-se identificar as demandas de cuidado domiciliar da criança nascida exposta ao HIV, sob a perspectiva da teoria ambientalista. Trata-se de estudo qualitativo exploratório-descritivo realizado de janeiro a abril de 2011. Participaram dez mães infectadas pelo HIV, com crianças nascidas expostas ao vírus, em Fortaleza, Ceará. Constituíram-se como instrumentos de coleta de dados: câmera fotográfica descartável e digital e formulários para captação de informações em saúde associadas ao ambiente domiciliar. Os resultados foram contextualizados de acordo com a teoria e organizados em categorias: "vulnerabilidades associadas à estrutura física da moradia"; "ar intradomiciliar e peridomiciliar impuro"; "água utilizada para consumo"; "rede de esgoto e saneamento"; "iluminação e ventilação da residência". Conclui-se que o ambiente domiciliar oferece condições ambientais desfavoráveis para a criança. Urge a realização de intervenções focalizadas no ambiente domiciliar, para promover a saúde da criança nascida exposta ao HIV.

Se objetivó identificar las demandas de atención en el hogar de los niños nacidos expuestos al VIH en la perspectiva de la teoría ambientalista. Estudio cualitativo exploratorio-descriptivo realizado entre enero y abril de 2011. Participaron diez madres VIH-positivas con bebés expuestos al virus, en Fortaleza, Ceará. Fueron instrumentos de recolección de datos: cámara desechable y digital y formularios para capturar información sobre la salud asociada con el ambiente del hogar. Los resultados fueron contextualizados de acuerdo a la teoría y organizado en categorías: vulnerabilidades asociadas con la estructura física de la casa; aire intra y peridoméstico impuro; agua utilizada para el consumo; saneamiento y alcantarillado; iluminación y ventilación de la residencia. Se concluye que el hogar ofrece condiciones ambientales desfavorables para el niño. Hay necesidad de intervenciones específicas en el entorno del hogar para promover la salud de los niños nacidos expuestos al VIH.

The purpose of this study was to identify the demands of home care of children born exposed to HIV in the perspective of the environmental theory. It consists of an exploratory descriptive qualitative study, developed between January and April of 2011. Study participants were ten HIV-infected mothers with infants exposed to the virus, living in Fortaleza, Ceará. The data collection instruments included: a disposable digital camera and forms to obtain information on health associated with the home environment. Results were contextualized according to the theory and organized into the following categories: vulnerabilities associated with the physical structure of the house; contaminated intra and peridomestic air; unclean water used for drinking; sanitation and sewerage system; lighting and ventilation of the house. In conclusion, the home environment offers unfavorable environmental conditions for the child. Targeted interventions in the home environment are necessary so as to promote the health of children born exposed to HIV.

Eventos adversos supuestamente atribuibles a la vacunación e inmunización en hijos de madres infectadas con el virus de la inmunodeficiencia humana / Supposedly attributable to vaccination and immunization in children of mothers infected with human immunodeficiency virus adverse events

Introducción: las vacunas son una de las intervenciones sanitarias más importantes y difundidas. La monitorización de su seguridad a través del registro de eventos adversos es imprescindible. Los hijos de madre infectada por el virus de la inmunodeficiencia humana (VIH), expuestos,infectados o serorrevertidos son un grupo particular de individuos dentro del esquema de inmunización. El objetivo del presente estudio fue describir la frecuencia de eventos adversos supuestamente atribuibles a la vacunación e inmunización (ESAVI) en los hijos de madres infectadas con VIH. Metodología: se realizó un estudio descriptivo, de corte transversal entre el 1º de setiembre de 2008 y el 28 de febrero de 2011 en el Centro Nacional de Referencia Obstétrico-Pediátrico VIH-SIDA del Centro Hospitalario Pereira Rossell con los pacientes allí controlados ( infectados y no infectados) que requerían vacunación en sus controles. Se registró el porcentaje y tipo de eventos producidos. Resultados: de 189 pacientes, 110 (58%) entregaron el formulario con un total de 157 registros. La mediana de edad fue de 2 meses (rango de 2 meses a 17 años). El 63% era menor de 6 meses. De los 110 niños, 34 eran infectados y 76 no infectados. Se registraron eventos adversos en 49 (44,5%) pacientes. Hubo 108 eventos leves y 23 graves. El porcentaje de ESAVI en ambos grupos fue similar (p>0,05). No se registraron hospitalizaciones ni eventos difíciles de catalogar como relacionados a vacunación. Conclusiones: las vacunas administradas en eseperíodo fueron seguras con similares ESAVI en ambos grupos de pacientes. Continuar vigilando la aparición de ESAVI y comparar los resultados año a año será importante para actualizar recomendaciones y garantizar la seguridad de los pacientes y sus cuidadores.

Eventos adversos supuestamente atribuibles a la vacunación e inmunización en hijos de madres infectadas con el virus de la inmunodeficiencia humana / Supposedly attributable to vaccination and immunization in children of mothers infected with human immunodeficiency virus adverse events

Introducción: las vacunas son una de las intervenciones sanitarias más importantes y difundidas. La monitorización de su seguridad a través del registro de eventos adversos es imprescindible. Los hijos de madre infectada por el virus de la inmunodeficiencia humana (VIH), expuestos,infectados o serorrevertidos son un grupo particular de individuos dentro del esquema de inmunización. El objetivo del presente estudio fue describir la frecuencia de eventos adversos supuestamente atribuibles a la vacunación e inmunización (ESAVI) en los hijos de madres infectadas con VIH. Metodología: se realizó un estudio descriptivo, de corte transversal entre el 1º de setiembre de 2008 y el 28 de febrero de 2011 en el Centro Nacional de Referencia Obstétrico-Pediátrico VIH-SIDA del Centro Hospitalario Pereira Rossell con los pacientes allí controlados ( infectados y no infectados) que requerían vacunación en sus controles. Se registró el porcentaje y tipo de eventos producidos. Resultados: de 189 pacientes, 110 (58%) entregaron el formulario con un total de 157 registros. La mediana de edad fue de 2 meses (rango de 2 meses a 17 años). El 63% era menor de 6 meses. De los 110 niños, 34 eran infectados y 76 no infectados. Se registraron eventos adversos en 49 (44,5%) pacientes. Hubo 108 eventos leves y 23 graves. El porcentaje de ESAVI en ambos grupos fue similar (p>0,05). No se registraron hospitalizaciones ni eventos difíciles de catalogar como relacionados a vacunación. Conclusiones: las vacunas administradas en eseperíodo fueron seguras con similares ESAVI en ambos grupos de pacientes. Continuar vigilando la aparición de ESAVI y comparar los resultados año a año será importante para actualizar recomendaciones y garantizar la seguridad de los pacientes y sus cuidadores.

Factors associated with mother-to-child transmission of the human immunodeficiency virus in Pernambuco, Brazil, 2000-2009.

OBJECTIVE: To identify risk factors associated with mother-to-child transmission of HIV in the Brazilian state of Pernambuco. METHODS: Retrospective cohort study with 1200 HIV-exposed children born in Pernambuco, registered up to the age of 2 months in a public programme to prevent vertical transmission. Univariate and multivariate logistic regression analyses were conducted for maternal and peripartum characteristics and prophylactic interventions, to identify risk factors for mother-to-child transmission of HIV. RESULTS: The transmission rate was 9.16% (95% CI: 7.4-10.9). The following risk factors were independently associated with transmission: non-use of antiretroviral during pregnancy (OR: 7.8; 95% CI: 4.1-15); vaginal delivery (OR: 2.02; 95% CI: 1.2-3.4); prematurity (OR: 2.5; 95% CI: 1.3-4.7); and breastfeeding (OR: 2.6; 95% CI: 1.4-4.6). CONCLUSIONS: This mother-to-child transmission rate is unacceptably high, as prophylactic interventions such as antiretroviral therapy and infant feeding formula are free of charge. Absence of antiretroviral therapy during pregnancy was the main risk factor. Therefore, early identification of exposed mothers and initiating prophylactic interventions are the main challenges for controlling transmission.

Seroprevalence of HIV, hepatitis B, and syphilis among pregnant women at the general hospital, Guatemala City, 2005-2009.

BACKGROUND: sexually transmitted infection (STI) screening in pregnancy provides an excellent opportunity for secondary prevention. OBJECTIVE: to document the epidemiology of HIV, hepatitis B, and syphilis among pregnant women at a Guatemalan national hospital. RESULTS: from 2004 to 2009, 118 (0.76%) of 15 563 of women tested in the prenatal clinic had HIV infection, 29 (0.22%) of 13 028 women tested had hepatitis B virus infection, and 78 (0.60%) of 13 027 had a positive test for syphilis. From August 1, 2007 through December 31, 2009, 29 482 women were tested in the obstetrical emergency room. A total of 63 were HIV positive (0.21%), 48 had hepatitis B (0.16%), and 196 had syphilis (0.66%). Of the 9196 births between August 2007 and July of 2008, 33 (0.36%) were to HIV-infected mothers. CONCLUSION: these 3 STIs were uncommon in our population and did not increase in incidence during the study period. HIV maternal-to-child transmission (MTCT) prevention programs were feasible in our setting.

A human immunodeficiency virus-positive infant with probable congenital histoplasmosis in a nonendemic area.

A 5-week-old infant presented with a fever, and was diagnosed with congenital human immunodeficiency virus and histoplasmosis. Both infections were likely transmitted vertically. The child was effectively treated with antifungal medications and highly active antiretroviral therapy. This represents the first case of delayed presentation of vertically transmitted histoplasmosis, and the first case in a nonendemic area.

Emergence of primary NNRTI resistance mutations without antiretroviral selective pressure in a HAART-treated child.

OBJECTIVE: The use of antiretrovirals (ARV) during pregnancy has drastically reduced the rate of the human immunodeficiency virus perinatal transmission (MTCT). As a consequence of widespread ARV use, transmission of drug resistant strains from mothers to their babies is increasing. Ultra-sensitive PCR techniques have permitted the quantification of minority viral populations, but little is known about the transmission of drug-resistant HIV-1 minority population in the setting of MTCT. METHODOLOGY/PRINCIPAL FINDINGS: We describe the case of a female child born to an HIV-infected mother, which had not taken any ARV during the pregnancy. The child's first genotype demonstrated a minor non-nucleoside reverse transcriptase inhibitor (K101E), and during her treatment with reverse transcriptase and protease inhibitors full resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI) emerged (G190A). Phenotypic/genotypic analysis of variant quasispecies through yeast TyHRT assay was conducted to characterize minority resistant viral strains circulating in both mother and child. Maximum likelihood and Bayesian MCMC phylogenetic analyses were performed with samples from the pair to assess genetic relatedness among minor viral strains. The analysis showed that the child received a minor NNRTI resistant variant, containing the mutation K101E that was present in less than 1% of the mother's quasispecies. Phylogenetic analyses have suggested common ancestry between the mother's virus strain carrying K101E with the viral sequences from the child. CONCLUSION: This is the first documentation of MTCT of a minority resistant strain of HIV-1. The transmission of minor resistant variants carries the threat of emergence of multi-drug primary mutations without identified specific selective pressures.

Longitudinal growth of infants born to HIV-1-infected mothers in Belo Horizonte, Brazil.

OBJECTIVE: To prospectively evaluate growth parameters assessed by weight and length in infected and uninfected infants born to HIV-1-infected mothers and followed from birth to 18 months. METHODS: A cohort consisting of ninety-seven uninfected and forty-two infected infants born to HIV-infected mothers enrolled from 1995 to 2004, and admitted during their first 3 months of life at a referral Pediatric AIDS Clinic in Belo Horizonte, Brazil. Infants were followed until 18 months of age. Data were analysed using mixed-effects linear regression models for weight and length fitted by restricted maximum likelihood. RESULTS: Infected infants contributed to 466 weight and 411 recumbent length measurements. Uninfected infants provided 924 weight and 907 length measurements. Mean birth weight and length were similar in both groups, 3.1 (sd 0.4) and 3.0 (sd 0.5) kg, and 48.7 (sd 1.4) and 48.8 (sd 2.9) cm for uninfected and infected infants, respectively. However, HIV-1 infection had an early impact in growth impairment: at 6 months of age, HIV-infected children were 1 kg lighter and 2 cm shorter than the uninfected. CONCLUSIONS: Growth faltering in weight, but not length, in HIV-infected children in Brazil is more marked than that reported in a European cohort, probably reflecting background nutritional deficiencies and concomitant infections. In these settings, early and aggressive nutritional management in HIV-1-infected infants should be a priority intervention associated with the antiretroviral therapy.

Comparación de tres estrategias de tamizaje para la prevención de la infección perinatal por VIH en Colombia: análisis de decisiones / A comparison of three screening strategies for prevention of perinatal HIV infection in Colombia: a decision analysis model

OBJETIVO: Comparar mediante un modelo de análisis de decisiones tres estrategias de tamizaje de la infección por el VIH en mujeres embarazadas según su relación costo-efectividad y proponer la más apropiada para el sistema de salud colombiano. MÉTODOS: Estudio económico basado en el análisis mediante árboles de decisión según tres estrategias de tamizaje de la infección por el VIH en mujeres embarazadas: la voluntaria, la universal y la opcional. Se consideró a todas las mujeres colombianas embarazadas sin diagnóstico de infección por el VIH que se presentaban para el parto. Se emplearon los costos médicos directos desde la realización de la prueba hasta un año después del parto, según el Sistema General de Seguridad Social en Salud. Se compararon las razones costo-efectividad y el ahorro de cada estrategia analizada. RESULTADOS: Por cada 10 000 mujeres, la estrategia universal permitió detectar 5 casos más que la estrategia voluntaria y 7 casos más que la opcional. La estrategia universal generó costos aproximados de US$ 17,00 por cada recién nacido positivo, es decir, menos de la mitad que lo calculado para la estrategia voluntaria (US$ 38,00) y menor que para la opcional (US$ 24,00). Según el análisis bifactorial, la estrategia de tamizaje universal fue menos costosa que la voluntaria y más efectiva que las otras dos estrategias, independientemente de la prevalencia, la tasa de positivos falsos del sistema de diagnóstico empleado y la tasa de aceptación materna para realizarse la prueba de tamizaje. CONCLUSIONES: La estrategia de tamizaje voluntaria, que se utiliza actualmente en Colombia, es más costosa que la universal a mediano y largo plazos y tiene menor efectividad y capacidad de prevención. Se recomienda a las autoridades nacionales de salud realizar el tamizaje de la infección por el VIH a todas las embarazadas colombianas con pruebas de tercera generación.

OBJECTIVES: To apply decision analysis to compare the cost-effectiveness of three strategies for HIV screening of pregnant women and to recommend the one most appropriate for the health care system of Colombia. METHODS: An economic study applying decision analysis to three types of HIV screening of expectant women: voluntary, universal, and optional. All the women in Colombia with unknown HIV status who were admitted for child birth were included. The study included all the direct medical costs incurred from the time of testing through the first year following delivery, according to the General System for Healthcare Social Security. Cost-effectiveness ratio and the savings of each of the strategies were compared. RESULTS: For every 10 000 women, the universal strategy detected five cases more than the voluntary strategy and seven cases more than the optional. The universal strategy carried a cost of approximately US$ 17 for each HIV-positive newborn; that is, less than half of that of the voluntary strategy (US$ 38) and less than the optional (US$ 24). According to the bifactorial analysis, the universal screening strategy was less costly than the voluntary and more effective than both of the others, regardless of prevalence, the false-positive rate of each method, and the rate of maternal compliance with screening. CONCLUSIONS: The screening strategy currently in use in Colombia is more costly (in both the medium- and long-term), less effective, and less capable of prevention, than the universal screening strategy. The recommendation to the national health authorities of Colombia is to begin screening all pregnant women for HIV infection using third-generation testing.

Auditory disorders and acquisition of the ability to localize sound in children born to HIV-positive mothers.

The objective of the present study was to evaluate children born to HIV-infected mothers and to determine whether such children present auditory disorders or poor acquisition of the ability to localize sound. The population studied included 143 children (82 males and 61 females), ranging in age from one month to 30 months. The children were divided into three groups according to the classification system devised in 1994 by the Centers for Disease Control and Prevention: infected; seroreverted; and exposed. The children were then submitted to audiological evaluation, including behavioral audiometry, visual reinforcement audiometry and measurement of acoustic immittance. Statistical analysis showed that the incidence of auditory disorders was significantly higher in the infected group. In the seroreverted and exposed groups, there was a marked absence of auditory disorders. In the infected group as a whole, the findings were suggestive of central auditory disorders. Evolution of the ability to localize sound was found to be poorer among the children in the infected group than among those in the seroreverted and exposed groups.

Auditory disorders and acquisition of the ability to localize sound in children born to HIV-positive mothers

The objective of the present study was to evaluate children born to HIV-infected mothers and to determine whether such children present auditory disorders or poor acquisition of the ability to localize sound. The population studied included 143 children (82 males and 61 females), ranging in age from one month to 30 months. The children were divided into three groups according to the classification system devised in 1994 by the Centers for Disease Control and Prevention: infected; seroreverted; and exposed. The children were then submitted to audiological evaluation, including behavioral audiometry, visual reinforcement audiometry and measurement of acoustic immittance. Statistical analysis showed that the incidence of auditory disorders was significantly higher in the infected group. In the seroreverted and exposed groups, there was a marked absence of auditory disorders. In the infected group as a whole, the findings were suggestive of central auditory disorders. Evolution of the ability to localize sound was found to be poorer among the children in the infected group than among those in the seroreverted and exposed groups.

[A comparison of three screening strategies for prevention of perinatal HIV infection in Colombia: a decision analysis model]. / Comparación de tres estrategias de tamizaje para la prevención de la infección perinatal por VIH en Colombia: análisis de decisiones.

OBJECTIVES: To apply decision analysis to compare the cost-effectiveness of three strategies for HIV screening of pregnant women and to recommend the one most appropriate for the health care system of Colombia. METHODS: An economic study applying decision analysis to three types of HIV screening of expectant women: voluntary, universal, and optional. All the women in Colombia with unknown HIV status who were admitted for child birth were included. The study included all the direct medical costs incurred from the time of testing through the first year following delivery, according to the General System for Healthcare Social Security. Cost-effectiveness ratio and the savings of each of the strategies were compared. RESULTS: For every 10,000 women, the universal strategy detected five cases more than the voluntary strategy and seven cases more than the optional. The universal strategy carried a cost of approximately US$ 17 for each HIV-positive newborn; that is, less than half of that of the voluntary strategy (US$ 38) and less than the optional (US$ 24). According to the bifactorial analysis, the universal screening strategy was less costly than the voluntary and more effective than both of the others, regardless of prevalence, the false-positive rate of each method, and the rate of maternal compliance with screening. CONCLUSIONS: The screening strategy currently in use in Colombia is more costly (in both the medium- and long-term), less effective, and less capable of prevention, than the universal screening strategy. The recommendation to the national health authorities of Colombia is to begin screening all pregnant women for HIV infection using third-generation testing.

[Timely implementation of interventions to reduce vertical HIV transmission: a successful experience in Brazil]. / Implementação oportuna de intervenções para reduzir a transmissão vertical do HIV: uma experiência brasileira bem-sucedida.

OBJECTIVE: To describe the impact, at the public maternity facility of a university hospital in Brazil, of the rapid implementation of new guidelines recommended by national consensus panels concerning the prevention of vertical HIV transmission. METHOD: We performed a retrospective study of deliveries by HIV-infected women at the public maternity facility of a university hospital in the city of Campinas, São Paulo, Brazil, from 1990 through 2000. The guidelines utilized at the facility during this period were: (1) from 1990 through 1994, contraindication to breast-feeding and no use of antiretroviral drugs; (2) 1995 and 1996, use of zidovudine (AZT) by the pregnant woman and the newborn; (3) 1997 and 1998, use of AZT according to the ACTG 076 protocol; and (4) 1999 and 2000, multiple antiretroviral agents and elective cesarean delivery. All the antiretroviral drugs were provided for free by Brazil's public health care system. The vertical transmission rate was calculated for each of the four stages, and the risk ratio for congenital transmission was calculated for each stage and for each prophylactic intervention separately (breast-feeding, type of antiretroviral drug, type of delivery). RESULTS: We studied 197 deliveries at the public maternity facility over that 1990-2000 period. Over the four stages, the rate of vertical transmission decreased: it was 32.3% in the first stage, 25.7% in the second, 2.2% in the third, and 2.9% in the fourth. The most pronounced decrease, observed from the second to the third stage, occurred after introduction of the full ACTG 076 regimen. The use of combined antiretroviral agents increased from 0% in the first stage to 46.4% in the fourth stage. There were no cases of vertical transmission in pregnant women treated with multiple drugs. The risk of vertical HIV transmission was 5 times as great with breast-feeding vs. no breast-feeding (risk ratio = 5.06), 5 times as great with no antiretroviral therapy vs. the full ACTG 076 regimen (risk ratio = 5.29), and 4 times as great with forceps delivery vs. elective cesarean delivery (risk ratio = 4.13). CONCLUSION: The timely adoption of up-to-date interventions recommended by national consensus panels, along with the free provision of antiretroviral drugs, was effective in reducing congenital HIV transmission in this public maternity facility. The interaction between the university hospital health service and the public health service reduced the time needed for implementation of proven, effective interventions, and this experience could serve as an example for other maternal and perinatal health situations.

Implementação oportuna de intervenções para reduzir a transmissão vertical do HIV: uma experiência brasileira bem-sucedida / Timely implementation of interventions to reduce vertical HIV transmission: a successful experience in Brazil

OBJETIVO: Descrever o impacto da implementação oportuna de novas condutas recomendadas por consensos clínicos nacionais dirigidos à prevenção da transmissão vertical de HIV na maternidade de um hospital universitário público no Brasil. MÉTODO: Realizou-se um estudo retrospectivo de coorte dos partos de mulheres infectadas pelo HIV atendidos na instituição de 1990 a 2000. As condutas adotadas nesse período foram: 1) até 1994, amamentação contra-indicada, sem uso de drogas anti-retrovirais; 2) de 1995 a 1996, uso de zidovudina (AZT) pela gestante e pelo recém-nascido; 3) de 1997 a 1998, uso de AZT conforme protocolo ACTG 076; e 4) de 1999 a 2000, terapia anti-retroviral múltipla e cesárea eletiva. Em todos os períodos, a distribuição das drogas foi gratuita. Foram calculadas as taxas de transmissão nas quatro fases e as razões de risco de transmissão congênita para as fases e para cada intervenção profilática (amamentação, tipo de terapia anti-retroviral, tipo de parto). RESULTADOS: Foram estudadas 197 gestações. Houve redução na transmissão vertical da primeira para a quarta fase, de 32,3 para 25,7, 2,2 e 2,9 por cento. A maior queda, observada na terceira fase, ocorreu após a introdução do esquema completo do ACTG 076. O uso de terapia anti-retroviral combinada aumentou de 0 por cento na primeira fase para 46,4 por cento na quarta fase. Não houve nenhum caso de transmissão vertical nas gestantes tratadas com múltiplas drogas. O risco de transmissão vertical foi 5 vezes maior com amamentação do que sem amamentação (razão de risco = 5,06), 5 vezes maior sem terapia anti-retroviral contra uso do esquema ACTG completo (razão de risco = 5,29) e 4 vezes maior para parto com fórcipe contra cesárea eletiva (razão de risco = 4,13). CONCLUSÃO: A adoção oportuna de intervenções atualizadas, recomendadas por consenso nacional de especialistas, com provisão gratuita de drogas, mostrou-se eficiente para reduzir a transmissão congênita do HIV.

OBJECTIVE: To describe the impact, at the public maternity facility of a university hospital in Brazil, of the rapid implementation of new guidelines recommended by national consensus panels concerning the prevention of vertical HIV transmission. METHOD: We performed a retrospective study of deliveries by HIV-infected women at the public maternity facility of a university hospital in the city of Campinas, São Paulo, Brazil, from 1990 through 2000. The guidelines utilized at the facility during this period were: (1) from 1990 through 1994, contraindication to breast-feeding and no use of antiretroviral drugs; (2) 1995 and 1996, use of zidovudine (AZT) by the pregnant woman and the newborn; (3) 1997 and 1998, use of AZT according to the ACTG 076 protocol; and (4) 1999 and 2000, multiple antiretroviral agents and elective cesarean delivery. All the antiretroviral drugs were provided for free by Brazil's public health care system. The vertical transmission rate was calculated for each of the four stages, and the risk ratio for congenital transmission was calculated for each stage and for each prophylactic intervention separately (breast-feeding, type of antiretroviral drug, type of delivery). RESULTS: We studied 197 deliveries at the public maternity facility over that 1990-2000 period. Over the four stages, the rate of vertical transmission decreased: it was 32.3 percent in the first stage, 25.7 percent in the second, 2.2 percent in the third, and 2.9 percent in the fourth. The most pronounced decrease, observed from the second to the third stage, occurred after introduction of the full ACTG 076 regimen. The use of combined antiretroviral agents increased from 0 percent in the first stage to 46.4 percent in the fourth stage. There were no cases of vertical transmission in pregnant women treated with multiple drugs. The risk of vertical HIV transmission was 5 times as great with breast-feeding vs. no breast-feeding (risk ratio = 5.06), 5 times as great with no antiretroviral therapy vs. the full ACTG 076 regimen (risk ratio = 5.29), and 4 times as great with forceps delivery vs. elective cesarean delivery (risk ratio = 4.13). Conclusion. The timely adoption of up-to-date interventions recommended by national consensus panels, along with the free provision of antiretroviral drugs, was effective in reducing congenital HIV transmission in this public maternity facility. The interaction between the university hospital health service and the public health service reduced the time needed for implementation of proven, effective interventions, and this experience could serve as an example for other maternal and perinatal health situations.

Features of whey protein concentrate supplementation in children with rapidly progressive HIV infection.

HIV infection is associated with subnormal GSH levels. An increase in glutathione levels has been observed in HIV-infected adults under oral whey protein supplementation. We studied the features associated with a whey protein concentrate supplementation in children with rapidly progressive AIDS. A prospective double-blind clinical trial was carried out for 4 months with 18 vertically HIV-infected children (1.98-6.37 years), under antiretroviral therapy, who had received whey protein, maltodextrin (placebo) or none. Erythrocyte glutathione concentration, T lymphocyte counts (CD4+ and CD8+) and occurrence of associated co-infections were evaluated. Wilcoxon's and Fischer's Exact tests were used to assess differences between whey protein-supplemented and control (placebo and non-supplemented) groups. A significant median increase of 16.14 mg/dl (p = 0.018) in erythrocyte glutathione levels was observed in the whey protein-supplemented group; the TCD4/CD8 lymphocyte ratio showed a non significant increase and lower occurrence of associated co-infections was also observed. In conclusion, whey protein concentrate supplementation can stimulate glutathione synthesis and, possibly, decrease the occurrence of associated co-infections.