HIV infection in pregnancy: epidemiology and clinical management

Article Abstract:

Human immunodeficiency virus (HIV) causes AIDS, and the rate of spread of HIV infection among women in the United States is growing. In women, HIV transmission occurs primarily by sharing paraphernalia for intravenous drug use or by heterosexual relations with infected partners. The rate of HIV infection in women is correlated with the rate of infection in newborns, as the virus is spread from mother to child perinatally, that is, in utero, during delivery, or postnatally from breast feeding. Approximately 25 to 40 percent of children born to HIV-infected mothers are also infected. Perinatal transmission of HIV accounts for over 80 percent of the pediatric cases of AIDS. It is important to determine if pregnant women, especially those in high-risk groups, are infected with HIV. If they test positive and the pregnancy is in the early stages, they are given the option to terminate it. There is controversial data about whether or not pregnancy increases the rate of progression to AIDS or AIDS related complex. If a woman with AIDS develops opportunistic infections during pregnancy, she may be treated differently, as many drugs may cause detrimental effects on the developing fetus. It does not appear that Caesarean delivery reduces the transmission of HIV. Those caring for newborns who could be infected with HIV must take precautions to avoid contact with the blood, vaginal secretions and amniotic fluid surrounding the infant. Mothers who are known or thought to be infected with HIV can relate to their infants the same as uninfected parents. Although there are studies suggesting that HIV can be transmitted through breast milk, this does not appear to occur readily. In infants, symptoms of HIV infection do not develop until the child is four to six months of age. The treatment of HIV-infected infants and children is standardized, and drug treatment protocols are now available. Community services and support groups may improve the quality of life for the infant. It must be realized that the earlier the infection is diagnosed, the earlier treatment can be initiated. Care of the HIV-infected infant and parent should be thoughtfully planned and include various medical subspecialties as well as social services. (Consumer Summary produced by Reliance Medical Information, Inc.)

Demographic aspects, HIV (Viruses), HIV, Disease transmission, Pregnancy, AIDS (Disease) in pregnancy

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HIV infection as a disease: the medical indications for early diagnosis

Article Abstract:

The majority of individuals who are infected with the human immunodeficiency virus (HIV) will eventually die from AIDS unless new, effective therapies are developed. Now that there are options for treatment early in infection, such as new antiviral drugs and antibiotic prophylaxis for opportunistic infections, it is suggested that HIV infection, before the development of AIDS, should be considered a disease by itself. This would have a complex and far-reaching impact on the management of those infected. It would lead to the development of ways to diagnose HIV infection early, ways to prevent opportunistic infections, and new courses of treatment for AIDS itself. Increasing numbers of individuals are being tested for HIV infection. However, to reduce the problem of high numbers of false positive test results, which would be seen if large numbers of individuals with a low probability of infection were being tested, physicians should make some judgments concerning who should be tested, based on the risk factors that the individual might have. Because of the psychological and social consequences of HIV testing, the testing should be voluntary. The physician must be informed of the test results so that the patient can be medically managed. Public authorities must also be informed so the patient's sexual partner is informed, to limit further spread of disease. Those infected should be grouped into early, middle and late disease forms, and managed accordingly. Systems of care and financial reimbursement should be available at all stages of the disease. Private or public health insurance companies should cover antiviral drugs and opportunistic infection prophylaxis in early HIV disease. The increased use of HIV tests should not de-emphasize the need for social support if the individual tests positive. Government regulations are needed to prevent the misuse of results, and anti-discrimination legislation is needed to cover housing and employment. Federal and state health care must be available for those who are uninsurable. The infected individual should be the primary concern, and social and political issues must not interfere with the delivery of the best care for the patient. (Consumer Summary produced by Reliance Medical Information, Inc.)

editorial

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On the use of laboratory markers as surrogates for clinical endpoints in the evaluation of treatment for HIV infection

Article Abstract:

It is thought that new treatments for infection with the human immunodeficiency virus (HIV) should be evaluated at intermediate endpoints, rather than at definite clinical endpoints such as the onset of AIDS or death. An early laboratory marker that could be used as an intermediate endpoint is the level of CD4-positive helper T cells, cells that are necessary for an immune response. A model with three transitional states is presented; the model compares treatments based on the ability of intermediate endpoints to predict clinical benefits. The three states are: patient is well; patient is alive but with an adverse marker; and patient has experienced a definitive clinical endpoint. Computer simulations of clinical trials show that time can be saved by using these endpoints. However, these endpoints can lead to serious overestimates of clinical benefits if delayed toxicity or transient clinical benefits are associated with the treatment. The use of laboratory endpoints also underestimates the clinical benefits when the treatment has no effect on the change from the well state to the existence of a clinical marker but reduces the rate of change from the existence of the adverse marker to the clinical endpoint. Treatments with these effects should not be evaluated using this model of laboratory endpoints. Besides assessing experimental treatments, the markers can also be used to modify the course of treatment for a particular individual. It is concluded from these simulation studies that by using laboratory endpoints, time can be saved in the evaluation of treatments for patients infected with HIV. The drawbacks to the use of laboratory markers as endpoints must be kept in mind when the treatment is being evaluated. (Consumer Summary produced by Reliance Medical Information, Inc.)

Evaluation, Measurement, Development and progression, Clinical trials, T cells

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