Mothers and Babies: Will It Help to Test for AIDS? : Medicine: Some Los Angeles doctors want voluntary screening of all pregnant women for HIV virus. Others say tests are futile and will only socially isolate the infected.
They show up in a doctor’s office or a clinic or a hospital ward with infections that hang on and on. Doctors try one thing, then another, but the babies stay sick.
Sometimes, their first serious illness is also their last. They are children at the mercy of HIV, the human immunodeficiency virus that causes AIDS.
Concerned that these HIV-infected babies and their mothers need earlier care than they are getting, Los Angeles doctors who specialize in pediatric AIDS are calling for routine voluntary testing of all pregnant women in Los Angeles County for infection with the AIDS virus.
Not just prostitutes or poor women whose sexual partners use drugs, but, for example, middle-class women who had several partners before marrying.
It is an idea whose time has come, these doctors say, because for the first time--through a network of federally established drug trials--doctors can offer mothers and children treatments that they hope will slow the progression of the devastating disease.
“To find just one mother at this early stage and do something about it would save so much in the long run,” said Dr. Yvonne Bryson, a UCLA professor who directs the Los Angeles Pediatric AIDS Consortium. “If we could prevent transmission to the baby, the actual cost and human cost couldn’t be compared.”
The Consortium, a coalition of Los Angeles hospitals and the County Department of Health, will begin trials within the next month to test whether giving the anti-viral drug AZT to newborns will prevent the AIDS virus from establishing itself in the children.
The drug is already being given to older children who are infected but asymptomatic, and to pregnant women to try to prevent transmission to their children. Other drugs also are being tested.
Currently, a third to half of the children born to HIV-infected mothers come down with AIDS. It usually appears within the first year of life, and death occurs sooner in children than in adults.
To Bryson, testing women routinely for AIDS is the best way to assure that they and their babies get the best possible health care--even if no one can offer them a cure for the fatal disease that has killed more than 68,000 Americans--1,059 of them children--since 1982.
But the idea of routinely testing all pregnant women for HIV infection does not come without controversy, even in areas of the country where the childhood AIDS problem is much greater than in the Los Angeles area.
In Miami, which has twice as many HIV-risk births every year (as does Los Angeles), Dr. Mary O’Sullivan is concerned that asking women to be tested for infection with the AIDS virus is asking them to take the chance of serious social discrimination if the test comes back positive.
“Why isolate them out just because they’re pregnant? Do you have any proof that what you have to offer is going to decrease the incidence of infection in the newborn?” asked O’Sullivan, professor of pediatrics at the University of Miami.
And drug trials in pregnant women are not far enough along to answer that question.
State AIDS office epidemiologist Frank Capell takes a middle ground. He suggests that public health dollars might be best spent in pushing HIV testing only in the specific urban areas where the number of HIV-infected, or seropositive, women is highest.
“The seropositives we saw in L.A. County were not just randomly distributed,” Capell said. “Probably three-fourths of the county had no seropositive women at all.”
The epidemiologist oversaw a study of every California birth during three-month period last year. Using blood samples routinely taken from babies to screen for genetic diseases, the study found evidence of HIV-infected mothers mainly in the poorer, high drug-use areas of Los Angeles, San Francisco and Alameda counties.
While the overall incidence rate in pregnant women in Los Angeles County was about 1 in 1,000--a rate considered high--among black women it was 1 in 344. Among Latino women it was 1 in 1,232.
Nationwide, the highest rates in the nation are in drug-abusing communities in northeastern cities--as high as 1 in 25.
Los Angeles County’s overall rate is high enough to justify recommending screening for every woman in the county, not just in public health clinics but also in private doctors’ offices, said Dr. Laurene Mascola, deputy chief of acute communicable disease control for the L.A. County Department of Health.
“I personally think that if there’s a disease you can screen for and have some impact on the outcome for fetus and mother, you should do it,” Mascola said. “It’s not as 100% as syphilis, where you can give a shot of penicillin and prevent the disease. But we are actively trying different strategies to reduce the risk.”
U.S. Centers for Disease Control guidelines say doctors or clinics should routinely conduct HIV tests in pregnant women in certain at-risk groups: intravenous drug users, recipients of blood transfusions before 1985, prostitutes, women who have had multiple sexual partners, and women who have a partner who is bisexual, a hemophiliac or who otherwise fits an at-risk profile.
And the CDC recommends that if the incidence among pregnant women is 1 or more in 1,000, routine testing of pregnant women in that area should be considered.
But in public health clinics that serve poor black women or Latinos, adding routine AIDS testing is an issue of money. Even if the $2 cost of the initial test is covered by state funds, the clinics are so overburdened that they would find it difficult to take on the education and counseling effort that would be needed if all 38,000 pregnant women they see in a year were to be tested, Mascola said.
Except for those participating in a study overseen by Mascola, women at the clinics are specifically offered the test only if they identify themselves as falling into a risk-factor group, she said.
But many women at the clinics--and in the community at large--don’t realize they may be at risk for AIDS.
“Half of our HIV-positive women don’t acknowledge any risk factors. Their partners are at risk and don’t tell them,” Mascola said.
This would include a partner who was previously bisexual or an intravenous drug user, since both those groups are at high risk.
Mascola’s pilot program tells women about their possible AIDS risk factors and offers testing; three-quarters of the women choose to take the test. The program found nine women infected with HIV out of 7,579 tested in the first 10 months of 1989, she said.
Those nine were referred for special care for themselves and their babies, she said, but it is the other 7,570 who she hopes will benefit most from the program’s educational component.
Similarly, other women of childbearing age in the county need to recognize that protecting themselves from AIDS also is protecting future children from it, public health officials say.
Repeatedly in the Los Angeles Pediatric AIDS Consortium, doctors see families in which the first sign that HIV might be a problem is when the baby’s infection is diagnosed many months after birth.
“The children of these mothers are born normal. They look fine, and so they disappear into the system,” Bryson said. She noted the case of one woman who was six months pregnant with her second child before doctors determined that her first child, her husband and she were all infected by HIV.
The AIDS virus is spread through blood, sexual activity (including intercourse without condoms) and from mother to child before or during birth. Breast milk from an infected woman also contains HIV.
Public health officials advise the use of condoms, and tell women that they should question a potential partner about AIDS risk factors before engaging in sexual activity.
So far, the AIDS Consortium has identified about 200 children in Los Angeles County infected with HIV. If the 1 per 1,000 infection rate in pregnant women holds up, that would mean at least 60 HIV-infected babies will be born each year here.
