The mother-to-child HIV transmission epidemic in Europe: evolving in the East and established in the West

Thorne, C. and Malyuta, R. and Semenenko, I. and Pilipenko, T. and Patel, D. and Bunders, M. and Newell, M.-L. (2006) The mother-to-child HIV transmission epidemic in Europe: evolving in the East and established in the West. AIDS, 20 (10). pp. 1419-1427. ISSN 02699370 01/2006; 20. DOI: 10.1097/01.aids.0000233576.33973.b3
Source: OAI


Objectives: To carry out an epidemiological analysis of the emerging epidemic in an Eastern European country and to compare the approach to prevention of mother-to-child transmission (MTCT) with that in Western Europe.
Design: Prospective cohort study established in 1985 in Western Europe and extended to Ukraine in 2000.
Methods: Data on 5967 HIV-infected pregnant women and their infants (1251 from Ukraine and 4716 from Western/Central Europe) was analysed. Factors associated with transmission were identified with logistic regression.
Results: HIV-infection among pregnant women enrolled in Western European centres has shifted from being largely injecting drug use (IDU)-related to heterosexually-acquired; in Ukraine IDU also gradually declined with women increasingly identified without specific risk factors. In Ukraine in 2000-2004 most (80%) women received single dose nevirapine (sdNVP) and/or short-course zidovudine prophylaxis [MTCT rate 4.2%; 95% confidence interval (CI), 1.8-8.0 for sdNVP with short-course zidovudine]; 2% (n = 27) received antenatal HAART and 33% (n = 418) delivered by elective caesarean section (CS); in Western European centres 72% of women received HAART (MTCT rate 1.0%; 95% CI, 0.4-1.9) and 66% delivered by elective CS during the same period.
Conclusions: Our findings indicate distinct differences in the epidemics in pregnant women across Europe. The evolution of the MTCT epidemic in Ukraine does not appear to be following the same pattern as that in Western Europe in the 1980s and 1990s. Although uptake of preventive MTCT prophylaxis has been rapid in both Western Europe and Ukraine, substantial challenges remain in the more resource-constrained setting in Eastern Europe.

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    • "The study is a nested sub-study of the European Collaborative Study (ECS) in Ukraine that have been enrolling mother-child pairs since 2000. The ECS is a birth cohort study addressing MTCT and its prevention and HIV infection in pregnancy and childhood, involving enrolment of pregnant HIV-infected women, with longitudinal follow-up of their infants (European Collaborative Study, 2006; Thorne et al., 2009). Four regional HIV/AIDS centres in Ukraine participate in the post-natal women's cohort study: odessa, Kiev, Krivoy Rog and Donetsk. "
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    ABSTRACT: Ukraine has the highest antenatal HIV prevalence in Europe. The national prevention of mother-to-child transmission (MTCT) programme has reduced the MTCT rate, but less attention has been given to the prevention of unintended pregnancy among HIV-positive women. Our objectives were to describe the reproductive health, condom use and family planning (FP) practices of HIV-positive childbearing Ukrainian women and to identify factors associated with different methods of post-natal contraception. HIV-infected childbearing women, diagnosed before or during pregnancy, were enrolled prospectively in a post-natal cohort study in four regional HIV/AIDS centres in Ukraine from December 2007. Logistic regression models were used to identify factors associated with post-natal FP practices. Data were available for 371 women enrolled by March 2009; 82% (n = 303) were married or cohabiting, 27% (97 of 363) reported a current HIV-negative sexual partner and 69% were diagnosed with HIV during their most recent pregnancy. Overall, 21% (75 of 349) of women were not using contraception post-natally (of whom 80% reported no current sexual activity), 50% (174 of 349) used condoms, 20% (74 of 349) relied solely/partially on coitus interruptus and 4% used hormonal methods or intrauterine device. Among married/cohabiting women, consistent use of condoms in the previous pregnancy [AOR 1.96 (95%CI 1.06-3.62)], having an HIV-positive partner [AOR 0.42 (0.20-0.87)], current sexual activity [AOR 4.53 (1.19-17.3)] and study site were significantly associated with post-natal condom use; 16% of those with HIV-negative partners did not use condoms. Risk factors for non-use of FP were lack of affordability [AOR 6.34 (1.73-23.2)] and inconsistent use of condoms in the previous pregnancy [AOR 7.25 (1.41-37.2)]. More than 40% of HIV-positive women in this population are at risk of unintended pregnancy and the one in six women in HIV-discordant couples not using barrier methods risk transmitting HIV to their partners. Our study results are limited by the observational nature of the data and the potential for both measured and unmeasured confounding.
    Human Reproduction 09/2010; 25(9):2366-73. DOI:10.1093/humrep/deq093 · 4.57 Impact Factor
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    • "A comprehensive approach to PMTCT, including a combination of antiretroviral therapy (ART) from early pregnancy, elective caesarean section and avoidance of breastfeeding, can reduce transmission rates to below 2% (European Collaborative Study 2005; Naver et al. 2006; Newell et al. 2007). While highly active ART (HAART, a combination of three or more antiretrovirals from at least two categories) is the most effective ART regimen for PMTCT purposes, benefit in terms of reducing MTCT can still be gained from less intense regimens (European Collaborative Study 2006; WHO 2006c). Avoidance of breastfeeding is recommended in developed countries; elective caesarean section to prevent transmission during delivery is common in Western Europe (European Collaborative Study 2005), but lesser in the United States and Eastern Europe (European Collaborative Study 2005; Kourtis et al. 2007a; Newell et al. 2007). "
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    ABSTRACT: The successes achieved in paediatric disease management in well-resourced countries in recent years highlight the vast divide between the care options, and ultimately survival, between developed and developing areas of the world. Using an extensive literature review, we quantify recent achievements in terms of improved survival and quality of life, and examine current evidence of the effects of treatment on the survival and morbidity of HIV-infected children in developing countries. When provided with the same care as their counterparts in developed countries, children in developing countries show similar improvements in survival and general health, with 1-year survival rates exceeding 90% in many African settings. Despite the challenges of providing comprehensive packages of care in resource-limited settings, there is an urgent need to scale up prevention and treatment of HIV infections in children, focussing on strengthening Prevention of Mother-to-Child Transmission programmes in order to reduce the numbers of infants who are infected in addition to reducing morbidity and mortality among their mothers.
    Tropical Medicine & International Health 08/2008; 13(9):1098 - 1110. DOI:10.1111/j.1365-3156.2008.02130.x · 2.33 Impact Factor
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    ABSTRACT: An HIV outbreak among Finnish injecting drug users (IDUs) occurred in 1998. By the end of 2005, 282 IDUs were in-fected, most of them by recombinant virus CRF01_AE of HIV. After a rapid spread, the outbreak subsided, and the prevalence of HIV among IDUs remained low (<2%). The purpose of the study was to describe the outbreak in order to recognise factors that have influenced the spread and restriction of the outbreak, and thus to find tools for HIV preven-tion. Data on Finnish IDUs newly diagnosed HIV-positive between 1998 and 2005 was collected through interviews and patient documents. Study I compared markers of disease progression between 93 Finnish IDUs and 63 Dutch IDUs. In study II, geographical spread of the HIV outbreak was examined and compared with the spatial distribution of employed males. In study III, risk behaviour data from interviews of 89 HIV-positive and 207 HIV-negative IDUs was linked, and prevalence and risk factors for unprotected sex were evaluated. In study IV, data on 238 newly diagnosed IDUs was combined with data on 675 sexually transmitted HIV cases, and risk factors for late HIV diagnosis (CD4 cell count <200/µL, or AIDS at HIV diagnosis) were analysed. Finnish IDUs infected with CRF01_AE exhibited higher viral loads than did Amsterdam IDUs infected with subtype B, but there was no difference in CD4 development. The Finnish IDU outbreak spread and was restricted socially in a marginalised IDU population and geographically in areas characterised by low proportions of employed males. Up to 40% of the cases in the two clusters outside the city centre had no contact with the centre, where needle exchange services were available since 1997. Up to 63% of HIV-positive and 80% of HIV-negative sexually active IDUs reported inconsistent condom use, which was associated with steady relationships and recent inpatient addiction care. Com-pared to other transmission groups, HIV-positive IDUs were diagnosed earlier in their infection. The proportion of late diagnosed HIV cases in all transmission groups was 23%, but was only 6% among IDUs diagnosed during the first four years of the epidemic. The high viral load in early HIV infection may have contributed to the rapid spread of recombinant virus in the Finnish outbreak. The outbreak was restricted to a marginalised IDU population, and limited spatially to local pockets of pov-erty. To prevent HIV among IDUs, these pockets should be recognised and reached early through outreach work and the distribution of needle exchange and other prevention activities. To prevent the sexual transmission of HIV among IDUs, prevention programmes should be combined with addiction care services and targeted at every IDU. The early detection of the outbreak and early implementation of needle exchange programmes likely played a crucial role in re-versing the IDU outbreak. Pistoshuumeiden käyttäjien HIV-epidemia todettiin pääkaupunkiseudulla vuonna 1998. Epidemia levisi aluksi nopeasti, mutta myös rajoittui muutamassa vuodessa. Tutkimuksen tavoitteena oli tunnistaa tekijöitä, jotka vaikuttivat epidemian leviämiseen ja rajoittumiseen, ja siten löytää keinoja HIV-epidemian ennaltaehkäisyyn. Aineisto käsitti 238 HIV-tartunnan saanutta pistoshuumeidenkäyttäjää, joiden tietoja verrattiin hollantilaisista HIV-positiivisista ja suomalaisista HIV-negatiivisista huumeidenkäyttäjistä kerättyihin tietoihin, miesten työllisyyslukujen alueelliseen jakaumaan ja pääkaupunkiseudun seksivälitteisiin HIV-tartuntoihin. HIV-epidemia levisi syrjäytyneiden pistoshuumeiden käyttäjien keskuudessa. Kaikki Helsingin keskustan ulkopuolella sijaitsevat huumeidenkäyttäjien rypäät sijaitsivat alueilla, joissa miesten työllisyysluvut olivat alle 70%. Muissa tutkimuksissa on osoitettu puhtaiden pistosvälineiden saatavuuden estävän HIV:n leviämistä. Pääkaupunkiseudun epidemiassa 40% keskustan ulkopuolella asuvista huumeidenkäyttäjistä jäi pistosvälineiden vaihdon ja terveysneuvonnan ulkopuolelle, koska heillä ei ollut yhteyksiä keskustaan, jossa terveysneuvonta ja pistosvälineiden vaihto aloitettin juuri ennen epidemiaa. Suomessa levinnyt viruksen alatyyppi (CRF01_AEfin) edesauttoi epidemian leviämistä, sillä suomalaisilla huumeidenkäyttäjillä todettiin korkeampia veren viruspitoisuuksia kuin hollantilaisilla B-alatyypin viruksella infektoituneilla huumeidenkäyttäjillä. Veren korkea viruspitoisuus lisää tartuttavuutta. HIV ei levinnyt ydinjoukon ulkopuolelle eikä uusille alueille. Epidemian rajoittumiseen vaikutti todennäköisesti sen varhainen toteaminen terveysneuvonnan kehittymisen ohella. Huumeidenkäyttäjien HIV-tartunnoista 1998-2001 vain 6% todettiin myöhäisessä vaiheessa (veren CD4-solut alle 200/µL tai AIDS-vaiheessa), kun kaikista pääkaupunkiseudun HIV-tartunnoista 23% todettiin myöhään. Yli puolet huumeidenkäyttäjien tartunnoista todettiin vankiloissa, päihdehoidossa tai terveysneuvontapisteissä; paikoissa joissa HIV-testiä tarjotaan aktiivisesti. HIV voi yhä levitä huumeiden käyttäjien keskuudessa joko pistämisen tai seksin välityksellä. Suojaamaton seksi on yleistä sekä HIV-positiivisten että HIV-negatiivisten huumeiden käyttäjien keskuudessa, etenkin vakituisissa suhteissa ja hiljattain päihdehoitoa tarvinneilla. Seksuaaliterveyden neuvontaa tulisi tarjota kaikille huumeidenkäyttäjille ja heidän seksikumppaneilleen. Terveysneuvonnan alueellinen hajauttaminen ja kohdistettu etsivä työ ovat avainasemassa huumeidenkäyttäjien HIV-tartuntojen toteamiseksi varhain ja epidemioiden ehkäisemiseksi.
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