Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

406 Abstracts 23321-23325

12th World AIDS Conference

23321 Use of zidovudine (ZDV) and pregnancy termination
among HIV-infected pregnant women in Thailand:
A survey of 480 physicians
Jeffrey S.A. Stringer1, P. Phanuphak2, E.M. Stringer1, P. Jetwana3,
E.M. Funkhouser4, N.S. Maisiak5, S.H. Vermund4. 1Dept OB/GYN, Univ.
Alabama at Birmingham, 340 OHB, G18 S. 20th St. Birmingham, AL 35294;
4Dept. Epidemiology U. Alabama Birmingham, Birmingham, AL; 5School of
Medicine, Univ. Alabama at Birmingham, Birmingham, AL, USA; 2Program on
AIDS Thai Red Cross Society, Bangkok; 3School of Medicine, Chulalongkorn
Univ Bangkok, Thailand
Objectives: To understand how Thai physicians employ ZDV and pregnancy
termination in caring for HIV-infected obstetrical patients.
Design: Mail Survey
Background and Methods: Although countries such as Thailand have begun
to make perinatal ZDV available to HIV-infected pregnant women as a matter of
public health policy, a major barrier to the use of this intervention lies in the failure
of physicians caring for obstetrical patients to incorporate ZDV prophylaxis into
actual clinical practice. To better understand this complex issue, we conducted a
postal survey of obstetricians and generalists in Thailand.
Results: Despite availability of the drug at no cost from government and Thai
Red Cross sources, 79.5% of the 480 respondents reported that they did not
routinely use ZDV prophylaxis. Factors associated in univariate analysis with
failure to use ZDV prophylaxis included: lack of OB/GYN training (OR = 2.8;
95% CI: 1.5-5.2); practice outside of Bangkok (OR = 2.6; 95% Cl: 1.6-4.3);
affiliation with a smaller hospital (OR = 2.2; 95% Cl: 1.4-3.6), with a provincial
or district hospital (OR = 2.1; 95% CI: 1.3-3.4), or with a non-teaching hospital
(OR = 1.7; 95% CI: 1.0-2.7); unfamiliarity with ACTG 076 (OR = 2.4; 95% CI:
1.4-3.9); and belief that perinatal ZDV administration is not cost effective (OR =
2.6; 95% CI: 1.5-4.6). Predictors of failure to use ZDV that remained significant
in multivariate analysis included: practice outside of Bangkok, the belief that ZDV
was not cost effective, and unfamiliarity with ACTG 076. Regarding pregnancy
termination, 45.3% of respondents believed elective abortion to be the best option
for HIV-infected pregnant women. Physicians specializing in OB/GYN (OR = 1.76;
95% CI: 1.12-2.77), practicing in Bangkok (OR = 1.95; 95% CI: 1.27-2.58), or
working in a larger hospital (OR = 1.73; 95% Cl: 1.16-2.58) were more likely to
support this practice.
Conclusion: We conclude that Thai physicians are not routinely using perinatal
ZDV prophylaxis, particularly those located in smaller, more remote hospitals. A
significant number of physicians support pregnancy termination in HIV-infected
patients.
23322 | The feasibility of short-course antiretroviral therapy for
the prevention of mother to child transmission of HIV in
Soweto, South Africa
James Mclntyre, G.E. Gray. Perinatal HIV Research Unit CH Baragwanath
Hospital PO Bertsham 2013, South Africa
Background: Despite the success of zidovudine as standard treatment for the
reduction of mother to child transmission in developed countries, current regimens
may not be suitable for many developing countries, due to the cost, infrastructure
requirements and rates of breastfeeding. Several trials of short-course antiretroviral therapy are in progress, with early results expected in late 1998. If these prove
successful, this approach would provide a cost-effective alternative for some
developing countries. This paper discusses the requirements for the introduction
of this therapy in South Africa's largest urban township. These include access to
maternity services, time of utilisation of antenatal care, laboratory facilities, drug
supply logistics, testing and counselling services, and infant feeding practices.
Results: Chris Hani Baragwanath Hospital in Soweto delivers 16 000 women
annually, with a further 7000 delivered at the associated midwife delivery clinics.
Antenatal care services are free and over 95% of pregnant women attend antenatal clinics and deliver in medical facilities. The mean gestational age at first
attendance is 23 weeks, with 88% of women attending before 36 weeks. Uptake of voluntary HIV counselling and testing, currently only available at hospital
level, is over 95%. The HIV seroprovalence was 18% in early 1998: giving an
estimated 3200 HIV positive women per year who could be identified in time to
start treatment at 36 weeks. Laboratory facilities are available with the capacity
to undertake sufficient HIV tests, and other laboratory work. A well-controlled
drug distribution system is in place at hospital and clinic level. Trained nurse
counsellors are available at all clinics and the hospital, backed up by volunteer
peer counsellors at the hospital. Staffing levels would need to be increased to
cope with the counselling workload. At present, over 80% of identified HIV positive
women formula feed their infants.
Conclusions: The conditions and infrastructure for the s implementation of
short-course antiretroviral therapy are largely available in Soweto. Additional staff
for counselling and funds for laboratory services and drug supply would be required. Decisions on the introduction of such therapy will be made on the basis
of efficacy results from the PETRA and other studies, and cost benefit analyses
using local data.

23323 1 Recommendations from 11 Latinamerican AIDS programs
to prevent HIV transmission through breastfeeding
Jose Antonio Izazola-Licea. Fundacion Mexicana Para La Salud, Periferico Sur
4809 C.P 14610 Mexico D.F, Mexico
Problem: It is estimated that between one-third to one-half of the total perinatal AIDS cases acquired HIV by their mothers milk (HIV transmission rate
through breastfeeding 16-43%). The benefits of breastfeeding in reducing of
infant mortality are widely acknowledged and promoted in developing countries.
Project: A consensus workshop with directors of National AIDS Programs, officials of infant nutrition programs, and international organizations was organized to
document current policies and practices regarding breastfeeding by HIV infected
women in Latinamerica and to seek regional recommendations to promote the
best alternative to prevent as many cases of HIV vertical transmission as possible.
Results: Thirty-eight representatives of national AIDS and infant nutrition
programs (Argentina, Brazil, Cuba, Costa Rica, Chile, Dominican Republic, Honduras, Mexico, Paraguay, Peru and Venezuela), of regional and national societies
of pediatricians and from four international organizations dealing with AIDS were
gathered (Brazil, Nov. 1997). In all the participating countries, except Honduras
and Dominican Republic, AZT was being provided (at different coverage rates)
according to the ACTG 076 protocol using public funds. All participating countries, except Honduras, contraindicated breastfeeding by HIV infected women and
sought the sustained provision of milk substitutes or milk from other non-infected
women (milk banks) as alternatives. It was concluded that even when health
personnel ignored the feasibility to substitute maternal milk, women should be
adequately counselled about the risks of HIV transmission to their infants to make
an informed decision. In middle income countries in Latinamerica, adequate and
sustained substitution of maternal milk is feasible using private (out-of-pocket)
and public funds.
Lessons Learned: It was concluded that ethically, breastfeeding must be
contraindicated whenever alternative nutrition sources could be provided under
a permanent basis. The experience of nine countries in latinamerica showed the
feasibility to limit the vertical transmission of HIV through the use of antiretrovirals
and substitution of maternal milk.
23324 Three pronged strategy to prevent mother to child
transmission
Kaizad Damania1, R.H. Merchant1, S. Arwari1, I.S. Gilada2, J. Karkare1.
SNowrosjee Wadia Maternity Hospital, Qrts. Acharya Donde Marg Parel,
Bombay; 2Indian Health Organization, Bombay, India
Objectives: To study the efficacy of three pronged intervention strategy to reduce
perinatal transmission of HIV 1 infection.
Design: Prospective, interventional study.
Methods: Interventional strategy in the form of antepartum zidovudine (ZDV) in
a dosage of 100 mgs. qds for at least 7 weeks prior to delivery, elective caesarean
section at term and no breast feeding (ZDV to infant for 6 weeks) was studied
prospectively in 45 women accepting the same. Their babies were followed-up
clinically regularly and with HIV antibody testing at 9 months, 1 year, 15 months
and 18 months interval.
Results: Of 40 women not accepting any interventional; 13 children remained
seropositive at the end of 18 months. A transmission rate of 32.5% for our populance. Of the 18 babies who till date have followed up beyond 18 months; NO
child has remained seropositive. All have become seronegative by 18 months.
Conclusion: A three pronged intervention strategy to attack all periods of
transmission in pregnancy (antenatal, intrapartum & postpartum) appears to be
extremely effective. Antenatal ZDV in lower dosage and shorter period (at least
7 weeks) may be utilized in resource setting as in India amongst women offered
and accepting the same.
23325 1 Within feed analysis of HIV ABs in human breast milk:
Implication for breastfeeding policy and strategies
Norman Nyazema. Dept. Clinical Pharmacology, PO Box A 178, Avondale
Harare, Zimbabwe
Objective: To investigate the variation of HIV specific immunoglobulins with
respect to point of feed
Design: Prospective, follow-up study.
Method: After a random selection, 20 pregnant women were recruited at an
ante-natal clinic where there was no mandatory test for HIV. The women gave
their consent to be followed up until the birth of the child. All the ethical requirements were fulfilled. Fore and hind samples of colostrum and mature milk
were collected 5 and 21 days postpartum respectively and stored at -70 ~'C. HIV
specific antibodies were determined in all samples using 2 commercial Elisa kits.
Results: Most women, average age 24 yrs, were between 26 and 32 weeks of
gestation and received the standard care. One of the assays detected HIV antibodies in 11 out of 20 colostrum samples and 3 out of 9 corresponding samples
of mature milk. The other assay showed that six quadrapule samples i. e. 6 out

of 20 milk samples, had HIV antibodies. Using the ODs obtained there appeared
to be no statistically significant variation in the quantity HIV specific antibodies
within feed.
Conclusion: From the ODs obtained it would appear that there was no difference in the quality of fore and hind milk, as far as protective antibodies
were concerned. To change our breastfeeding policy and its strategies a bigger