The Gaps That Remain: A Commentary on the 2024 JPHMP Article “Late Identification of Perinatal Transmission of HIV in an Infant at High-Risk”

Le résumé fourni par la source

Prevention of mother-to-child transmission (PMTCT) of HIV has been a key target for reducing the global burden of HIV for decades. The World Health Organization’s first set of PMTCT guidelines was produced in 2000.1 Then-President George W. Bush set prevention of transmission to children as a goal in 2002 with the International Mother and Child HIV Prevention Initiative, which later became a part of the U.S. President’s Emergency Plan for AIDS Relief in 2003.2 The Centers for Disease Control and Prevention (CDC) established HIV care and prevention guidelines for the United States specifically focused on the perinatal period in 2006.3 Since that time, massive advances have been made toward eliminating perinatal HIV transmission in the United States4; there were only 32 cases of perinatally acquired HIV among infants born in the United States in 2019, meeting the PMTCT elimination goal.5 Indeed, PMTCT is hardly mentioned in the “National HIV/AIDS Strategy for the United States 2022-2025,” which was published in 2021, though considerations for managing HIV in children are discussed.6 Still, important factors contributing to perinatal HIV cases in the United States each year include transmission among people of reproductive age leading to HIV acquisition during pregnancy and gaps in the uptake of measures to prevent transmission to the infant in the perinatal period.7 In the 2024 JPHMP article, “Late Identification of Perinatal Transmission of HIV in an Infant at High-Risk,” the authors describe a case of maternal to child transmission (MTCT) of HIV, despite New York State Department of Health (NYSDOH) perinatal HIV testing and treatment policies being followed. The authors performed a careful retrospective review of the case, including analysis of remnant specimens, to understand the contributing factors that led to this event. They concluded that infant acquisition of HIV likely occurred in utero, and levels of HIV nucleic acids on day 1 of life were under the limits of detection of standard qualitative testing. They hypothesized that appropriate initiation of antiretroviral medications to the mother perinatally and to the infant after birth led to undetectable HIV RNA, with viral rebound after discontinuation that was not identified until the infant was 4 months old. The NYSDOH responded swiftly, updating perinatal HIV testing and treatment protocols to close this gap by adding a testing point at 2-3 months for infants deemed to be high risk. The updated guidelines more closely mirror the US Department of Health and Human Services (HHS) 2006 guidelines. One challenge highlighted here is the decentralized public health system in the United States. Many states changed their HIV testing guidelines to align with CDC’s 2006 guidance,3 but 5 states still had policies that contradicted federal recommendations in 2011,8 and by 2018, no state had fully adopted the 2006 recommendations across all 4 populations described (adults, adolescents, pregnant women, and newborns).9 Given the critical nature of the perinatal period, such departures can result in gaps where delayed diagnosis, or transmission, can occur. While the actionable change from this case analysis pertained to HIV perinatal testing guidelines, the “root cause” of the in utero MTCT of HIV was in fact centered around the mother’s health—namely viremia during pregnancy and lack of prenatal care.10-12 The underlying reasons for the mother’s lack of antenatal viral suppression are not known, though the authors comment on numerous social and structural barriers that may have contributed. Indeed, in the current landscape of HIV care in the United States, where antiretroviral therapy is highly effective, relatively easy to tolerate, and theoretically affordable under the Ryan White Care Act, HIV transmission is often driven by unaddressed social and structural determinants of health (SDoHs).13-16 Both the “National HIV/AIDS Strategy for the United States 2022-2025”6 and the HHS Ending the HIV Epidemic17,18 initiative emphasize the importance of addressing SDoH in the response. Unfortunately, this case is an illustrative example of multiple SDoHs coinciding, including comorbid substance use and mental health disorders, poverty, housing insecurity, systemic racism,19 and stigma, which ultimately resulted in MTCT. The case study additionally underscores the intersectionality of SDoH that impacts both HIV and prenatal care services, making pregnant women with HIV and women at risk of acquiring HIV during pregnancy particularly vulnerable. In the current sociopolitical climate, it is important to call attention to the numerous structural barriers that limit access to and utilization of these essential health services. The authors specifically comment on the criminalization of substance use during pregnancy as a barrier to prenatal care. Similar to HIV transmission criminalization laws, such policies and practices are not associated with reductions in maternal use or fetal harm and instead reduce utilization of prenatal care for those who need it the most.20 There remain critical gaps in insurance coverage for reproductive and prenatal care, especially for underinsured women in states without Medicaid expansion and immigrants.21 The recent defunding and closures of comprehensive women’s health clinics have jeopardized access to HIV screening in young women, which has rippling downstream effects, even contributing to an HIV outbreak among people injecting drugs in Scott County, Indiana, in 2014-2015.22 The consequences extend beyond HIV transmission—barriers to reproductive care have also played a role in the skyrocketing rates of congenital syphilis observed in the last decade.23,24 To truly address the MTCT of HIV, it is clear that the harmful policies surrounding women’s health care must change, as improving maternal health is central to this mission.25 In conclusion, we commend the authors for performing this case study to identify the policy-based gaps that led to the delayed diagnosis of HIV in an infant and to amend the NYSDOH HIV perinatal testing guidelines accordingly. The CDC’s Elimination of Mother-to-Child Transmission of HIV Stakeholders Group has highlighted the importance of case review as part of their perinatal HIV service coordination strategy.21 All perinatal HIV transmission events are now considered sentinel events and require reporting and careful review. These in-depth case studies may lead to important tailoring of state and national policy guidelines, bringing us closer to the elimination of MTCT of HIV. Complete elimination of MTCT will also require difficult work to combat social and structural forces affecting the health of women living with HIV.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.