HIV Seroconversion During Pregnancy and Mother-to-Child HIV Transmission: Data from Enhanced Perinatal Surveillance, United States, Singh S, Lampe M, Surendera Babu A, Rao S, Borkowf CB, Nesheim SR XIX International AIDS Conference Washington, DC July 26, 2012 No financial relationships to disclose National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

Background In the US, the Centers for Disease Control and Prevention (CDC) recommends that opt-out HIV screening be included in the routine panel of prenatal screening tests for all pregnant women In addition, CDC recommends repeat third-trimester testing in areas with elevated HIV infection among pregnant women and women at high risk Decline in mother-to-child transmission (MCT) in the US since the early 1990s CDC. Revised Recommendations for HIV Testing of Adults, Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR, September 22, 2006, 55(RR14);1-17.

Background Acquisition and transmission of HIV by women is higher during pregnancy 1 Studies of acute infection during pregnancy in the US include: –Birkhead et al (2010) 2 reported 13.8% (9/65) in New York City of perinatal infections occurred in maternal primary infection –Patterson et al (2007) 3 reported 50% (3/6) in North Carolina of perinatal infections occurred in maternal primary infection Acute infection during pregnancy can lead to higher MCT due to increased viral load during acute infection 4 1 Mugo NR et al. AIDS 2011;25: Birkhead GS et al. Obstet Gynecol 2010;115: Patterson KB et al. AIDS 2007;21: Marinda ET et al. Int J Epid 2011;40:

Objectives To estimate the numbers of seroconversions during pregnancy (DP) and prior-to-pregnancy (PTP) To examine the maternal and infant characteristics and uptake of interventions between DP and PTP seroconverters To determine the proportion of perinatal infection which occur in the context of maternal primary infections To compare the MCT between DP and PTP seroconverters

Enhanced Perinatal Surveillance EPS is a population ‑ or facility-based surveillance system for HIV ‑ infected mothers and their perinatally-exposed children EPS includes –Case ascertainment –Linking of mother ‑ infant pairs –Review of medical records for HIV testing history, prenatal care and treatment, follow ‑ up to assess infection status of infants and initiation of HIV ‑ related care Data sources –Prenatal care records –Labor and delivery charts –Pediatric HIV medical records –Birth and death certificates –Mother’s HIV medical records for care –Health department record

GA SC TX NY LA PR MD DE CT NJ

Methods HIV-infected women who delivered live infants EPS data linked with National HIV Surveillance System data through June 2011 Determined number of DP and PTP seroconverters –DP seroconverters had negative HIV test during pregnancy and positive HIV test during pregnancy, labor/delivery or 90 days after infant date of birth –PTP seroconverters diagnosed prior to pregnancy

Methods Comparisons were limited to DP and PTP seroconverters Differences in characteristics and intervention uptake between DP and PTP seroconverters assessed by the chi-squared test Determined proportion of perinatal infection which occur in the context of maternal primary infections Calculated MCT among DP and PTP seroconverters Estimated annual percent change used to examine trends in percentages of DP and PTP seroconverters and MCT in seroconverter groups

Assumptions for Handling Missing Data Conditions –Used infant date of birth to replace missing HIV positive test date –If HIV positive or negative tests missing, used additional information from EPS questionnaire Initiation of ART Variable on mother’s HIV status –HIV-positive before this pregnancy –HIV-positive at the time of delivery

RESULTS

HIV Seroconversions During Pregnancy and Prior-to-Pregnancy, EPS, N (%) All Pregnancies 2,0641,9751,8141,7201,5431,19210,308 During Pregnancy 8 (0.4)26 (1.3)14 (0.8)28 (1.6)26 (1.7)22 (1.9)124 (1.2)* Prior-to- Pregnancy 1,470 (71.2)1,381(69.9)1,283 (70.7)1,204 (70.0)1,061 (68.8)836 (70.1)7,235 (70.2) Unclassifiable586 (28.4)568 (28.8)517 (28.5)488 (28.4)456 (29.6)334 (28.0)2,949 (28.6) *Estimated Annual Percent Change p<0.0001)

Maternal Characteristics Among DP and PTP Seroconverters, EPS, * Characteristics DP Seroconverter N (%) PTP Seroconverter N (%) P-value Age at Delivery (years)< (15.3)391 (5.4) (41.1)1374 (19.1) (37.1)3753 (52.2) (6.5)1677 (23.3) Race/Ethnicity0.63 Black76 (62.3)4767 (66.9) Hispanic33 (27.1)1578 (22.1) White12 (9.8)710 (10.0) Other1 (0.8)74 (1.0) *Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information

Maternal Characteristics Among DP and PTP Seroconverters, EPS, * Characteristics DP Seroconverter N (%) PTP Seroconverter N (%) P-value Marital Status<0.005 Single89 (88.1)3899 (73.8) Married11 (10.9)1201 (22.7) Divorced/Separated/Widowed1 (1.0)181 (3.4) Transmission Category0.061 Injection Drug Use5 (6.4)646 (13.6) Heterosexual Contact Ɨ 65 (83.3)3384 (71.4) Other8 (10.3)707 (14.9) Place of Birth0.45 United States/Dependent Areas91 (79.8)5108 (76.8) Non-United States Areas23 (20.2)1541 (23.2) *Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information Ɨ Persons whose transmission category is classified as heterosexual contact are persons who report specific heterosexual contact with a person known to have, or to be at high risk for, HIV infection (e.g., an injection drug user)

Infant Characteristics by Maternal Time of Seroconversion, EPS, * Infant Characteristics DP Seroconverter N (%) PTP Seroconverter N (%) P-value HIV Infection Status of Infant< Infected16 (13.0)118 (1.7) Not Infected79 (64.2)5458 (77.8) Indeterminate28 (22.8)1439 (20.5) Gestational Age0.44 Normal80 (65.6)4382 (62.2) Preterm42 (34.4)2668 (37.8) Birth Weight0.087 Normal104 (83.9)5574 (77.4) Low Birth Weight20 (16.1)1628 (22.6) *Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information

Maternal and Infant Interventions Among DP and PTP Seroconverters, EPS, * Interventions DP Seroconverter N (%) PTP Seroconverter N (%) P-value Receipt of Prenatal Care0.32 Yes119 (96.8)6591 (94.7) No4 (3.3)367 (5.3) Breastfeeding< Yes24 (20.9)52 (0.8) No91 (79.1)6807 (99.2) Mode of Delivery0.003 Vaginal66 (53.7)2872 (40.8) Elective C-section32 (26.0)2966 (42.1) Non-elective C-section23 (18.7)1045 (14.8) C-section, unknown type2 (1.6)159 (2.3) *Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information

Maternal and Infant Interventions Among DP and PTP Seroconverters, EPS, * Interventions DP Seroconverters N (%) PTP Seroconverters N (%)P-value Prenatal ARV< Yes43 (34.7)6193 (85.6) No81 (65.3)1042 (14.4) Intrapartum ARV< Yes62 (50.0)6290 (86.9) No62 (50.0)945 (13.1) Infant ARV< Yes94 (75.8)6873 (95.0) No30 (24.2)362 (5.0) Any ARV< Yes94 (75.8)6972 (96.4) No30 (24.2)263 (3.6) All Three ARV< Yes42 (33.9)5702 (78.8) No82 (66.1)1533 (21.2) *Missing values were excluded from the analysis. The number of records for each variable does not sum to the total number of records due to missing information

28-36 Weeks 36+ Weeks

Perinatal HIV Transmission Among DP and PTP Seroconverting Women, EPS, N (%) Perinatal HIV Transmission Among All Deliveries 56 (2.7)35 (1.8)42 (2.3)29 (1.7)26 (1.7)22 (1.9)210 (2.0) Perinatal HIV Transmission Among DP Seroconverters 2 (25.0)3 (11.5)2 (14.3)3 (10.7)2 (7.7)4 (18.2)16 (12.9) Perinatal HIV Transmission Among PTP Seroconverters 32 (2.2)22 (1.6)21 (1.6)17 (1.4)14 (1.3)12 (1.4)118 (1.6)

Limitations EPS is a population-based and facility-based surveillance system and cannot be generalized to determine national estimates Surveillance areas use specific methods based on HIV-reporting laws or Institutional Review Board assurance which may result in variation in data collection methods Completeness of data including negative test date

Discussion From 2005 to 2010 there was a 25% estimated annual increase in the percent of DP seroconverters Unadjusted differences observed between PTP and DP seroconverters include mode of delivery, breastfeeding, HIV infection status of infant and ARVs MCT occurred among 2.0% of all deliveries and MCT among DP seroconverters was 12.9% and PTP seroconverters was 1.6% The proportion of perinatal infection which occur in the context of maternal primary infections was 7.6% Only 23.4% of DP seroconverters were tested during the CDC-recommended third trimester period

Conclusion Mother-to-child transmission could be further reduced by greater adherence to CDC (2006) recommendations in the Revised Recommendations for HIV Testing of Adults, Adults, Adolescents, and Pregnant Women in Health-Care Settings CDC’s HIV Testing Recommendations:

Acknowledgements Coauthors EPS Program Margaret Lampe Suzanne Whitmore Aruna Surendera Babu Gary Weeks Shubha Rao Veena Minasandram Craig Borkowf Sabitha Dasari Steve Nesheim Renee Freeman Grantee staff Previous Work EPS Participants Stephanie Sansom Nan Ruffo

For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone: CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention Sonia Singh, PhD MHS Epidemiologist HIV Incidence and Cases Surveillance Branch Division of HIV/AIDS Prevention National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention Centers for Disease Control and Prevention 1600 Clifton Road NE, MS E-47 Atlanta, GA Phone: (404)