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Identification of Levels of Maternal HIV-1 RNA Associated With Risk of Perinatal Transmission
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1996
Year
High Hiv-1 LevelsReproductive HealthPerinatal TransmissionGynecologyHigh-risk PregnancyMaternal ImmunizationHuman RetrovirusClinical EpidemiologyReproductive MedicinePublic HealthSexual And Reproductive HealthHiv-1 Rna LevelsVirologyMaternal HealthNewborn MedicinePlacental DiseaseMaternal-fetal MedicineChronic Viral InfectionHivHiv-1 Rna CopiesAids PathogenesisPediatricsPregnancyMedicine
<h3>Objective.</h3> —To determine if there are levels of human immunodeficiency virus type 1 (HIV-1) associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which zidovudine treatment reduces perinatal transmission. <h3>Design.</h3> —A nonrandomized prospective cohort study. <h3>Setting.</h3> —University medical center and two general hospital affiliates from May 1989 to September 1994. <h3>Patients.</h3> —Ninety-two HIV-1—seropositive women (95 pregnancies) and their 97 infants. <h3>Intervention.</h3> —Forty-two mothers (43 pregnancies) received zidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic zidovudine for the first 6 weeks after delivery. <h3>Main Outcome Measure.</h3> —HIV-1 infection status of the infant. <h3>Results.</h3> —Twenty of the 97 infants were perinatally infected with HIV-1. Transmitting mothers were more likely to have plasma HIV-1 RNA levels higher than 50000 copies per milliliter at delivery than nontransmitting mothers (15 [75.0%] of 20 transmitters vs four [5.3%] of 75 nontransmitters;<i>P</i><.001). None of the 63 women with less than 20 000 HIV-1 RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral zidovudine during gestation showed an eightfold median decrease in plasma RNA levels (median [25th and 75th percentile], 43043 [5699 and 63 053] copies per milliliter before zidovudine vs 4238 [603 and 5116] HIV-1 RNA copies per milliliter at delivery;<i>P</i><.001), and none transmitted. Four zidovudine-treated women with high HIV-1 levels transmitted despite the presence of zidovudine-sensitive virus in vitro in both the mothers and their infants. <h3>Conclusions.</h3> —Maternal HIV-1 RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associated with both a high risk and a low risk of transmission. Our results also suggest that zidovudine exerts a major protective effect by reducing maternal HIV-1 RNA levels prior to delivery and that further strategies are needed to prevent perinatal transmission in women with high or increasing virus levels and/or zidovudine-resistant virus. (<i>JAMA</i>. 1996;275:599-605)