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AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Pregnancy and paediatrics L. Sherr
a
a
Clinical Psychologist , St Mary's Hospital , Praed Street, London, W1, UK Published online: 25 Sep 2007.
To cite this article: L. Sherr (1990) Pregnancy and paediatrics, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 403-408, DOI: 10.1080/09540129008257763 To link to this article: http://dx.doi.org/10.1080/09540129008257763
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
403
AIDS CARE, VOL. 2, NO.4,1990
Pregnancy and paediatrics L. SHERR
Downloaded by [University of Kiel] at 14:32 25 December 2014
Clinical Psychologist, St Mary's Hospital, Raed Street., London W l , UK
There was a considerable upsurge of papers in this category compared to previous international conferences. This may mark both the increasing numbers of mothers and babies affected but also the recognition of the wide ranging impact of AIDS and HIV infection. The acknowledgement of AIDS and HIV in infants has also increased focus on women. Despite the fact that childbirth is only one of a number of life roles for women it may well be that long awaited attention is now being focused on women not so much in their own right, but more as the mothers of potentially infected infants. There were 308 papers on children compared to 83 papers on women. The papers on children were divided into many subsections (clinical presentation 39; diagnosis 26; development 1; foster care '4; haemophilia 4; HIV antigen 2; immunology 14; neonates 19; neurological 14; orphans 1; pathology 2; prevalence 15; prevention 15; prognosis 16; progression 16; psychology 7; sexual abuse 1; social impact 14; vertical transmission 53; treatment 16; twins 1; vaccination 2; other 15). This wide range of papers covered a multitude of areas. This review will concentrate on the psychosocial papersOne of the problems with the data as a whole is overrepresentation of USA papers. For example in the following oral sessions close on 80% of papers were from the USA (includmg a small number of joint USA studies.)
Session USA Papen
Issues in vertically transmitted HIV infection, 518; Perinatal Pediamc and Family Issues, 818; Anti retroviral therapy in Children and pregnant women, 618. This trend, although slightly less obvious, was s t i l l seen in the poster sessions. For example: HIV Testing prenatal and family planning clinics, 6/8; Determinants of Risk Behaviour; women, children and adolescents, 16/20; Perinatal Pediamc and Family Issues, 19/25. Thus much of the data, even if of high standard, may have little relevance to different cultures and settings. Conclusions from this review must be made within these limits.
Impact One of the major findings of this conference was the widespread impact of HIV on family members when a pregnant mother and her baby are affected by HIV. This covers the parents, the wider family and the siblings
HIV transmission Pokrovsky et al. reported on HIV infection in 152 children and 12 mothers through syringes. From Romania Beldescu et al.
Downloaded by [University of Kiel] at 14:32 25 December 2014
404
SAN FRANCISCO
SUMMARIES:L SHERR
The differences between Africa and the West may be due to numerous factors. The Mother’s chical status was again endorsed as a possible influence on vertical transmission (Nsuawi, THC658). Research is proceeding to examine prognostic markers which could be helpful in the early identification of HIV infection. Use of polymerase chain reaction (PCR) was reported in a few studies which may hopefilly lead to a more conclusive diagnosis for young infants. (Brandt, TC544;Henrion, THC545; Vendrel, THC616). Ferris et d . (THC546) used polymerase chain reaction in a study of 35 babies born to seropositive mothers and cautioned that a higher frequency of maternal transmission of HIV than previously inferred from serological and clinical detection may exist with genes remaining in a latent state. Pregnancy was not associated with progression of HIV infection in two studies. (Berrebi, THC651 in France and Bledsoe, THC652 USA). Lasley Bibbs (THC655) found that HIV positive women had a significantly higher pregnancy rate than I-IIV negative controls. An interesting case study was reported by Crombleholme (THC605) on a mother treated with AZT prior to pregnancy who
(THC104) described two risk factors associated with HIV; namely hospitalization with microtransfusion or injections. HIV infection was occurring in young infants as a result of unscreened blood and blood products together with inadequate sterilization techniques for needles and syringes. A new infant to mother route in the presence of continued breast feeding, mouth ulcers and breast lesions was documented (Kuznetsovo, THC 48 USSR). Among 264 infected children the 94 non-breast feeders had no infected mothers. Twelve HIV positive mothers were identified from seroprevalence studies of 163,600. Seven were mothers of HIV negative children, four were mothers of dead children and one was the sexual pamer of an HIV-infected man. In other cities 16 HIV positive mothers were similarly identified. Duration of suckling and age of child was not important.
Vertical transmission Reports of vertical transmission rates still range from 20 to 4096. Reports from Africa seem to be higher (in the 30%) and those from Europe to be lower (in the 20%). The table below summarizes studies where vertical transmission percentages were quoted:
Avrhor
Cenne
Prazuck (THC610) Datta (THC611) Hira (THC612) Lepage ct al. (THC659) Van de Perre (THC43) Ndugwa (THC42) Lallemmt (THC656) Delaporte (THC618) Rickard ct al. (THC608) Holt (THC617) Zucotti (THC613) Tovo et al. (THC660) Oleske (THC607) Halsey ( T H C W ) (PB442)
Burkmo Fasso Nairobi Zambia Rwanda Rwanda Uganda Congo Gabon Buenos Aues HaiU man Italy Newark USA Haiti Sweden
~
~~
~~
~
Vrrrical Transmission
~
36% to 4596 33% 39% 33% 34% 31% 42% 17.6% 40% 15.4% 22% 19.2% 19% 25% 33% ~~
(Where rates vary from published abstracts t h ~ sreflects reporting of data presented
at the conference).
PREGNANCY AND PAEDIATRICS 405
opted to continue drug therapy. However, vertical transmission was not prevented.
Downloaded by [University of Kiel] at 14:32 25 December 2014
HIV screening in pregnancy Barbacci (THC41) examined the identification rates of HIV in pregnant women when screening was offered to high risk women compared to a policy of universal screening. Although the latter policy identified higher proportions of HIV positive women, the ‘benefits’ that Barbacci outlined may be open to debate. She claimed these would include identification at less than 20 weeks so that termination could be offered (yet only three out of 81 women terminated in this study one of which had a subsequent term pregnancy and 85% of women elected to continue their pregnancy in the presence of HIV in a study by Stratton et ul. of 49 Obstetric centres SC665); prevention of transmission (yet how this is achieved is unclear); prevention of subsequent pregnancy (yet data from the conference and previous studiesparticularly Sunderland, 1989) show that many women with HIV continue with multiple pregnancies; to prevent breast feeding (which is still open to much debate) and to r e c o p e and manage’. Kiefer (SC664) maintained that universal voluntary screening was more cost-effective than targetted screening but the crucial factor within this paradigm was the different seroprevalence conditions which may affect policy dramatically. However their cost analysis did not include the cost of pre- and post-test counselling. This could be considerable. Stratton et ul. (SC665) documented that HIV positive test results were given in person at 49 medical centres in the USA. Post-test counselling sessions were over 30 minutes for HIV positive women and under 20 minutes for HIV negative women. Caspe (SC667) examined post-pamun counselling and testing in New York. They found that 45% of 80 consecutive subjects had received late or no ante-natal care. Seventy four per cent had used drugs during
pregnancy and the authors emphasized the need to target services to a group who may be at high risk but have few contacts with care agencies. Santana (SC66) surveyed clinics treating over 3,000 pregnant women where HIV education was recommended. They found that this education was well accepted. However they proceed to conclude that “voluntary testing of all pregnant women is essential for perinatal AIDS prevention” without stating clearly how this would be achieved. Ndugga (SC668) reported on acceptability of HIV screening in Kenya. Acceptance was high (95% of 783 subjects) yet 53% of women screened did not return for their results. It may be that the psychological pressure on women in ante-natal clinics to accept screening, even with counselling, is high. Women can exert control outside of the situation by refusing to return for results. Irion (SC671) reported on 2,364 patients screened ante-natally for HIV in Switzerland. Knowledge of sero-status did not have an important influence on pregnancy decisions. Some workers see HIV screening in pregnancy as a useful epidemological tool. Stegagno (3,175) examined an alternative method whereby 67,337 blood samples from newborns were screened to reveal 82 HIV positive results.
Termination Studies continue to report that knowledge of HIV positive serostatus does not necessarily lead to termination of pregnancy (Irion, SC671; Barbacci, THC41; Stratton, SC665.) Cowan et ul. (SC708) studied 48 HIV positive women and 98 HIV negative women and found that knowledge of serostatus did not influence rates of subsequent pregnancy although in this study there was an effect on index pregnancy. Jakobs (SD8 19) outlined the psychological needs of HIV positive women and described the trauma of learning of pregnancy and HIV at the same time, the
406
SAN FRANCISCO SUMMARIES: L. SHERR
role of misinformation, the stress caused by decision making about the future of the pregnancy and the strain created by hospitalization (for termination or delivery). Lopita (THC653) found no association between presence of HIV infection and spontaneous abortion.
Downloaded by [University of Kiel] at 14:32 25 December 2014
Pregnancy outcome Ndugwa (THC42) examined perinatal outcome in infants in Uganda. Of 3,612 women screened, 1,032 (28%) were HIV positive. They were younger than the HIV negative but did not differ in TB or transfusion history. A high proportion were symptomatic (44.8%); 60.8% had a pregnancy complication. There were no differences with regard to delivery factors and caeserian section had no effect. Gestation was significantly lower for the HIV positive women (38.3 weeks compared to 39.0 weeks) as well as lower birthweights. No comparisons were presented between outcome for the symptomatic and asymptomatic mothers. They recorded a 31% vertical transmission rate at 15 months of age and also noted that a reverse T4 T8 ratio at 6 months may be an early marker of infection. Van de Perre (THC43) also examined various markers which may help predict infant infection. Henrion (THCU) identified higher incidence of transmission to infants where mothers had CD4
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Pregnancy and paediatrics L. Sherr
a
a
Clinical Psychologist , St Mary's Hospital , Praed Street, London, W1, UK Published online: 25 Sep 2007.
To cite this article: L. Sherr (1990) Pregnancy and paediatrics, AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV, 2:4, 403-408, DOI: 10.1080/09540129008257763 To link to this article: http://dx.doi.org/10.1080/09540129008257763
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
403
AIDS CARE, VOL. 2, NO.4,1990
Pregnancy and paediatrics L. SHERR
Downloaded by [University of Kiel] at 14:32 25 December 2014
Clinical Psychologist, St Mary's Hospital, Raed Street., London W l , UK
There was a considerable upsurge of papers in this category compared to previous international conferences. This may mark both the increasing numbers of mothers and babies affected but also the recognition of the wide ranging impact of AIDS and HIV infection. The acknowledgement of AIDS and HIV in infants has also increased focus on women. Despite the fact that childbirth is only one of a number of life roles for women it may well be that long awaited attention is now being focused on women not so much in their own right, but more as the mothers of potentially infected infants. There were 308 papers on children compared to 83 papers on women. The papers on children were divided into many subsections (clinical presentation 39; diagnosis 26; development 1; foster care '4; haemophilia 4; HIV antigen 2; immunology 14; neonates 19; neurological 14; orphans 1; pathology 2; prevalence 15; prevention 15; prognosis 16; progression 16; psychology 7; sexual abuse 1; social impact 14; vertical transmission 53; treatment 16; twins 1; vaccination 2; other 15). This wide range of papers covered a multitude of areas. This review will concentrate on the psychosocial papersOne of the problems with the data as a whole is overrepresentation of USA papers. For example in the following oral sessions close on 80% of papers were from the USA (includmg a small number of joint USA studies.)
Session USA Papen
Issues in vertically transmitted HIV infection, 518; Perinatal Pediamc and Family Issues, 818; Anti retroviral therapy in Children and pregnant women, 618. This trend, although slightly less obvious, was s t i l l seen in the poster sessions. For example: HIV Testing prenatal and family planning clinics, 6/8; Determinants of Risk Behaviour; women, children and adolescents, 16/20; Perinatal Pediamc and Family Issues, 19/25. Thus much of the data, even if of high standard, may have little relevance to different cultures and settings. Conclusions from this review must be made within these limits.
Impact One of the major findings of this conference was the widespread impact of HIV on family members when a pregnant mother and her baby are affected by HIV. This covers the parents, the wider family and the siblings
HIV transmission Pokrovsky et al. reported on HIV infection in 152 children and 12 mothers through syringes. From Romania Beldescu et al.
Downloaded by [University of Kiel] at 14:32 25 December 2014
404
SAN FRANCISCO
SUMMARIES:L SHERR
The differences between Africa and the West may be due to numerous factors. The Mother’s chical status was again endorsed as a possible influence on vertical transmission (Nsuawi, THC658). Research is proceeding to examine prognostic markers which could be helpful in the early identification of HIV infection. Use of polymerase chain reaction (PCR) was reported in a few studies which may hopefilly lead to a more conclusive diagnosis for young infants. (Brandt, TC544;Henrion, THC545; Vendrel, THC616). Ferris et d . (THC546) used polymerase chain reaction in a study of 35 babies born to seropositive mothers and cautioned that a higher frequency of maternal transmission of HIV than previously inferred from serological and clinical detection may exist with genes remaining in a latent state. Pregnancy was not associated with progression of HIV infection in two studies. (Berrebi, THC651 in France and Bledsoe, THC652 USA). Lasley Bibbs (THC655) found that HIV positive women had a significantly higher pregnancy rate than I-IIV negative controls. An interesting case study was reported by Crombleholme (THC605) on a mother treated with AZT prior to pregnancy who
(THC104) described two risk factors associated with HIV; namely hospitalization with microtransfusion or injections. HIV infection was occurring in young infants as a result of unscreened blood and blood products together with inadequate sterilization techniques for needles and syringes. A new infant to mother route in the presence of continued breast feeding, mouth ulcers and breast lesions was documented (Kuznetsovo, THC 48 USSR). Among 264 infected children the 94 non-breast feeders had no infected mothers. Twelve HIV positive mothers were identified from seroprevalence studies of 163,600. Seven were mothers of HIV negative children, four were mothers of dead children and one was the sexual pamer of an HIV-infected man. In other cities 16 HIV positive mothers were similarly identified. Duration of suckling and age of child was not important.
Vertical transmission Reports of vertical transmission rates still range from 20 to 4096. Reports from Africa seem to be higher (in the 30%) and those from Europe to be lower (in the 20%). The table below summarizes studies where vertical transmission percentages were quoted:
Avrhor
Cenne
Prazuck (THC610) Datta (THC611) Hira (THC612) Lepage ct al. (THC659) Van de Perre (THC43) Ndugwa (THC42) Lallemmt (THC656) Delaporte (THC618) Rickard ct al. (THC608) Holt (THC617) Zucotti (THC613) Tovo et al. (THC660) Oleske (THC607) Halsey ( T H C W ) (PB442)
Burkmo Fasso Nairobi Zambia Rwanda Rwanda Uganda Congo Gabon Buenos Aues HaiU man Italy Newark USA Haiti Sweden
~
~~
~~
~
Vrrrical Transmission
~
36% to 4596 33% 39% 33% 34% 31% 42% 17.6% 40% 15.4% 22% 19.2% 19% 25% 33% ~~
(Where rates vary from published abstracts t h ~ sreflects reporting of data presented
at the conference).
PREGNANCY AND PAEDIATRICS 405
opted to continue drug therapy. However, vertical transmission was not prevented.
Downloaded by [University of Kiel] at 14:32 25 December 2014
HIV screening in pregnancy Barbacci (THC41) examined the identification rates of HIV in pregnant women when screening was offered to high risk women compared to a policy of universal screening. Although the latter policy identified higher proportions of HIV positive women, the ‘benefits’ that Barbacci outlined may be open to debate. She claimed these would include identification at less than 20 weeks so that termination could be offered (yet only three out of 81 women terminated in this study one of which had a subsequent term pregnancy and 85% of women elected to continue their pregnancy in the presence of HIV in a study by Stratton et ul. of 49 Obstetric centres SC665); prevention of transmission (yet how this is achieved is unclear); prevention of subsequent pregnancy (yet data from the conference and previous studiesparticularly Sunderland, 1989) show that many women with HIV continue with multiple pregnancies; to prevent breast feeding (which is still open to much debate) and to r e c o p e and manage’. Kiefer (SC664) maintained that universal voluntary screening was more cost-effective than targetted screening but the crucial factor within this paradigm was the different seroprevalence conditions which may affect policy dramatically. However their cost analysis did not include the cost of pre- and post-test counselling. This could be considerable. Stratton et ul. (SC665) documented that HIV positive test results were given in person at 49 medical centres in the USA. Post-test counselling sessions were over 30 minutes for HIV positive women and under 20 minutes for HIV negative women. Caspe (SC667) examined post-pamun counselling and testing in New York. They found that 45% of 80 consecutive subjects had received late or no ante-natal care. Seventy four per cent had used drugs during
pregnancy and the authors emphasized the need to target services to a group who may be at high risk but have few contacts with care agencies. Santana (SC66) surveyed clinics treating over 3,000 pregnant women where HIV education was recommended. They found that this education was well accepted. However they proceed to conclude that “voluntary testing of all pregnant women is essential for perinatal AIDS prevention” without stating clearly how this would be achieved. Ndugga (SC668) reported on acceptability of HIV screening in Kenya. Acceptance was high (95% of 783 subjects) yet 53% of women screened did not return for their results. It may be that the psychological pressure on women in ante-natal clinics to accept screening, even with counselling, is high. Women can exert control outside of the situation by refusing to return for results. Irion (SC671) reported on 2,364 patients screened ante-natally for HIV in Switzerland. Knowledge of sero-status did not have an important influence on pregnancy decisions. Some workers see HIV screening in pregnancy as a useful epidemological tool. Stegagno (3,175) examined an alternative method whereby 67,337 blood samples from newborns were screened to reveal 82 HIV positive results.
Termination Studies continue to report that knowledge of HIV positive serostatus does not necessarily lead to termination of pregnancy (Irion, SC671; Barbacci, THC41; Stratton, SC665.) Cowan et ul. (SC708) studied 48 HIV positive women and 98 HIV negative women and found that knowledge of serostatus did not influence rates of subsequent pregnancy although in this study there was an effect on index pregnancy. Jakobs (SD8 19) outlined the psychological needs of HIV positive women and described the trauma of learning of pregnancy and HIV at the same time, the
406
SAN FRANCISCO SUMMARIES: L. SHERR
role of misinformation, the stress caused by decision making about the future of the pregnancy and the strain created by hospitalization (for termination or delivery). Lopita (THC653) found no association between presence of HIV infection and spontaneous abortion.
Downloaded by [University of Kiel] at 14:32 25 December 2014
Pregnancy outcome Ndugwa (THC42) examined perinatal outcome in infants in Uganda. Of 3,612 women screened, 1,032 (28%) were HIV positive. They were younger than the HIV negative but did not differ in TB or transfusion history. A high proportion were symptomatic (44.8%); 60.8% had a pregnancy complication. There were no differences with regard to delivery factors and caeserian section had no effect. Gestation was significantly lower for the HIV positive women (38.3 weeks compared to 39.0 weeks) as well as lower birthweights. No comparisons were presented between outcome for the symptomatic and asymptomatic mothers. They recorded a 31% vertical transmission rate at 15 months of age and also noted that a reverse T4 T8 ratio at 6 months may be an early marker of infection. Van de Perre (THC43) also examined various markers which may help predict infant infection. Henrion (THCU) identified higher incidence of transmission to infants where mothers had CD4
