Achieving Perinatal HIV Elimination Goals
Significant progress has been made in the diagnosis, prevention, and treatment of HIV, with various elimination goals being set by the Centers for Disease Control and Prevention (CDC). While most facets of these initiatives require additional steps to be on pace to meet the goals, one significant goal was met in recent years: the achievement of the perinatal elimination goal in 2019, as outlined by the CDC’s 2012 Framework for Elimination of Perinatal Transmission of HIV in the United States.
The goals included as part of the perinatal transmission framework are an incidence of less than 1 case of perinatal HIV per 100,000 live births and a perinatal transmission rate of less than 1%.
For further information on this achievement and to learn more about what comes next, Consultant360 reached out to the lead study author, Margaret A. Lampe, RN, MPH, who is a nurse and epidemiologist in the Division of HIV Prevention at the CDC and leads the CDC's domestic maternal, perinatal, and infant health activities on the Treatment Research Team in the HIV Research Branch in the Division of HIV Prevention.1
To begin, could you discuss what prompted this analysis? Why now?
Margaret Lampe: We actually intended to do this analysis a year earlier. However, we wanted to undertake a data quality review with over 40 health departments to ensure that we had our numbers correct. Sometimes reporting through surveillance can leave some questions. After that data quality review, we determined that we met the elimination goals in 2019. Since we did that analysis, however, we've continued to see declines in perinatal transmissions. In the year 2021, we had reports of only 21 infants with perinatally acquired HIV infection, which suggests that those gains have been maintained.
We have cautious optimism. All the data for 2022 births have not been submitted to the CDC yet, and while we are very hopeful that those gains have been maintained, we have heard anecdotal reports of some increased transmissions in a couple of jurisdictions.
C360: As you mentioned, the last year of your study was the first year that both diagnosis and transmission rate elimination goals were achieved. How do you think that reaching these elimination goals will inform future clinical practice for preventing perinatal HIV?
ML: In terms of informing future clinical practice, we're hopeful that clinicians take heart in that their efforts are making a difference. This is a tremendous public health success, a tremendous clinical medicine success, a success really across the board with a number of disciplines.
There are new areas of focus. In January of this year, federal recommendations for infant feeding have changed. If a woman during her pregnancy has sustained HIV viral suppression and she has the desire to breastfeed, this is something that she and her clinician can work through together to support her with feeding her infant the healthiest food, which is breast milk. But it can require a tremendous amount of support and coordination to ensure that the mother has the support she needs to keep her viral load suppressed, provide the infant antiretroviral prophylaxis, and to conduct HIV testing of the infant. We know that if a mother's viral load is suppressed, the risk of transmission through breastfeeding is less than 1%, but not zero. That said, we lack adequate data in the US and other resource-rich countries, where women with HIV have been advised against breastfeeding until now. That's a data gap that we would like to fill.
Achieving these elimination goals might also inform clinical practice for other perinatal infections. Congenital syphilis in this country is also quite preventable with screening and interventions during pregnancy, but unfortunately we are seeing consistent increases in cases of congenital syphilis. We do hope to use some of these strategies for perinatal HIV to translate to preventing congenital syphilis.
C360: How can health care practitioners utilize a multidisciplinary approach for preventing and eliminating perinatal HIV?
ML: Some of the most effective programs and clinical settings involve a multidisciplinary approach. HIV continues to carry a fair bit of stigma. Women have reported that when they experience a welcoming approach in a clinical setting, even in reception for prenatal care, it can make a difference, especially when they are concerned about stigma. Of course, ensuring clinicians continue to understand the clinical aspects of perinatal HIV prevention and HIV treatment during pregnancy is very important. In the cases where transmission sometimes does occur, it is not uncommon for substance use disorder or mental health to be a challenge. Collaborating with psychiatry, substance use treatment during pregnancy and postpartum are critical collaborations. Engaging with social work and nursing to create a supportive environment for women is so helpful. Group "centering" prenatal care for women with HIV has been shown to be feasible and effective, with improvements in retention in care and viral suppression. There is an excellent model in Houston.2 The Ryan White Care program has supportive services beyond providing medications. Maintaining that network of multidisciplinary support is going to be essential, especially as women opt to breastfeed. It's going to be essential for pediatricians and lactation consultants to really understand HIV prevention and support mothers and babies through that process.
C360: What are the next steps for research in the elimination of perinatal HIV?
ML: As I mentioned earlier, we have limited understanding of the risk of HIV transmission through breastfeeding in resource rich countries like the United States and many countries in Europe. Having a coordinated data approach, a research approach to understanding women's infant feeding desires, their practices, and challenges in terms of maintaining viral suppression, maintaining adequate milk supply, and the logistics of breast feeding. We would to study transmission risk during breastfeeding as it relates to maternal viral load, maternal antiretroviral regimen, and potential pediatric regimens for prophylaxis. We also need to research the ideal HIV testing frequency of breastfeeding. For so many years, we had recommended against breastfeeding so it may take us some time to fund and collect these data to better advise women with HIV and their providers about breastfeeding.
HIV has been an area in medicine with rapid development of new, highly effective antiviral therapies. In the United States, we're very quick to adopt ones that have been shown to be effective in non-pregnant adults. But one challenge is that we have very limited safety data on newer antiretrovirals during pregnancy as it relates to pregnancy outcomes, birth defects, and maternal health. An area of research that needs to improve is monitoring of the safety of antiretrovirals. There's currently the Antiretroviral Pregnancy Registry (APR), which is funded by the pharmaceutical industry as a part of FDA requirements.3 It's a voluntary, prospective reporting registry. For an exposure during pregnancy to be counted, a provider must report it prior to the pregnancy outcome. Acquiring enough exposures during pregnancy to detect safety signals or to have reassuring data can take many years. It is important for us to improve reporting to the APR so that we can advise women about the best options for antiretroviral regimens prior to and during pregnancy.
In July of this year, my colleagues Dr Athena Kourtis and Dr Weiming Zu, myself, and others at CDC published a paper in the Lancet HIV where we utilized medical claims data to create a cohort of pregnant women to investigate a safety signal of dolutegravir and neural tube defects.4 In 2018, there was a safety signal of dolutegravir with neural tube defects in Botswana and that impacted clinical care of women with HIV around the world because we lacked the safety data. For about three years women who were of reproductive potential and not on consistent contraception were advised against taking dolutegravir. After more data was collected that signal was no longer observed and verified in our paper in July that there was no association with dolutegravir and neural tube defects. And so again, having prospective data during pregnancy could really be beneficial.
I think it's important to note that this paper was written using data from 2019, and as I mentioned, the number of perinatal HIV cases remain low through 2021. However, I think we are not yet seeing the impacts of the pandemic, the economic changes that Americans are facing, particularly Americans in poverty, how they impact pregnant women with HIV and perinatal transmission. And so we are really looking forward to seeing, at a minimum, how these factors have impacted perinatal transmission and look forward to developing our best strategies to supporting women and infants who are impacted by HIV.
1. Lampe MA, Nesheim SR, Oladapo KL, Ewing AC, Wiener J, Kourtis AP. Acheiving elimination of perinatal HIV in the United States. Pediatrics. 2023;151(5):e2022059604. doi:10.1542/peds.2022-059604
2. McKinney J, Jackson J, Sangi-Haghpeykar H, et al. HIV-adapted group prenatal care: assessing viral suppression and postpartum retention in care. AIDS Patient Care STDS. 2021;35(2):39-46. doi:10.1089/apc.2020.0249.
3. The Antiretroviral Pregnancy Registry. Updated August 2022. Accessed October 11, 2023. https://www.apregistry.com
4. Kourtis AP, Zhu W, Lampe MA, Huang YA, Hoover KW. Dolutegravir and pregnancy outcomes including neural tube defects in the USA during 2008-20: a national cohort study. Lancet HIV. 2023;10(9):e588-e596. doi:10.1016/S2352-3018(23)00108-X10.1016/S2352-3018(23)00108-X