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Pregnancy in Perinatally HIV-Infected Adolescents
and Young Adults -- Puerto Rico, 2002
February 28, 2003
http://www.thebody.com/cdc/pregnant_teens.html
Since
the introduction of highly active antiretroviral (ARV) therapy in the
United States in the mid-1990s, the life expectancy of U.S. children who
were infected perinatally with human immunodeficiency virus (HIV) has
increased substantially. As a result, the number of perinatally
HIV-infected females in the United States who are becoming both sexually
active and pregnant is increasing. During August 1998-May 2002, a total
of 10 pregnancies were identified among eight perinatally HIV-infected
adolescents and young adults in Puerto Rico; in April 2002, the Puerto
Rico Department of Health (PRDOH) asked CDC to assist in assessing such
pregnancies. This report describes these pregnancies and discusses
factors associated with sexual activity and pregnancy. The findings
suggest that increasing numbers of pregnancies will occur among
perinatally HIV-infected adolescents and young adults and that
appropriately tailored reproductive health interventions should be
developed.
Adolescents and young adults were identified by their health-care
providers or by PRDOH, and chart reviews and interviews were conducted
during April-August 2002. For females with two pregnancies, interview
and chart data on the first pregnancy are reported. Case-patients were
defined as perinatally HIV-infected adolescents or young adults with a
history of pregnancy, and controls were defined as perinatally
HIV-infected females with no history of pregnancy. All controls were
age-matched to <1 year of the age of the pregnant females, except
for one patient aged 22 years who had been aged 19 years when she was
pregnant; she was matched to a control aged 19 years. Perinatal
infection was defined as confirmed HIV-positive serostatus of the
patient's biologic mother or an HIV risk factor for the biologic mother
and the absence of any other risk factors (e.g., sexual abuse or blood
transfusions) for the patient.
A
total of eight case-patients were identified in four cities in Puerto
Rico. The median age of the case-patients was 18 years (range: 15-22
years), and the median age at the time of first pregnancy was 17 years
(range: 13-19 years). Among the 10 pregnancies to the eight patients,
seven pregnancies in six patients resulted in live-born infants; as of
February 24, no cases of mother-to-child HIV transmission were reported.
In addition, two pregnancies ended in elective abortions and one in a
spontaneous abortion.
Five
case-patients had first pregnancies that resulted in live-born infants;
all five received some prenatal care, and four (80%) received ARV
therapy consistently during their pregnancies. All infants received
zidovudine prophylaxis after delivery. The median viral load of these
case-patients during pregnancy was 35,822 copies/mL (range:
3,535-163,064 copies/mL), and the median CD4 count during pregnancy was
218 cells/mm3
(range: 19-956 cells/mm3).
The majority of the case-patients were highly ARV-experienced, with a
median of >9 years (range: 3-12 years) of ARV therapy, and five
case-patients had each taken at least nine different ARV medications
during their lifetimes. All four case-patients who were tested for viral
resistance had multiple genotypic mutations.
Five
of the eight case-patients reported unintended pregnancies, and two
reported using condoms as a form of birth control at the time they
conceived. Six case-patients are now living with partners; one is in
school, two left school because they were pregnant, and five left for
reasons other than pregnancy or motherhood.
Eight
controls were included in the analysis. The median age of case-patients
and of controls at the time they were interviewed was 18 years (range:
15-22 years) and 17 years (range: 14-19 years), respectively. The median
age of HIV diagnosis was 7 years (range: 0-13 years) for case-patients
and 4 years (range: 2-13 years) for controls. Differences in clinical
outcomes included a median viral load since 1999 of 16,263 copies/mL
(range: 5,251-65,571 copies/mL) for case-patients and of 53,071 copies/mL
(range: 54-476,139 copies/mL) for controls and a median CD4 count since
1999 of 251 cells/mm3
(range: 72-1,296 cells/mm3)
for case-patients and of 293 cells/mm3
(range: 66-1,002 cells/mm3)
for controls.
Behavioral and social characteristics associated with sexual activity
and pregnancy were compared for all 16 case-patients and controls; all
eight case-patients and two controls who reported being active sexually
were asked questions about sexual activity. More case-patients than
controls had dropped out of school before pregnancy and had friends who
had become pregnant before they did (Table).
The mean age when they were first told their HIV status was 13 years
(range: 12-15 years) for case-patients and 12 years (range: 8-14 years)
for controls. The median age at first sexual activity was 15 years
(range: 13-18 years) for case-patients and 17 years (range: 15-18 years)
for controls. The median time that elapsed between being told their HIV
status and becoming sexually active was 2 years (range: 0-5 years) for
case-patients and 5 years (range: 4-6 years) for controls. Three
case-patients and no controls became sexually active at the same age
that they were first told their HIV status.
Case-patients and controls were asked about their counseling needs with
respect to sexual activity, pregnancy, and birth control, and
case-patients were asked about discussions of sexual activity,
pregnancy, and birth control before their pregnancies. Two case-patients
and five controls reported having discussed sexual activity, pregnancy,
or birth control with a family member. Of all 16 persons surveyed, 10
wanted more reproductive health information, 10 believed that
health-care providers were an important source of reproductive health
information, and eight believed that families and schools should discuss
these topics.
Reported by C. Zorrilla, M.D., I. Febo, M.D., Univ. of Puerto Rico, San
Juan; I. Ortiz, M.D., J.C. Orengo, M.D., S. Miranda, M.P.H., M.
Santiago, M.P.H., A. Rodriguez, M.D., J. Rullan, M.D., Puerto Rico Dept
of Health. K. Dominguez, M.D., M.G. Fowler, M.D., A. Greenberg, M.D.,
Div. of HIV/AIDS Prevention, National Center for HIV, STD, and TB
Prevention; M. McConnell, M.D., EIS Officer, CDC.
Editorial Note
This
report describes pregnancies in perinatally HIV-infected adolescents and
young adults for the first time and highlights the challenges in
developing appropriately tailored reproductive health services for this
growing population in the United States. During the early 1980s, when
the first perinatally acquired AIDS cases were documented, infection in
the majority of children progressed rapidly to death. Therefore, these
children were not expected to survive to adolescence and mature to
become sexually active. The findings of this investigation suggest that
the risk-taking sexual behaviors of perinatally HIV-infected adolescents
and young adults might not differ from those of non-HIV-infected
adolescents and young adults
5,
6.
Although ARV therapy has made perinatal HIV transmission in this
population infrequent in the United States
7,
as the perinatally HIV-infected population ages, increasing numbers of
pregnancies in perinatally HIV-infected female adolescents and young
adults can be anticipated, and reproductive health issues affecting this
population will need to be addressed.
Factors that might be associated with pregnancy in these females include
a relatively late age at disclosure of HIV status and inconsistent
condom use with sex partners. These findings underscore the need for
early disclosure of HIV status to infected adolescents and young adults
and for increased discussions about sexual risk reduction among all
perinatally infected adolescents and young adults. Providing families
with the tools for HIV disclosure to children and for reproductive
health discussions before sexual initiation might reduce risky behaviors
among these females.
The
findings in this report are subject to at least two limitations. First,
the small sample size makes the findings largely descriptive. Second,
matching by age might not reflect social or physical development. Both
of these limitations reduce the degree to which generalizations can be
based on the data. Enhanced efforts to identify pregnancies among
perinatally HIV-infected adolescents and young adults and more in-depth
investigation of such pregnancies could better characterize the factors
associated with pregnancies and birth outcomes.
The
finding of genotypic mutations of HIV isolated in all persons tested in
Puerto Rico reinforces the importance of preventing secondary HIV
transmission both to infants and sex partners. Surveillance of birth
outcomes in perinatally HIV-infected adolescents and young adults and of
cases of mother-to-child transmission and transmission of drug-resistant
virus should continue. To permit accurate monitoring of trends in HIV
transmission, clinicians should report births to HIV-infected women and
adolescents to their health departments according to state surveillance
guidelines for HIV/AIDS reporting. In addition, to assist CDC with
determining pregnancy outcomes among this population, clinicians are
urged to report pregnancies among perinatally HIV-infected adolescents
and young adults directly to CDC, telephone, 404-639-6141, or e-mail,
mmcconnell@cdc.gov, through June 2003.
Acknowledgements
This
report is based on data contributed by L Ortiz, Univ of Puerto Rico, San
Juan; L Pena, O Garcia, MD, Pediatric Immunology Clinic, Bayamon; D
Padilla, R Delgado, MD, Center for Prevention and Treatment of
Transmissible Diseases, Ponce; A Negron, M de los Angeles del Rio, MD,
Center for Prevention and Treatment of Transmissible Diseases, Mayaguez;
E Perez, R Jimenez, Puerto Rico Dept of Health. B Bohannon, Northrup
Grumman Mission System, Atlanta, Georgia.
References
1.
De
Martino M, Tovo PA, Balducci M, et al. Reduction in mortality with
availability of antiretroviral therapy for children with perinatal HIV-1
infection. JAMA 2000;284:190-7.
2.
Gortmaker S, Hughes M, Cervia J, et al. Effect of combination therapy
including protease inhibitors on mortality among children and
adolescents infected with HIV-1. N Engl J Med 2001;345:1522-8.
3.
Lee
LM, Karon JM, Selik R, Neal JJ, Fleming PL. Survival after AIDS
diagnosis in adolescents and adults during the treatment era, United
States, 1984-1997. JAMA 2001;285:1308-15.
4.
Battles H, Weiner LS. From adolescence through young adulthood:
psychosocial adjustment associated with long-term survival of HIV. J
Adolesc Health 2002;30:161-8.
5.
CDC. Youth risk behavior surveillance -- United States, 2001. In: CDC
surveillance summaries (June 28). MMWR 2002;51(No. SS-4):50.
6.
Santelli JS, DiClemente RJ, Miller KS, Kirby D. Sexually transmitted
diseases, unintended pregnancy, and adolescent health promotion. In:
Fisher M, Juszczak L, Klerman LV, eds. Adolescent Medicine: State of
the Art Reviews, Vol. 10, No. 1. Philadelphia, Pennsylvania: Hanley
and Belfur, 1999.
7.
Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal
transmission of HIV/AIDS in the United States. JAMA
1999;282:531-8.
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