[Domestic violence during pregnancy: screening and management]. / Les violences conjugales pendant la grossesse: dépistage et orientation par les soignants.

Because pregnant women are seen regularly for prenatal visits and most often develop a feeling of trust with the health care providers, pregnancy offers an important opportunity to detect domestic violence. Visible physical lesions are obvious signs of domestic violence but detection is much more difficult when the signs are limited to various sequelae, exacerbation of chronic conditions, psychosomatic problems, or obstetrical complications. It is even more difficult when the disorders are essentially psychological. If there is the slightest doubt, the clinician should, after gaining the patient's trust, ask a few simple questions. When domestic violence is discovered, the physician should evaluate its severity, note all useful elements in the medical record, and as required, write a medical certificate declaring temporary disability. The patient needs treatment but also information and support. It may be necessary to report the case to the judiciary or administrative authorities.

[Two-year follow-up of an opioid-user cohort treated with high-dose buprenorphine (Subutex)]. / Suivi à 2 ans d'une cohorte de patients dépendants aux opiacés traités par buprénorphine haut dosage (Subutex).

AIM OF THE STUDY: Care for opioid users changed greatly in France in 1996 when general practitioners (GP) were allowed to prescribe high-dose sublingual buprenorphine (Subutex((R))) for maintenance treatment of major opioid dependence. In order to evaluate treatment benefits, a prospective epidemiological 2-year follow-up was initiated in May 1996 with the participation of 105 French GPs. METHODS: A cohort of outpatient opioid users who started high-dose sublingual buprenorphine maintenance therapy at study onset or who had recently started were included in a prospective epidemiological study by GPs involved in management of drug abusers. Patients were followed for 2 years with collection of standardized information at 1, 3, 6, 12, and 24 months. The main evaluation criteria were follow-up by the same GP throughout the study and retention in the care system 2 years later. For patients who fulfilled these criteria, secondary end points were analyzed: information about buprenophine prescription, social status, and hepatitis B and C and HIV seroconversions. RESULTS: The 101 GPs included 919 patients and 909 were analyzed 2 years later. At study onset, a majority of the patients (70.6%) were taking an ongoing maintenance treatment, 10.5% had previously received such a treatment and the treatment was initiated for 18.8%. At the end of the study, 508 patients (55.9%) were still being followed by the same GP and 101 (11.1%) were followed by another healthcare provider (another GP, hospital or specialized center). No information about the care giver was available for 82 patients (9%). Among the other patients, 123 (13.5%) were lost to follow-up, 24 (2.6%) had moved, 23 (2.6%) were incarcerated, 11 (1.2%) had successfully discontinued drug usage and 7 (0.8%) had died. Other reasons for unsuccessful follow-up by the same GP were mainly (for 6 patients each): relapse, switch to methadone, no medical information, non-compliance with scheduled controls. Among the patients followed by the same GP, declaration of heroin and drug intake significantly decreased (p<0.001), and social status (GAF scale) and TMSP evaluation significantly improved (p<0.001). The social situation (housing condition and work) also improved significantly (p<0.001). The rate of buprenorphine treatment was 84% with longer and less fractionated prescriptions. The HBV, HBC and HIV seroconversion rates were low in this high-risk population (2.7%, 4.1% and 0.8% respectively). CONCLUSION: This two-year follow-up of 909 opioid users showed that nearly 70% of the patient remained within the healthcare system, mainly with the same GP or more rarely with another practitioner. Among the 508 patients still followed by the same GP, maintenance treatment with high-dose buprenorphine was observed in more than 80% of the patients. These patients had a significantly improved social status, a significant decrease in drug intake and a significant improvement in their social adaptation and severity of drug abuse.

Lack of behavioural risk factors for squamous intraepithelial lesions (SIL) in HIV-infected women.

HIV-infected women have a high prevalence of abnormal Papanicolaou smears and cervical intraepithelial neoplasia. A multiparametric analysis of epidemiological and behavioural risk factors has been performed in a cohort of 204 HIV-infected women in an outpatient clinic with the aim to investigate risk factors associated with squamous intraepithelial lesions (SIL) in HIV-seropositive women. The prevalence of SIL in the study population was 35.7%. Univariate and multivariate analysis of demographic, behavioural and immunological variables only identified cigarette smoking > 20/day and CD4+ cell counts < or = 200 x 10(6)/L as risk factors significantly associated with SIL in the study population. We found no epidemiological/behavioural risk factors specifically associated with SIL in HIV-infected women as compared with the general population. The results suggest that the high prevalence of SIL in HIV disease is related to acquired immune deficiency in HIV-seropositive women.

[Effectiveness of measures taken in France to reduce the risks of heroin addiction via intravenous route]. / Bilan de l'efficacité des mesures prises en France pour réduire les risques de l'héroïnomanie par voie veineuse.

French policy towards illicit drug use is based on abstinence, and on withdrawal for drug-dependent users. Its basis is the December 31, 1970 law, which is still applicable, and prohibits the use of theses drugs, even in private. It provides for prison sentences for users who do not accept to be treated. Under the pressure of new events, in particular the epidemics of AIDS, hepatitis B and C, the reappearance of tuberculosis, and an increasing marginalization of drug users, a harm reduction policy was developed. The first measure taken was to authorize over-the-counter sale of syringes and needles in pharmacies in May 1987. It was only in 1993 that programs were established: needle exchange, methadone maintenance centers, drop-in centers, sleep in, and bus for care, involvement of general practitioners, improved access to hospitals, better medical care of prisoners, participation of associations of former users, and licensing of buprenorphine high dosage for the treatment of drug dependency. The results have been clear: the number of consultations in specialized treatment centers increased, the incidence of HIV decreased spectacularly, overdoses decreased substantially, and arrests for heroin use and misdemeanours declined. However, harm reduction policies do not solve all the problems. They are applicable only to intravenous heroin users, and don't avoid using others licit or illicit drugs. Substitute drugs can be injected or resold. Finally, the prevalence of hepatitis C infection has not significantly decreased and the decrease in HIV infections is less marked among young users and women.

Papanicolaou smears in human immunodeficiency virus-seropositive women during follow-up.

OBJECTIVE: To assess the outcome of cervical squamous intraepithelial lesions (SIL) in human immunodeficiency virus (HIV)-seropositive women. METHODS: Papanicolaou smears were followed-up prospectively in a group of 60 HIV-positive women every 6 months for 18 months. RESULTS: The cumulative incidence of SIL at 18 months was 9% in 27 women who presented with normal Papanicolaou smears at entry. In 33 women who initially presented with SIL, the rate of persistence of cervical lesions was 95% (18 of 19) in untreated patients and 61% (eight of 13) in women who underwent surgery. In women with low-grade SIL, the persistence or progression of cervical lesions was observed in 92% of the cases (12 of 13). No invasive cancer was observed during the 18 months of the study period. CONCLUSION: Although the long-term outcome of SIL in this population remains unknown, our results emphasize the high rate of persistence of SIL and the relative inefficiency of conventional treatment in HIV-infected women. These findings contrast with the natural history of SIL in immunocompetent women.

[AIDS and the obstetrician-gynecologist]. / Le SIDA et le gynecologue-accoucheur.

PIP: This work provides current information and recommendations concerning prenatal care and treatment of seropositive women. The influence of pregnancy on HIV infection is difficult to assess because of the need to dissociate effects of the natural development of the illness from those possibly aggravated by pregnancy. It now appears that pregnancy is deleterious primarily in women who have AIDS or a significant immune deficit. Affects of HIV infection on the fetus related to the virus itself, to the immune deficit, and to thrombopenia have been described. Complications related to the virus vary from country to country. Secondary infections in a mother with a compromised immune system may affect the infant, while complications related to thrombopenia have been very rare. It is not yet known at what moment of pregnancy infection of the fetus by the mother is most likely to occur, but much evidence exists of infection at some moment before birth. There is some evidence that over 70% of infections occur late in pregnancy, although earlier infection has been demonstrated. Infection during delivery and breast feeding have also been demonstrated. The frequency of maternal-fetal transmission is variable in different countries. It was 14.4% in the most recent European collaborative survey, 20% in the French survey, 20 to 25% in the US, and 35% or over in Africa. Mothers at advanced stages of disease are more likely to infect their infants. Some 20% of infected infants are gravely ill from birth, while another large group begins to become ill at around six months and follows a course similar to that of adults. Women who already have AIDS are usually under the care of a physician at the start of pregnancy. In most cases, the mother is asymptomatic. A complete physical examination should be performed including CD4 and CD8 lymphocyte count and related tests. The HIV status of the partner should be assessed, as should the ability of the couple to raise a child. The choice of whether to proceed with the pregnancy must be made by the mother. In France, over 50% of HIV positive mothers choose to continue their pregnancies. AZT treatment should begin if the level of CD4 lymphocytes is less than 200. Treatments to prevent opportunistic infection should be administered. Prenatal diagnosis of HIV infection is theoretically possible but difficult to carry out. The woman's HIV status should be reassessed every two or three months as the pregnancy progresses. It is not yet known whether cesarean delivery can lessen the risks of perinatal transmission. Labor and delivery are not affected by the infection. Fetal lesions should be scrupulously avoided. The woman's lower genital tract may be disinfected every four hours of labor and immediately before delivery with a solution of benzalkonium chloride 0.1%. The infant should be thoroughly cleansed of all traces of maternal blood and the cord disinfected before any skin-piercing procedure is performed. Breast feeding is contraindicated in Europe but not in developing countries at this time. Pregnancy is formally discouraged in seropositive women, but as a practical matter it is often impossible to prevent a young woman from seeking a desired pregnancy.^ieng

[HIV seropositivity and desire for children]. / Séropositivé VIH et désir d'enfant.

Growing numbers of women and men who are HIV infected and aware of their serostatus, want to have children. Gynecologists are involved in the dilemmas of counseling those couples about reproductive decisions. For HIV infected women, pregnancy is contra-indicated, mostly because of the risk of transmission to the fetus/infant. However, no rational argument can abolish the desire of many young women to have children in the face of the life-threatening infection. The clinical and immune status of the would-be mothers, her partner's serostatus and the availability of family members to rear an orphaned child, must be considered. For seronegative women with HIV-infected partners, after confirming that seroconversion is not occurring, the partner's clinical and immune status must be evaluated. The risk of transmission through unprotected intercourse increases with the degree of immune suppression in the partner. The couple's stability and the woman's motivations for becoming pregnant must also be carefully evaluated. About one third of such discordant couples separate after the birth of their child. For selected couples who have clearly decided to attempt pregnancy, the objective of reproductive counseling is to reduce their risk of heterosexual transmission. The partner's sperm should not be used for insemination because techniques have not yet been established to eliminate HIV from sperm preparations. Insemination with HIV-negative donors' sperm can be considered. An alternative is the "natural" method, consisting in having unprotected intercourse only during ovulation. Administration of zidovudine to the man in order to reduce the amount of virus excreted has been discussed.(ABSTRACT TRUNCATED AT 250 WORDS)

[HIV seropositivity and desire for children]. / Seropositive VIH et desir d'enfant.

PIP: The number of women who learn of their HIV seropositivity and still want to have a child is growing. If the woman is HIV seropositive, pregnancy is not advised, but it is difficult if not impossible to prevent a young woman from a having wanted child. No rational argument can suppress this desire that the life-threatening illness exacerbates. The counselor must consider the clinical and immune status of the mother, the serostatus and health status of the partner, and the likelihood of family members raising the child. If the woman is HIV seronegative and her partner is HIV seropositive, the counselor must first make sure that the women does not seroconvert and that her desire for a child is real. Then the counselor must evaluate the partner's clinical and immune status. The risk of HIV transmission to the woman increases with the degree of immune suppression of the partner. It is also important to determine the stability of the discordant couple because about 33% separate after childbirth. It is only after having analyzed all these elements that the counselor and the couple can consider one of the proposed solutions. Since techniques of sperm decontamination having not yet been established, the decision is boiled down to extreme solutions: artificial insemination with sperm from an HIV negative donor or, after a spermogram and hysterography, the natural method involving intercourse only during successive periods of ovulation. The partner needs to take zidovudine to reduce the amount of sperm ejaculated. In case of pregnancy, it is necessary to recognize seroconversion, an indication for AZT. ELISA and studies on p24 antigenemia must be conducted each month of the pregnant woman. Couples must continue to use condoms after the delivery because a seroconversion would nullify all earlier efforts. Breast feeding can transmit HIV to the infant. Professional guidelines forbid tubal infertility surgery and in vitro fertilization in couples where the woman or man is HIV infected. The opinion of the French National Ethics Commission will be sought on less invasive infertility therapy.^ieng

Virus excretion in the cervicovaginal secretions of pregnant and nonpregnant HIV-infected women.

In order to estimate the prevalence of viral excretion in cervicovaginal secretions, we made a cross-sectional study of 55 HIV-infected women. The patient population was diverse, including pregnant and nonpregnant women in different disease stages from three centers. Virus replication was found in the cell-free supernatant from 12 of 55 cervicovaginal samples (21.8%) by coculture on the CD4-positive cell line CEM-C113. In addition, cell-associated virus was detected in five of a subgroup of 22 samples testing negatively on cell-free supernatant. The prevalence of HIV in the cell-free supernatant was not related to disease stage, zidovudine therapy, transmission group, or history of sexually transmitted diseases. Excretion of HIV was significantly higher in our population of pregnant women (eight of 21, 38%) compared with an unmatched group of nonpregnant women (four of 34, 11.8%; p = 0.04). These results provide evidence of cell-free virus shedding as well as the presence of cell-associated virus in the genital secretions of HIV-infected women.