Born Free from HIV
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LISA: Say hi. Say hi. Say hello.
SUSAN DENTZER: Even more than most mothers, this one — whom we’ll call Lisa — has a special reason to feel happy about her new baby.
LISA: Only two more…
SUSAN DENTZER: Lisa, who doesn’t want to be identified, is infected with HIV, the virus that causes AIDS. So far, tests indicate her baby girl is HIV-free.
LISA: Yes, she took two, two tests so far. She gets one more when she’s four months old, but they’ll test her until she’s 18 months or a year.
SUSAN DENTZER: Mary — that’s not her real name — is another mother witnessing a miracle. She’s also HIV positive, and she asked us to shield her true identity. Mary told us she lost an infant son to AIDS in 1989. Her first husband, a former drug user, died five years later. Now 37, Mary has earned a master’s degree and remarried.
DR. ARLENE BARDAGUEZ: Let’s try to talk a little bit about the plans for your delivery.
SUSAN DENTZER: She carefully planned a second pregnancy with her obstetrician Dr. Arlene Bardaguez. In mid-September, Mary delivered a baby girl. Two initial tests have shown that the baby is HIV-free, but like any new mother, a grateful Mary still worries.
MARY: You know, I’ll have fears, I’m sure, with her … when she coughs, or if she has thrush. I don’t know, these normal things that some, you know, that babies do get.
SUSAN DENTZER: Do you ever worry that you will die before the baby grows up?
MARY: I do. I do worry about that, probably like any parent would, that, you know, I want to see my child grow and become an adult. So it’s a concern of mine, but does it consume my life? It does not.
SUSAN DENTZER: Women like Mary and Lisa represent a surprising new face of HIV in the United States. Thanks to antiretroviral drugs, many are living long and relatively healthy lives. What’s more, a growing understanding of how HIV transmission occurs has prompted changes in the way pregnant women with HIV are treated in the U.S. As a result, the odds are overwhelming that their babies will be born HIV-free.
Dr. Mary Glenn Fowler is with the federal Centers for Disease Control and Prevention in Atlanta.
DR. MARY GLENN FOWLER: In the U.S., we can tell a mother that her risk of transmission is reduced down to about 1 to 2 percent. In most of the world, without the new interventions with antiretrovirals that we have available, transmission rates are anywhere between 25 to 40 percent.
SUSAN DENTZER: And in fact, elsewhere in the world, roughly three-quarters of a million babies are now born annually with HIV. By contrast, there’s been a huge decline in the number of HIV-infected infants born here. That’s a big change from the 1980s. Then, HIV-positive “border babies” who had been abandoned by their already sick mothers languished for months in inner-city hospitals. Now, that’s a rarity.
DR. MARY GLENN FOWLER: In the early ’90s, we had approximately 2,000 women, between 1,000 and 2,000 women, delivering infected babies each year, and we have really reduced that down to close to 280-370 being infected.
DR. ARLENE BARDAGUEZ: He will be able to stay with you.
SUSAN DENTZER: Dr. Bardaguez delivered the babies of both Mary and Lisa.
DR. JAMES OLESKE: How you doing?
SUSAN DENTZER: She and her colleague, pediatrician James Oleske, have been treating HIV-infected moms and kids for years at university hospital in Newark, N.J.
DR. JAMES OLESKE: All the indicators are that this baby is not gong to be infected, which is great.
SUSAN DENTZER: The doctors say that in the early years of the epidemic, AIDS was almost always a death sentence for mother and infant.
DR. JAMES OLESKE: Patients suffered so much in the early days with this disease. Kids died really horrible, painful deaths.
SUSAN DENTZER: That began to change with the advent of antiretroviral drugs in the mid-to-late 1980s. The drugs sharply lowered the level of HIV virus in the blood, slowing or halting progression of the disease.
But a developing baby’s blood supply is separate from its mother’s. It wasn’t at all clear whether antiretroviral drugs would help stem maternal-to-child transmission. So in the late 1980s, Bardaguez and Oleske helped to bring about a large clinical trial. It tested what happened when pregnant HIV-infected women were given one early antiretroviral drug, AZT.
DR. JAMES OLESKE: And lo and behold, when we did that, we saw instead of the 30 percent of infants being infected and sick and dying of AIDS, it went down to 8 percent.
DR. MARY GLEEN FOWLER: Since that time, we’ve really built on this knowledge, and we’ve added other very potent antiretrovirals, so that usually most women during pregnancy will actually receive three or sometimes four antiretrovirals during the pregnancy, and that can reduce transmission to the one to two percent that we see.
SUSAN DENTZER: Researchers have also learned a great deal about just when during pregnancy and labor HIV transmission can occur. In only about one in five cases does it happen during the months the fetus is developing in the uterus. By contrast, two out of three instances of transmission actually occur during labor and delivery.
DR. MARY GLENN FOWLER: The placenta is actually a very good protection, sort of a natural protection, and it’s around labor and delivery as the baby is going through the birth canal that there’s much more exposure to maternal blood.
SUSAN DENTZER: So doctors now try to expedite labor and delivery, often through cesarean section. They’ve also learned that HIV transmission can occur through breast feeding. Now U.S. mothers with HIV are told not to.
MARY: I would have liked to breast feed, because I know the positive aspects of breast feeding for the child. But I don’t have … my situation is different, and I accept that.
SUSAN DENTZER: Despite the success in slashing transmission rates, several hundred babies in the U.S. are still infected through their mothers each year. Bardaguez explains why the moms appear to be spreading the virus.
DR. ARLENE BARDAGUEZ: The ones that we still have seen here are patients with no prenatal care that did not receive any medication either before or during labor. So, you know, the painful thing is, like, we know that we can either use drugs or modify obstetrical care, and we still are seeing some cases because of lack of advance knowledge about it.
DR. JAMES OLESKE: This is a tragic public health failure. And it’s, by the way, very cost inefficient. Every child who is infected with HIV, lifetime cost is hundreds of thousands of dollars, and prevention is pennies.
SUSAN DENTZER: Doctors like Bardaguez and Oleske, along with public health officials, are now redoubling efforts to stem the remaining transmission cases. One goal is to insure that an HIV test is included in the routine battery of tests every pregnant woman receives. But the CDC says at least on in five pregnant women are not being tested.
So one fail-safe strategy is to use new rapid turnaround HIV tests, such as this one called OraQuick. It can be given to women even in labor. In about 20 minutes, it can make a preliminary determination of whether or not a woman is HIV-positive. If the answer is yes, she can be given antiretroviral drugs while in labor. Her baby then gets the drugs for the first six weeks of life.
The approach has been shown to prevent all but a few infants from becoming infected. Those results give hope to women like Mary. At the time her baby was delivered in mid-September, the level of virus in Mary’s blood was undetectable. As she had planned in advance with Dr. Bardaguez, Mary was given AZT intravenously while in labor. Even as she waits for definitive test results about her child’s HIV status, she told us she had no regrets about becoming a mother again.
MARY: A lot of progress has been made within HIV and AIDS and within the medical history compared to what I did go through in ’89, and I made a decision from there, and my positives did outweigh my negatives.
SUSAN DENTZER: Although tests of the DNA of Mary’s baby show no virus present, the baby is still being given an oral solution of AZT just to be safe. She’s likely to be tested several more times until she’s 18 months of age.