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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
Women and children L. Sherr
a
a
St Mary's Hospital, Praed St , London, W2 1NY, UK Published online: 25 Sep 2007.
To cite this article: L. Sherr (1991) Women and children, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 423-432, DOI: 10.1080/09540129108251603 To link to this article: http://dx.doi.org/10.1080/09540129108251603
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AIDS CARE, VOL. 3, NO. 4,1991
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Women and children L. SHERR Downloaded by [The University of Manchester Library] at 15:44 23 November 2014
St Mary’s Hospital, Praed St,London W2 INY, UK
For the first time in the series of interna- However, the fact that oral presentations tional Conferences there was an obvious essentially only started after three in the presence of research highlighting the impact afternoon, with eight simultaneous sessions, of HIV on women and children. The number often meant gross overlap. Running from of papers on children far outweighed those session to session was not possible given the on women, yet the women issues were ac- sprawling conference site and many excelknowledged and not simply subsumed under lent discussions were simply held in the the heading of family or pregnancy. Al- endless lines outside the Uffizzi gallery. though this marks a welcome development, it was clear from both the quality of the papers and the organization of the sessions Women that this was only a start and there is a long There were particular themes of note on way to go. women. These related to their role in the There were two specific sections deevolving pandemic generally, and to manivoted to women and children. However festations of the illness particularly. HIV these lunchtime sessions were rather frusinfection is not only prevalent in women, trating. They were neither academic nor a but in certain areas it equals the prevalence forum for the voice of affected groups. Inof men. Chin reported that 1/40 men and deed it felt that the token gesture of plan1/40 women in Sub Saharan Africa were ning the sessions was an attempt to acknowinfected. Furthermore, women are uniquely ledge the issues with little more progress. involved in vertical transmission of HIV. The papers were mixed, the discussions ofSmith (MC3171) noted that 95 women in ten marked audience frustration and the lack Scandinavia have AIDS (40 Denmark, 39 of simultaneous translation for these sessions Sweden, 16 Norway). Prognosis for women muffled the voices that often needed to be was poorer than for men. The number heard. The bulk of the progress was reported infected in the USA was reported as in papers which were somehow haphazardly 17,000-with most since 1989 and heterodotted through the poster sessions and varisexual contact the major source of infection. ous talks. The psychosocial aspects were not clearly delineated and were often appended to medical sections. This review will attempt Behaviour to identify some of the works of major interest to emerge from the conference and focus HIV affected the behaviour of women on a on the psychological rather than the medical. variety of indices. Lai (MC3005) found
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FLORENCE SUMMARIES: L. SHERR
changes in sexual and contraceptive practices to protect partners and unborn children in their study of 42 women (78% IVDU; 23 Asymptomatic and with 19 AIDWARC). Only 67% received post-test counselling. Fifty -four percent would avoid pregnancy, 82% used condoms and 19% would continue pregnancy. Eversley (MD4045) examined 267 female family planning attenders and found no relation between perception of risk and condom use or risk reduction. Batter (MD4013) studied 4,656 women screened for HIV. Two hundred and forty-one were HIV-positive and 186 were followed up. Ninety percent accepted counselling. There was no effect on decisions to have subsequent children. Although at the time of counselling 50% intended to tell their partner, one year later only 5% had informed. Similarly although 88% intended to use condoms at one year follow up only 20% had used them. Japheth (WC3095) found 173 HIV-positive women out of 3,363 tested at family planning clinics. High parity and previous abortions were associated with HIVpositive but no significant associates were observed between use of contraceptive methods and HIV. Armstrong (MD4241) examined drug users ( n = 599 non pregnant) and found 96% to have at least one risk factor for HIV. Women who had been sterilized (27%) were more likely to be sexually active and less likely to use condoms. Cervical abnormalities A group of studies examined findings of cervical abnormalities in women with HIV. La Guardia (MC97) recorded 48% abnormal pap smears in a sample of 44 women with HIV. Cervical dysplasia according to T cell count revealed higher abnormality rates (61%) where counts were (200 and 38% where counts were between 200-900. Thus the severity of cervical dysplasia was associated with immune competency. This was confirmed by Warne (MC3113) who found menstrual abnormalities and bleeding be-
tween periods in a group of Intravenous drug users (IDUs) who were HIV-positive ( n = 76) compared to negatives (n = 37). Chipangwi (MC98) found that HIV and Human Papiloma Virus (HPV) correlated with abnormal cytology which increased with level of immunosuppression. Williams (MC3116) studied 90 women (55 HIVpositive and 35 HIV-negative) who were injection drug users in San Francisco. They found all five subjects with cervical smears evaluated as CIN were HIV-positive as were three out of 4 subjects with anal intraepithelial neoplasia. This growing body of literature may signify the need to examine AIDS defining illnesses. If immunosuppression is contributing to an increased mortality in woman by way of cervical disease, its non-inclusion may lead to underestimates in epidemiology in women, which will underestimate future progression and directly effect the provision of funding and resources to this group.
Psychosocial impact of HIV on women The psychosocial impact of HIV on women was profound in numerous studies. Lecrount (MD4258) studied the families of 37 children in the Netherlands and recorded frequent socio economic distress with less than one third reporting a professional income. Forty-five percent were on public assistance. Gender differences were recorded by Carey (MD4230) who compared 401 males and 41 females. Females were more likely to be married, less likely to be employed outside the home, less likely to have post high school education. Men suppressed negative emotion (anger anxiety and unhappiness) more than women. Women were diagnosed more frequently with Major Depression and men more frequently with Alcohol use disorders. Limitation of this study data as it reports ‘nearly significant’ findings and it is unclear what this means. Richie (MD4249) carried out focus groups for 92 women in USA jails. Anonymous serosurvey
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WOMEN AND CHILDREN
in 1990 found 25.8% female inmates HIV infected. Intervention programmes increased knowledge and adjusted intended behaviour. Golden (WC309 1) examined gender influences in drug users and found that among women barter drugs were associated with continuing high risk sex and conclude that economic and sex risks must be addressed in intervention. Brown (MB2028) evaluated 37 women with HIV and found persistent impairment in sexual functioning. Major mood disorders, suicidality or psychiatric hospitalisation were uncommon. Hausermann (TUD115) examined women in the UK Uganda and Zambia and highlighted the lack of rights and concomitant vulnerability of women.
Pregnancy Kurth (MD4235) examined pregnancy decision making in l l women and they urged that screening programmes take into account and understand the complexity of such decisions.
HIV in pregnancy The epidemiology of HIV and pregnancy was studied in numerous centres together with the implications. Gillet (WC3284) studied 307 pregnancies in 264 HIV-positive women over 7 years in France which resulted in 129 deliveries, 170 abortions, 5 miscarriages and 3 ectopic pregnancies. Characteristics of a cohort of pregnant women (WC3256 WITS Study group) were examined in 127 HIV infected pregnant women. Less than 10% had AIDS and over half had low CD4 counts. Couturier (WC3246) reported on outcome of screening on 11,593 samples which revealed a prevalence of 4.1 per 1,000 in Paris. This was 2.5 times higher in women who terminated than those who delivered.
HI V testing HIV testing of pregnant women continues apace. A few studies are now mentioning
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counselling, yet refusal rates are often low, non existant or not reported. Other studies fail to report counselling. Some gather samples from women in labour without any detailed discussion on the content or logistics of counselling during contractions, which would make interesting reading. A worrying trend among studies emerges when workers report HIV rates among those who refuse to be tested. Ethically it is unclear how testing in the absence of permission can be justified (e.g. Michelozzi, WC3254). Some of the many screening studies are summarised below in Table 1. In the light of these studies, two papers were of note. Meadows (MC3330) surveyed 300 women in early pregnancy and followed up 50 at 28 weeks gestation. Thirty-six percent reported that they had been tested for HIV although 28% reported that they had received no counselling at all. Of those who were found to be in risk groups, none were either counselled or tested. Wieser (MC3333) questioned whether voluntary HIV testing was really voluntary in a Swiss setting. Consecutive women attenders (n = 112) were interviewed; 73.2% were tested before they attended the hospital clinic; 20.5% were tested on arrival. All 105 were HIV-negative (5.4% refixed testing). Of those tested, 58% had been informed and only 72% were told their negative result. Forty-one point nine percent were not informed and five would have refused if asked. It seems that lip service is being paid to counselling (both pre- and post-test) for pregnant women.
Influence of HIV on pregnancy Continued monitoring of HIV in pregnancy is important and seems not to render complications. Johnstone (WC3239) compared 149 HIV-positive pregnancies with controls. Induced and spontaneous abortions were common but not more so than controls. HIV was not associated with labour/delivery problems or perinatal mortality but was with drug use and low birth weight. MacCallum
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FLORENCE SUMMARIES: L. SHERR
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Table 1. Screening for HIV in pregnant women Author
Centre
Ankrah MD4246
Uganda 9189-10/90
1,511
Boulos MC3015
Haiti 7/86-8/88 8/89-6190
4,474 1,720
Bulterys WC3234 Chao 3097
Rwanda Rwanda 10/89-3/91
2,560 3,649
Coll WC3281
Spain
763
Conway WC3268 Couturier WC3246
USA Paris
47,874 11,593
Davo WC3282 Duarte WC3257 Horn WC3262
Benin Brazil 1987-90 Uganda
3,755 12,212 3,700
Japheth WC3095
Nairobi, Kenya
3,363
Longo WC3224
San Paul0 5-11/1990
Kinshasa, Zaire Mokwa WC3251 Michelozzi WC3254 Italy 4/89-12/90
Ndinya WC3264 Samdal WC3279
Nairobi (1986-90) Norway 1987-91
Samundi WC3236
Madras
Zanchetta WC3242
Milan
(WC3238) found no overall excess infection complications during pregnancy. Berrebi (WB2042) examined complications of pregnancy for 39 HIV-positive drug users, 63 HIV-negative drug users and 3,017 controls. Complications appeared to result from drug use rather than HIV.
Influence of pregnancy on disease progression Berrebi (WB2046) examined the influence of pregnancy on HIV disease in 200 women (54 who delivered, 65 who terminated and
n Tested
500 8,521 63,315
8,486 312,677 150 pa 273
Outcome 60% consent 11.3% positive ‘invited’ to participate 8% positive (1990) No refusal reported women in labour 12 HIV-positive--1.6% 4.1 per 1,OOO 2.5 times high for termination Anonymous 90 HIV-positive Increase over time 6 to 39 28% HIV-positive 173 positive (5.1%) 95% consented 6 HIV-positive (1.2%) Written consent 0.35% positive 97% tested HIV higher in refusers than consenters Women in labour 98.1% consent 0.007% positive 2 HIV-positive ( 1.3%) in 1990 0.36% rate
81 controls who were not pregnant). No influences on any measures taken were noted as a result of either pregnancy or termination for asymptomatic women. The effects of symptomatic women now need examination. Mazzorello (WC3235) reported that disease progression was similar in pregnant and nonpregnant women. Trends indicated a need for longer term follow up with larger samples. Nzila (MC3149) examined the effects of pregnancy and STDs on disease progression and found that both may contribute to accelerated progression of disease but there was no observed trend for more rapid deterioration.
WOMEN AND CHILDREN
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Treatment Early studies are now monitoring the effects of treatment on pregnancy, pregnancy outcome and the foetus. These results are urgently needed. AZT has been monitored (Ferrazin, MC3023; Irion, WB2001). These workers report normal outcome but caution must be exerted as the numbers are small ( n = 1 in the latter study). Carcassi (WC3228) reported on 9 infants born to mothers with AIDS who continued AZT treatment. Again the limited case numbers create a difficulty, but the data suggests no evidence of teratogenic effects and low incidence of vertical transmission ( 11% vertical transmission compared to 30% in a control group). Risk factors Risk factors for women, especially those of childbearing age, may help to target intervention and prevention programmes. Couturier (WC3246) studied the mothers of 327 paediatric cases of AIDS of whom 250 (76.4%) were infected perinatally. Mothers were infected via heterosexual contact for 54.8% of the sample and IV drug use for 38.4%. Duarte (WC3257) showed that 54.5% mentioned a risk factor whereas 45.6% denied such information. Risk factors which were mentioned included IV drug use, STD, sexual promiscuity and blood transfusions (n = 90).
Vertical transmission The rate of vertical transmission may be an important factor in pregnancy decision making and will also help predicting future paediatric epidemiology and service need. Datta (MC3) studied vertical transmission in Africa and reported a rate of 48.4%. Kreiss (MC3062) examined the timing of vertical transmission and noted correlates with maternal viral count, When this was >10 transmission was increased. De Martino (MC3045) examined 58 sibships. The study involved 92 mothers
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with more than one pregnancy and a total of 185 children (99 male, 86 female). Forty-five point seven percent of second children were infected. One out of 24 (4.1%) were infected if a sibling was not infected and second and third child were not at increased risk. St Louis (MC3027) examined maternal factors associated with HIV transmission. From September 1989 to April 1990 324 HIV-positive mothers (with 331 children) and 254 HIV-negative mothers (with 260 children) were studied. Outcome data showed 26% were infected vertically. Low maternal T 4 lymphocytes was the strongest predictor of transmission. Varying rates of vertical transmission are recorded in Table 2 below: The list is not comprehensive, but shows that with extended follow up and prospective studies the rates seem to be lower than initially reported in the literature.
Predictors of vertical transmission A number of studies examined vertical transmission in the light of maternal health. Monforte (C49) studied possible predictors of vertical transmission in 76 mother child pairs retrospectively. Maternal age and behaviour were not associated but a strong association was found between maternal advanced disease, maternal HIV p 24 antigenemia and HIV vertical transmission. Ninetytwo percent of antigenemic and or symptomatic women transmitted HIV infection to their children whereas 8% of mothers without such markers did so. Rudin (WC3247) followed 51 HIVpositive pregnant women of whom 21 terminated. Four women showed an HIV seroconversion during pregnancy and two of their infants showed severe symptoms before 3 months of age. Gabiano (WC3241) studied 342 children and identified a 19% vertical transmission rate at 18 months follow up. Symptomatic women infected their children more frequently. Muggiasca (WB2000) examined the effects of maternal stage of infection and vertical transmission for 48
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FLORENCE SUMMARIES: L. SHERR
Table 2. Studies reporting vertical mansmission
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% vertical
Study
Centre
Ankarh MD4246 Alvarez WB2007 Ladeda MC3075 Carcassi WC3228 Gabiano WC3241 Samdal WC3279 Formny WC3280 Bongain WC3285 Kovacs WB2038
Uganda Madrid Buenos Aires Italy Italy Norway Spain France USA (LA)
n 103 30 16 9 (AZT) 342 312,677 175 126 74
women. Babies born to symptomatic mothers presented with greater immunological manifestations of disease. Feeding. Breast and bottle feeding are still issues under debate. Vonesch (MC3024) examined colostrum and detected viral antibody. Van de Perre (WC33) examined 219 mother infant pairs in Kigali, Rwanda, where mothers were HIV negative at delivery and 16 seroconversions were observed in the following 16.6 months. Nine infants also seroconverted. One was excluded as PCR was positive in the infant at birth. Early post partum seroconversion in the mother was associated with a higher risk of mother to infant transmission. These writers postulate that colostrum or breast milk could be the route involved. Hu (WC3071) examined HIV transmission risk and breast feeding advice and urged that distinctions were made between general population data and individual recommendations. Terminations Soeiro (WC3250) examined frequency of HIV-1 infection of human foetuses in abortus tissues obtained from 25 HIV-positive pregnant women. Twenty-eight percent were found and some as early as 13 weeks. Pivnick (WC3227) examined continuity of mother child co-residence on reproductive decision making. Of 50 women, 17 became
transmission
Follow-up (months)
15.5 23.0 37.0 11.0 19.0 30.0 19.0 25-30 26-27
18 20 12 12 18 18
pregnant with the knowledge of HIV serostatus-8 continued, 9 terminated. Unnecessary separations may influence decisions to terminate. Michelozzi (WC3254) examined HIV prevalence for those delivering, voluntary abortions and spontaneous abortions.
Children Rates of neonatal HIV vary in Europe from 5.1 cases per hundred thousand in Spain to 4 in Switzerland, 2.2 in Italy and lower in Germany UK and Holland. In the USSR Pokrovsky (WC3056) reported that of the 637 people HIV-positive, 257 children and 1 adult have been associated with nosocomial infection and a further 17 mothers have been implicated via breast feeding. Outcome Oxtoby (WC36) examined USA cases of 2,324 children for age of AIDS diagnosis. She cautions that recent birth years may be biased towards young children and data from 82-86 may be more informative. The risk of developing AIDS in the first year of life was reported as >20% and >10% per year for the subsequent 3 years. The role of antiviral therapy in reducing or prolonging AIDS diagnosis is yet to be examined. Datta followed 388 children of HIVpositive mothers. This study compared children who subsequently seroconverted and seroreverted within the group, to a sample of 360 children of HIV negative women.
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WOMEN AND CHILDREN 429
Birth weight of the infected children was lower. Maturity was similar and there were no differences in ICU admission or jaundice, nor excess congenital malformations. Failure to thrive was greater for the exposed children-positive and negative. A quarter of the infected children died before 5 years compared to 12% of the exposed negatives and 5% of the healthy controls. Rates of pneumonia were high in all three groups with greater levels in the HIV infected and exposed compared to the controls. Six cases of tuberculosis were recorded, but none in the control group. Two of the children were uninfected exposed children which highlights the problem of uninfected children who are exposed to infectious agents if their parents have AIDS. The rate of Measles was greater in the HIV-positive group than control. For those who were HIV infected there was a recorded 25% probability of mortality compared to 12% in the HIV exposed but uninfected children and 5% in the controls. Seventy-five percent of the infected children survived for 5 years. Guay (MC96) studied HIV in Ugandan mothers which was associated with increased mortality in infants in the first 18 months of life with severe failure to thrive the most frequent sign. In Africa, no intravenous drug use was involved in vertical transmission. In a study from December 1988 to September 1990 1,257 pregnant women in Kampala were evaluated by workers blind to serostatus. The study was based on 490 HIVpositive women, 189 HIV-negative. At 18 months 119 were available for follow up. In the HIV-positive group 82 (19.2%) deaths had occurred compared to 13 (8%) in the HIV-negative group. Stillbirth rate was also higher in the HIV-positive group (3.9% compared to 1.6%). Mortality at 18 months for the HIV-positive group was high (24%) with 53% exhibiting signs of illness and 37% diagnosed with AIDS. Buravtsova (WA1348) examined age and HIV exposure in 203 children infected with HIV during nosocomial outbreaks. Mortality was correlated with age (children
under 1 year showing a 29% mortality with a 0% mortality above 5 years). Giaquinto (WC37) examined natural history of paediatric HIV ( n = 132). Vertical transmission after 18 months was 15.5%; 30% of the infected children presented with AIDS in the first 6 months and most died. Progression to AIDS slowed substantially during the next two years. In the first year of life a low CD4 count was not correlated with AIDS development as in adults. Kamenga (WC3244) examined effects of HIV and STDs on low birth weight which was nearly doubled among children of HIVpositive women (21% vs 11%) with a trend towards lower birth rate for lower T 4 levels. This finding was confirmed by Bulterys (WC3234). Tovo (WC3240) compared outcome for those infected perinatally ( n = 414) with those infected via blood product administration ( n = 89). Clinical outcome and survival was markedly better in transfused patients. Hague (WC3237) showed a greater risk of transmission to a child born within the year of a mother’s seroconversion than in subsequent 5 years. Transmission was also associated with advanced disease in the mother. Natural history of infection seems to vary in different areas. For example Grosch Worner (WB2066) reported on 121 children in Germany. Transmission rate was 32% and symptomatic HIV was observed in 11%. Neonatal morbidity was low (5%). Natural history in Argentina (Capdeville, WB2056) revealed that deaths occur earlier than in developed countries by following 1 15 children. In Rwanda Lepage (WC46) examined natural history and vertical transmission in 218 children studied prospectively. Mortality of children born to HIV-positive mothers was increased, particularly at the ages of 6-1 5 months. Vertical transmission was estimated at 30%. Neurodevelopment There is a growing body of literature on
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430 FLORENCE SUMMARIES:L.
SHERR
problematic neurodevelopmental sequelae for children with AIDS (Durako, 2137). Mellins (WB2020) examined cognitive functioning for a group of 31 children infected with HIV. Deficits in skills were noted. An excellent prospective study by Hittleman (TUB37) examined delays to language and motor development. The group were compared with HIV-negative controls drawn from the clinics which would control for low socioeconomic status from long term data commencing at 44 weeks post conception by assessors blind to serostatus. Children completed a battery of tests including the Einstein, Bayley, Fagin Social responsiveness. The sample comprised 18 HIVpositive, 51 born to HIV-positive mothers who seroreverted and 73 HIV-negative controls. At 24 months of age there were high levels of disabilities in the HIV-positive children. Unlike the Datta study, seroreverters did not differ from the control children. High motor disabilities were present at every assessment point. For children greater than 2 years, disabilities were noted in 47% affected compared to 2% of seroreverters and 3% controls. Cognitive disabilities were only noticeable at 15 months of age. Time to first language emergence did not differentiate groups. Motor delays emerged earlier than the cognitive delays. Other studies were somewhat different. Condini (WB2393) compared neurological development in 15 infected children and 45 non infected children born to HIV-positive mothers. Some differences occurred, but HIV did not affect cognitive development when clinical symptoms of AIDS were not present. Diamond (WB2065) examined 83 children born to HIV-positive mothers in foster care (27 positive, 30 negative and 26 indeterminate). Children with HIV showed many signs of neurological impairment. Large numbers of negative children displayed major neurological findings. Catch up was displayed by children in care from both groups. Drug use was also of consideration.
Treatment implications Studies reported data on the effects of various compounds on infant and child progress, as well as some of the difficulties in treatment. Rivera (WB2005) studied 67 children taking zidovudine. Thirty-one percent identified problems in administration of the medication. Problems for compliance were associated with bitter after-taste of the drug and the rigid schedule of administration. Where counts were possible (57%) 21% had ommitted more than a third of prescribed amount. Wolters (WB2051) examined the effect of DDI treatment on cognitive functioning of HIV-positive children. Although there were no significant differences after 12 months, the authors conclude that DDI maintains cognitive functioning. Neplas (WC3178) assessed 24 infants and found few differences as a result of HIV but confounding effects of drug use.
Family needs The family needs in the presence of HIV infection are highly complex (Novello, WC3255). Magherini (WB2383) examined 20 families attending clinic and found high levels of psychological problems due to HIV related health conditions. Problems manifested by the children were often due to family problems. Of note was the fact that health care personnel either exhibited deep emotional involvement and/or psychological refusal to cope with stress in caring for children with this disease. Valentina (WD61) examined the impact of AIDS on families and the economic and health care costs of maintaining family integrity.
Twins A few studies of twins were reported at the conference. An international cohort is under way. Martino (3046) presented data from the Italian cohort of twins ( n = 2 3 twin pairs-23 female and 23 male). Twenty of
WOMEN AND CHILDREN
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Table 3. Italian cohm of twins Subjects
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n Both positive Both negative 1 infected
Mono
Di
5
8 1 6 1
1 4 0
the twenty-three mothers had no symptoms at delivery. For the children four were indeterminate and nine out of 37 were infected. For 1/10 both twins were infected (see Table 3).
Orphans The final section highlights one of the major growing problems to face societies globally -that of AIDS orphans. These can result either directly or indirectly from HIV and present a long term challenge. Not only do we need to examine the effects of AIDS on the 5.5 million orphans expected, but also to a new class of ‘orphans’ comprised of the elderly parents who were formally cared for by able bodied children. Another hidden problem is the ramifications on children who were cared for by their parents, but who are now being cared for by other children, the elderly or, at worst, no-one. A comprehensive study (Kamenga, TUD59) examined over 400 children who became orphaned with a control group. Most children had been cared for by extended families. However, this may present an overstretching of resources. Kamenga listed the needs such families faced such as 78% households need clothing and 70% need food. They found that 70% of households tried to get the child to school. No housing was a problem for 59%. A further problem arose when children (unable to undertake adult labour) inherited land. Not only did this result in abandoned land, but reduced income from this resource to all remaining family members. Although the short term needs of the children may receive some focus the long term needs are also acute.
Uncertain Total
5 2 3 0
18 4
13 1
Another group of orphans received some attention at the conference. Ferrara (MC3322) reported in depth on HIV in Romanian children. By May 1991 there were 1,345 paediatric HIV infections accounted for by parenteral factors (58.6%), transfusion (35.6%), Haemophilia (0.4%) and mother to child (5.4%). Not only do paediatrics constitute 93.7% of Rumanian cases but also equal half of the European cases. On examination 99.1% were less than 4 years old and 71.9% were in public institutions. Most infections occurred via medical settings. Hersh (THD109) examined route of infection in these children in depth. By June 1991 1,436 children were identified with 92% under 4 years and 67% abandoned. For 697 of the children the mother was located and tested. These workers examined 12,189 abandoned children and found 11% were HIV-positive (n = 101) as well as a high rate of Hepatitis B positivity. All mothers located were negative. Two children had undergone blood transfusions, but donors who were located were negative. Children received a high number of percutaneous injections (mean 206 range 5-580). HIV-positive children had higher rates of injections and days spent in hospital. Conclusions After ten years of knowledge on HIV it seems that the pendulum has now turned in the direction of women and children. This marks a welcome beginning. There are many specific issues related to these groups which need to be understood. Women need to be studied in their own right and not simply as ‘vectors of spread to (innocent?) children’.
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Pre and post test counselling must be taken seriously in this group. The medical profession is the highest risk factor for paediatric HIV in Europe as the majority of cases have
resulted from nosocomial infection. The ramifications of HIV on cognitive development is of concern.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Women and children L. Sherr
a
a
St Mary's Hospital, Praed St , London, W2 1NY, UK Published online: 25 Sep 2007.
To cite this article: L. Sherr (1991) Women and children, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 3:4, 423-432, DOI: 10.1080/09540129108251603 To link to this article: http://dx.doi.org/10.1080/09540129108251603
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
AIDS CARE, VOL. 3, NO. 4,1991
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Women and children L. SHERR Downloaded by [The University of Manchester Library] at 15:44 23 November 2014
St Mary’s Hospital, Praed St,London W2 INY, UK
For the first time in the series of interna- However, the fact that oral presentations tional Conferences there was an obvious essentially only started after three in the presence of research highlighting the impact afternoon, with eight simultaneous sessions, of HIV on women and children. The number often meant gross overlap. Running from of papers on children far outweighed those session to session was not possible given the on women, yet the women issues were ac- sprawling conference site and many excelknowledged and not simply subsumed under lent discussions were simply held in the the heading of family or pregnancy. Al- endless lines outside the Uffizzi gallery. though this marks a welcome development, it was clear from both the quality of the papers and the organization of the sessions Women that this was only a start and there is a long There were particular themes of note on way to go. women. These related to their role in the There were two specific sections deevolving pandemic generally, and to manivoted to women and children. However festations of the illness particularly. HIV these lunchtime sessions were rather frusinfection is not only prevalent in women, trating. They were neither academic nor a but in certain areas it equals the prevalence forum for the voice of affected groups. Inof men. Chin reported that 1/40 men and deed it felt that the token gesture of plan1/40 women in Sub Saharan Africa were ning the sessions was an attempt to acknowinfected. Furthermore, women are uniquely ledge the issues with little more progress. involved in vertical transmission of HIV. The papers were mixed, the discussions ofSmith (MC3171) noted that 95 women in ten marked audience frustration and the lack Scandinavia have AIDS (40 Denmark, 39 of simultaneous translation for these sessions Sweden, 16 Norway). Prognosis for women muffled the voices that often needed to be was poorer than for men. The number heard. The bulk of the progress was reported infected in the USA was reported as in papers which were somehow haphazardly 17,000-with most since 1989 and heterodotted through the poster sessions and varisexual contact the major source of infection. ous talks. The psychosocial aspects were not clearly delineated and were often appended to medical sections. This review will attempt Behaviour to identify some of the works of major interest to emerge from the conference and focus HIV affected the behaviour of women on a on the psychological rather than the medical. variety of indices. Lai (MC3005) found
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FLORENCE SUMMARIES: L. SHERR
changes in sexual and contraceptive practices to protect partners and unborn children in their study of 42 women (78% IVDU; 23 Asymptomatic and with 19 AIDWARC). Only 67% received post-test counselling. Fifty -four percent would avoid pregnancy, 82% used condoms and 19% would continue pregnancy. Eversley (MD4045) examined 267 female family planning attenders and found no relation between perception of risk and condom use or risk reduction. Batter (MD4013) studied 4,656 women screened for HIV. Two hundred and forty-one were HIV-positive and 186 were followed up. Ninety percent accepted counselling. There was no effect on decisions to have subsequent children. Although at the time of counselling 50% intended to tell their partner, one year later only 5% had informed. Similarly although 88% intended to use condoms at one year follow up only 20% had used them. Japheth (WC3095) found 173 HIV-positive women out of 3,363 tested at family planning clinics. High parity and previous abortions were associated with HIVpositive but no significant associates were observed between use of contraceptive methods and HIV. Armstrong (MD4241) examined drug users ( n = 599 non pregnant) and found 96% to have at least one risk factor for HIV. Women who had been sterilized (27%) were more likely to be sexually active and less likely to use condoms. Cervical abnormalities A group of studies examined findings of cervical abnormalities in women with HIV. La Guardia (MC97) recorded 48% abnormal pap smears in a sample of 44 women with HIV. Cervical dysplasia according to T cell count revealed higher abnormality rates (61%) where counts were (200 and 38% where counts were between 200-900. Thus the severity of cervical dysplasia was associated with immune competency. This was confirmed by Warne (MC3113) who found menstrual abnormalities and bleeding be-
tween periods in a group of Intravenous drug users (IDUs) who were HIV-positive ( n = 76) compared to negatives (n = 37). Chipangwi (MC98) found that HIV and Human Papiloma Virus (HPV) correlated with abnormal cytology which increased with level of immunosuppression. Williams (MC3116) studied 90 women (55 HIVpositive and 35 HIV-negative) who were injection drug users in San Francisco. They found all five subjects with cervical smears evaluated as CIN were HIV-positive as were three out of 4 subjects with anal intraepithelial neoplasia. This growing body of literature may signify the need to examine AIDS defining illnesses. If immunosuppression is contributing to an increased mortality in woman by way of cervical disease, its non-inclusion may lead to underestimates in epidemiology in women, which will underestimate future progression and directly effect the provision of funding and resources to this group.
Psychosocial impact of HIV on women The psychosocial impact of HIV on women was profound in numerous studies. Lecrount (MD4258) studied the families of 37 children in the Netherlands and recorded frequent socio economic distress with less than one third reporting a professional income. Forty-five percent were on public assistance. Gender differences were recorded by Carey (MD4230) who compared 401 males and 41 females. Females were more likely to be married, less likely to be employed outside the home, less likely to have post high school education. Men suppressed negative emotion (anger anxiety and unhappiness) more than women. Women were diagnosed more frequently with Major Depression and men more frequently with Alcohol use disorders. Limitation of this study data as it reports ‘nearly significant’ findings and it is unclear what this means. Richie (MD4249) carried out focus groups for 92 women in USA jails. Anonymous serosurvey
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WOMEN AND CHILDREN
in 1990 found 25.8% female inmates HIV infected. Intervention programmes increased knowledge and adjusted intended behaviour. Golden (WC309 1) examined gender influences in drug users and found that among women barter drugs were associated with continuing high risk sex and conclude that economic and sex risks must be addressed in intervention. Brown (MB2028) evaluated 37 women with HIV and found persistent impairment in sexual functioning. Major mood disorders, suicidality or psychiatric hospitalisation were uncommon. Hausermann (TUD115) examined women in the UK Uganda and Zambia and highlighted the lack of rights and concomitant vulnerability of women.
Pregnancy Kurth (MD4235) examined pregnancy decision making in l l women and they urged that screening programmes take into account and understand the complexity of such decisions.
HIV in pregnancy The epidemiology of HIV and pregnancy was studied in numerous centres together with the implications. Gillet (WC3284) studied 307 pregnancies in 264 HIV-positive women over 7 years in France which resulted in 129 deliveries, 170 abortions, 5 miscarriages and 3 ectopic pregnancies. Characteristics of a cohort of pregnant women (WC3256 WITS Study group) were examined in 127 HIV infected pregnant women. Less than 10% had AIDS and over half had low CD4 counts. Couturier (WC3246) reported on outcome of screening on 11,593 samples which revealed a prevalence of 4.1 per 1,000 in Paris. This was 2.5 times higher in women who terminated than those who delivered.
HI V testing HIV testing of pregnant women continues apace. A few studies are now mentioning
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counselling, yet refusal rates are often low, non existant or not reported. Other studies fail to report counselling. Some gather samples from women in labour without any detailed discussion on the content or logistics of counselling during contractions, which would make interesting reading. A worrying trend among studies emerges when workers report HIV rates among those who refuse to be tested. Ethically it is unclear how testing in the absence of permission can be justified (e.g. Michelozzi, WC3254). Some of the many screening studies are summarised below in Table 1. In the light of these studies, two papers were of note. Meadows (MC3330) surveyed 300 women in early pregnancy and followed up 50 at 28 weeks gestation. Thirty-six percent reported that they had been tested for HIV although 28% reported that they had received no counselling at all. Of those who were found to be in risk groups, none were either counselled or tested. Wieser (MC3333) questioned whether voluntary HIV testing was really voluntary in a Swiss setting. Consecutive women attenders (n = 112) were interviewed; 73.2% were tested before they attended the hospital clinic; 20.5% were tested on arrival. All 105 were HIV-negative (5.4% refixed testing). Of those tested, 58% had been informed and only 72% were told their negative result. Forty-one point nine percent were not informed and five would have refused if asked. It seems that lip service is being paid to counselling (both pre- and post-test) for pregnant women.
Influence of HIV on pregnancy Continued monitoring of HIV in pregnancy is important and seems not to render complications. Johnstone (WC3239) compared 149 HIV-positive pregnancies with controls. Induced and spontaneous abortions were common but not more so than controls. HIV was not associated with labour/delivery problems or perinatal mortality but was with drug use and low birth weight. MacCallum
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Table 1. Screening for HIV in pregnant women Author
Centre
Ankrah MD4246
Uganda 9189-10/90
1,511
Boulos MC3015
Haiti 7/86-8/88 8/89-6190
4,474 1,720
Bulterys WC3234 Chao 3097
Rwanda Rwanda 10/89-3/91
2,560 3,649
Coll WC3281
Spain
763
Conway WC3268 Couturier WC3246
USA Paris
47,874 11,593
Davo WC3282 Duarte WC3257 Horn WC3262
Benin Brazil 1987-90 Uganda
3,755 12,212 3,700
Japheth WC3095
Nairobi, Kenya
3,363
Longo WC3224
San Paul0 5-11/1990
Kinshasa, Zaire Mokwa WC3251 Michelozzi WC3254 Italy 4/89-12/90
Ndinya WC3264 Samdal WC3279
Nairobi (1986-90) Norway 1987-91
Samundi WC3236
Madras
Zanchetta WC3242
Milan
(WC3238) found no overall excess infection complications during pregnancy. Berrebi (WB2042) examined complications of pregnancy for 39 HIV-positive drug users, 63 HIV-negative drug users and 3,017 controls. Complications appeared to result from drug use rather than HIV.
Influence of pregnancy on disease progression Berrebi (WB2046) examined the influence of pregnancy on HIV disease in 200 women (54 who delivered, 65 who terminated and
n Tested
500 8,521 63,315
8,486 312,677 150 pa 273
Outcome 60% consent 11.3% positive ‘invited’ to participate 8% positive (1990) No refusal reported women in labour 12 HIV-positive--1.6% 4.1 per 1,OOO 2.5 times high for termination Anonymous 90 HIV-positive Increase over time 6 to 39 28% HIV-positive 173 positive (5.1%) 95% consented 6 HIV-positive (1.2%) Written consent 0.35% positive 97% tested HIV higher in refusers than consenters Women in labour 98.1% consent 0.007% positive 2 HIV-positive ( 1.3%) in 1990 0.36% rate
81 controls who were not pregnant). No influences on any measures taken were noted as a result of either pregnancy or termination for asymptomatic women. The effects of symptomatic women now need examination. Mazzorello (WC3235) reported that disease progression was similar in pregnant and nonpregnant women. Trends indicated a need for longer term follow up with larger samples. Nzila (MC3149) examined the effects of pregnancy and STDs on disease progression and found that both may contribute to accelerated progression of disease but there was no observed trend for more rapid deterioration.
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Treatment Early studies are now monitoring the effects of treatment on pregnancy, pregnancy outcome and the foetus. These results are urgently needed. AZT has been monitored (Ferrazin, MC3023; Irion, WB2001). These workers report normal outcome but caution must be exerted as the numbers are small ( n = 1 in the latter study). Carcassi (WC3228) reported on 9 infants born to mothers with AIDS who continued AZT treatment. Again the limited case numbers create a difficulty, but the data suggests no evidence of teratogenic effects and low incidence of vertical transmission ( 11% vertical transmission compared to 30% in a control group). Risk factors Risk factors for women, especially those of childbearing age, may help to target intervention and prevention programmes. Couturier (WC3246) studied the mothers of 327 paediatric cases of AIDS of whom 250 (76.4%) were infected perinatally. Mothers were infected via heterosexual contact for 54.8% of the sample and IV drug use for 38.4%. Duarte (WC3257) showed that 54.5% mentioned a risk factor whereas 45.6% denied such information. Risk factors which were mentioned included IV drug use, STD, sexual promiscuity and blood transfusions (n = 90).
Vertical transmission The rate of vertical transmission may be an important factor in pregnancy decision making and will also help predicting future paediatric epidemiology and service need. Datta (MC3) studied vertical transmission in Africa and reported a rate of 48.4%. Kreiss (MC3062) examined the timing of vertical transmission and noted correlates with maternal viral count, When this was >10 transmission was increased. De Martino (MC3045) examined 58 sibships. The study involved 92 mothers
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with more than one pregnancy and a total of 185 children (99 male, 86 female). Forty-five point seven percent of second children were infected. One out of 24 (4.1%) were infected if a sibling was not infected and second and third child were not at increased risk. St Louis (MC3027) examined maternal factors associated with HIV transmission. From September 1989 to April 1990 324 HIV-positive mothers (with 331 children) and 254 HIV-negative mothers (with 260 children) were studied. Outcome data showed 26% were infected vertically. Low maternal T 4 lymphocytes was the strongest predictor of transmission. Varying rates of vertical transmission are recorded in Table 2 below: The list is not comprehensive, but shows that with extended follow up and prospective studies the rates seem to be lower than initially reported in the literature.
Predictors of vertical transmission A number of studies examined vertical transmission in the light of maternal health. Monforte (C49) studied possible predictors of vertical transmission in 76 mother child pairs retrospectively. Maternal age and behaviour were not associated but a strong association was found between maternal advanced disease, maternal HIV p 24 antigenemia and HIV vertical transmission. Ninetytwo percent of antigenemic and or symptomatic women transmitted HIV infection to their children whereas 8% of mothers without such markers did so. Rudin (WC3247) followed 51 HIVpositive pregnant women of whom 21 terminated. Four women showed an HIV seroconversion during pregnancy and two of their infants showed severe symptoms before 3 months of age. Gabiano (WC3241) studied 342 children and identified a 19% vertical transmission rate at 18 months follow up. Symptomatic women infected their children more frequently. Muggiasca (WB2000) examined the effects of maternal stage of infection and vertical transmission for 48
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FLORENCE SUMMARIES: L. SHERR
Table 2. Studies reporting vertical mansmission
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% vertical
Study
Centre
Ankarh MD4246 Alvarez WB2007 Ladeda MC3075 Carcassi WC3228 Gabiano WC3241 Samdal WC3279 Formny WC3280 Bongain WC3285 Kovacs WB2038
Uganda Madrid Buenos Aires Italy Italy Norway Spain France USA (LA)
n 103 30 16 9 (AZT) 342 312,677 175 126 74
women. Babies born to symptomatic mothers presented with greater immunological manifestations of disease. Feeding. Breast and bottle feeding are still issues under debate. Vonesch (MC3024) examined colostrum and detected viral antibody. Van de Perre (WC33) examined 219 mother infant pairs in Kigali, Rwanda, where mothers were HIV negative at delivery and 16 seroconversions were observed in the following 16.6 months. Nine infants also seroconverted. One was excluded as PCR was positive in the infant at birth. Early post partum seroconversion in the mother was associated with a higher risk of mother to infant transmission. These writers postulate that colostrum or breast milk could be the route involved. Hu (WC3071) examined HIV transmission risk and breast feeding advice and urged that distinctions were made between general population data and individual recommendations. Terminations Soeiro (WC3250) examined frequency of HIV-1 infection of human foetuses in abortus tissues obtained from 25 HIV-positive pregnant women. Twenty-eight percent were found and some as early as 13 weeks. Pivnick (WC3227) examined continuity of mother child co-residence on reproductive decision making. Of 50 women, 17 became
transmission
Follow-up (months)
15.5 23.0 37.0 11.0 19.0 30.0 19.0 25-30 26-27
18 20 12 12 18 18
pregnant with the knowledge of HIV serostatus-8 continued, 9 terminated. Unnecessary separations may influence decisions to terminate. Michelozzi (WC3254) examined HIV prevalence for those delivering, voluntary abortions and spontaneous abortions.
Children Rates of neonatal HIV vary in Europe from 5.1 cases per hundred thousand in Spain to 4 in Switzerland, 2.2 in Italy and lower in Germany UK and Holland. In the USSR Pokrovsky (WC3056) reported that of the 637 people HIV-positive, 257 children and 1 adult have been associated with nosocomial infection and a further 17 mothers have been implicated via breast feeding. Outcome Oxtoby (WC36) examined USA cases of 2,324 children for age of AIDS diagnosis. She cautions that recent birth years may be biased towards young children and data from 82-86 may be more informative. The risk of developing AIDS in the first year of life was reported as >20% and >10% per year for the subsequent 3 years. The role of antiviral therapy in reducing or prolonging AIDS diagnosis is yet to be examined. Datta followed 388 children of HIVpositive mothers. This study compared children who subsequently seroconverted and seroreverted within the group, to a sample of 360 children of HIV negative women.
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Birth weight of the infected children was lower. Maturity was similar and there were no differences in ICU admission or jaundice, nor excess congenital malformations. Failure to thrive was greater for the exposed children-positive and negative. A quarter of the infected children died before 5 years compared to 12% of the exposed negatives and 5% of the healthy controls. Rates of pneumonia were high in all three groups with greater levels in the HIV infected and exposed compared to the controls. Six cases of tuberculosis were recorded, but none in the control group. Two of the children were uninfected exposed children which highlights the problem of uninfected children who are exposed to infectious agents if their parents have AIDS. The rate of Measles was greater in the HIV-positive group than control. For those who were HIV infected there was a recorded 25% probability of mortality compared to 12% in the HIV exposed but uninfected children and 5% in the controls. Seventy-five percent of the infected children survived for 5 years. Guay (MC96) studied HIV in Ugandan mothers which was associated with increased mortality in infants in the first 18 months of life with severe failure to thrive the most frequent sign. In Africa, no intravenous drug use was involved in vertical transmission. In a study from December 1988 to September 1990 1,257 pregnant women in Kampala were evaluated by workers blind to serostatus. The study was based on 490 HIVpositive women, 189 HIV-negative. At 18 months 119 were available for follow up. In the HIV-positive group 82 (19.2%) deaths had occurred compared to 13 (8%) in the HIV-negative group. Stillbirth rate was also higher in the HIV-positive group (3.9% compared to 1.6%). Mortality at 18 months for the HIV-positive group was high (24%) with 53% exhibiting signs of illness and 37% diagnosed with AIDS. Buravtsova (WA1348) examined age and HIV exposure in 203 children infected with HIV during nosocomial outbreaks. Mortality was correlated with age (children
under 1 year showing a 29% mortality with a 0% mortality above 5 years). Giaquinto (WC37) examined natural history of paediatric HIV ( n = 132). Vertical transmission after 18 months was 15.5%; 30% of the infected children presented with AIDS in the first 6 months and most died. Progression to AIDS slowed substantially during the next two years. In the first year of life a low CD4 count was not correlated with AIDS development as in adults. Kamenga (WC3244) examined effects of HIV and STDs on low birth weight which was nearly doubled among children of HIVpositive women (21% vs 11%) with a trend towards lower birth rate for lower T 4 levels. This finding was confirmed by Bulterys (WC3234). Tovo (WC3240) compared outcome for those infected perinatally ( n = 414) with those infected via blood product administration ( n = 89). Clinical outcome and survival was markedly better in transfused patients. Hague (WC3237) showed a greater risk of transmission to a child born within the year of a mother’s seroconversion than in subsequent 5 years. Transmission was also associated with advanced disease in the mother. Natural history of infection seems to vary in different areas. For example Grosch Worner (WB2066) reported on 121 children in Germany. Transmission rate was 32% and symptomatic HIV was observed in 11%. Neonatal morbidity was low (5%). Natural history in Argentina (Capdeville, WB2056) revealed that deaths occur earlier than in developed countries by following 1 15 children. In Rwanda Lepage (WC46) examined natural history and vertical transmission in 218 children studied prospectively. Mortality of children born to HIV-positive mothers was increased, particularly at the ages of 6-1 5 months. Vertical transmission was estimated at 30%. Neurodevelopment There is a growing body of literature on
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430 FLORENCE SUMMARIES:L.
SHERR
problematic neurodevelopmental sequelae for children with AIDS (Durako, 2137). Mellins (WB2020) examined cognitive functioning for a group of 31 children infected with HIV. Deficits in skills were noted. An excellent prospective study by Hittleman (TUB37) examined delays to language and motor development. The group were compared with HIV-negative controls drawn from the clinics which would control for low socioeconomic status from long term data commencing at 44 weeks post conception by assessors blind to serostatus. Children completed a battery of tests including the Einstein, Bayley, Fagin Social responsiveness. The sample comprised 18 HIVpositive, 51 born to HIV-positive mothers who seroreverted and 73 HIV-negative controls. At 24 months of age there were high levels of disabilities in the HIV-positive children. Unlike the Datta study, seroreverters did not differ from the control children. High motor disabilities were present at every assessment point. For children greater than 2 years, disabilities were noted in 47% affected compared to 2% of seroreverters and 3% controls. Cognitive disabilities were only noticeable at 15 months of age. Time to first language emergence did not differentiate groups. Motor delays emerged earlier than the cognitive delays. Other studies were somewhat different. Condini (WB2393) compared neurological development in 15 infected children and 45 non infected children born to HIV-positive mothers. Some differences occurred, but HIV did not affect cognitive development when clinical symptoms of AIDS were not present. Diamond (WB2065) examined 83 children born to HIV-positive mothers in foster care (27 positive, 30 negative and 26 indeterminate). Children with HIV showed many signs of neurological impairment. Large numbers of negative children displayed major neurological findings. Catch up was displayed by children in care from both groups. Drug use was also of consideration.
Treatment implications Studies reported data on the effects of various compounds on infant and child progress, as well as some of the difficulties in treatment. Rivera (WB2005) studied 67 children taking zidovudine. Thirty-one percent identified problems in administration of the medication. Problems for compliance were associated with bitter after-taste of the drug and the rigid schedule of administration. Where counts were possible (57%) 21% had ommitted more than a third of prescribed amount. Wolters (WB2051) examined the effect of DDI treatment on cognitive functioning of HIV-positive children. Although there were no significant differences after 12 months, the authors conclude that DDI maintains cognitive functioning. Neplas (WC3178) assessed 24 infants and found few differences as a result of HIV but confounding effects of drug use.
Family needs The family needs in the presence of HIV infection are highly complex (Novello, WC3255). Magherini (WB2383) examined 20 families attending clinic and found high levels of psychological problems due to HIV related health conditions. Problems manifested by the children were often due to family problems. Of note was the fact that health care personnel either exhibited deep emotional involvement and/or psychological refusal to cope with stress in caring for children with this disease. Valentina (WD61) examined the impact of AIDS on families and the economic and health care costs of maintaining family integrity.
Twins A few studies of twins were reported at the conference. An international cohort is under way. Martino (3046) presented data from the Italian cohort of twins ( n = 2 3 twin pairs-23 female and 23 male). Twenty of
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Table 3. Italian cohm of twins Subjects
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n Both positive Both negative 1 infected
Mono
Di
5
8 1 6 1
1 4 0
the twenty-three mothers had no symptoms at delivery. For the children four were indeterminate and nine out of 37 were infected. For 1/10 both twins were infected (see Table 3).
Orphans The final section highlights one of the major growing problems to face societies globally -that of AIDS orphans. These can result either directly or indirectly from HIV and present a long term challenge. Not only do we need to examine the effects of AIDS on the 5.5 million orphans expected, but also to a new class of ‘orphans’ comprised of the elderly parents who were formally cared for by able bodied children. Another hidden problem is the ramifications on children who were cared for by their parents, but who are now being cared for by other children, the elderly or, at worst, no-one. A comprehensive study (Kamenga, TUD59) examined over 400 children who became orphaned with a control group. Most children had been cared for by extended families. However, this may present an overstretching of resources. Kamenga listed the needs such families faced such as 78% households need clothing and 70% need food. They found that 70% of households tried to get the child to school. No housing was a problem for 59%. A further problem arose when children (unable to undertake adult labour) inherited land. Not only did this result in abandoned land, but reduced income from this resource to all remaining family members. Although the short term needs of the children may receive some focus the long term needs are also acute.
Uncertain Total
5 2 3 0
18 4
13 1
Another group of orphans received some attention at the conference. Ferrara (MC3322) reported in depth on HIV in Romanian children. By May 1991 there were 1,345 paediatric HIV infections accounted for by parenteral factors (58.6%), transfusion (35.6%), Haemophilia (0.4%) and mother to child (5.4%). Not only do paediatrics constitute 93.7% of Rumanian cases but also equal half of the European cases. On examination 99.1% were less than 4 years old and 71.9% were in public institutions. Most infections occurred via medical settings. Hersh (THD109) examined route of infection in these children in depth. By June 1991 1,436 children were identified with 92% under 4 years and 67% abandoned. For 697 of the children the mother was located and tested. These workers examined 12,189 abandoned children and found 11% were HIV-positive (n = 101) as well as a high rate of Hepatitis B positivity. All mothers located were negative. Two children had undergone blood transfusions, but donors who were located were negative. Children received a high number of percutaneous injections (mean 206 range 5-580). HIV-positive children had higher rates of injections and days spent in hospital. Conclusions After ten years of knowledge on HIV it seems that the pendulum has now turned in the direction of women and children. This marks a welcome beginning. There are many specific issues related to these groups which need to be understood. Women need to be studied in their own right and not simply as ‘vectors of spread to (innocent?) children’.
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Pre and post test counselling must be taken seriously in this group. The medical profession is the highest risk factor for paediatric HIV in Europe as the majority of cases have
resulted from nosocomial infection. The ramifications of HIV on cognitive development is of concern.
