Reproductive and sexual health needs of US girls perinatally infected with HIV not being met

The sexual and reproductive health needs of adolescent girls infected with HIV at birth need closer attention, according to investigators from the United States writing in the June edition of the American Journal of Public Health. The researchers calculated that 27% of girls infected with HIV by their mother were sexually active by the age of 19, with 17% of these sexually active girls experiencing one of more pregnancy, and over half having abnormal cervical cells.

Thanks to potent antiretroviral therapy increasing numbers of children infected with HIV at birth are now entering adolescence and are becoming sexually active. Rates of pregnancy and the effectiveness of interventions to prevent mother-to-child transmission of HIV in girls who were themselves infected by their mother are not currently well established. There are also no data on the reproductive and sexual health of young perinatally infected women.

Investigators therefore estimated rates of pregnancy, pregnancy outcome, genital infections, and cervical abnormalities in a cohort of 638 perinatally-infected adolescents aged under 25. The source of the study was children enrolled in the Pediatric AIDS Clinical Trials Group (PACTG) protocol 219C.

The investigators assessed a girl as being sexually active if she informed healthcare staff about sexual activity, became pregnant, had a sexually transmitted infection, or had abnormal cervical cytology. On this basis, the investigators calculated that 174 girls (27% of the cohort) were sexually active. Sexually active girls were older than those who were not yet having sex (mean age 19 versus 15 years), more likely to be Hispanic (36% versus 26%), more likely to live on their own (23% versus 1%), more likely to have a viral load above 10,000 copies/ml (25% versus 18%), more likely to have a CD4 percentage below 15% (16% versus 9%), and less likely to be taking antiretroviral therapy (77% versus 87%).

A total of 38 girls experienced a pregnancy between their 13^th birthday and last study visit. This provided a cumulative incidence rate of 17.2% of first pregnancy by the age of 19 for the entire study population, and 24% for the girls known to be sexually active.

In addition to the first pregnancy, six girls also experienced a second pregnancy and one girl had a third pregnancy. Of the 38 first pregnancies, 28 resulted in live births (there were two miscarriages and eight abortions), three of the second pregnancies resulted in live birth (the other three being aborted), and the single third pregnancy resulted in live birth.

The rate of mother-to-child transmission was 3%, and all 32 girls whose pregnancy resulted in live birth took antiretroviral therapy to prevent perinatal transmission, with 26 taking three anti-HIV drugs.

Attention was then turned to the incidence of genital infections in the girls. By age 19, genital warts were diagnosed in 8% of sexually active girls, with trichomoniasis diagnosed in 7%, chlamydia in 6%, gonorrhoea in 4% and syphilis in 2%.

The investigators also wished to establish if girls in the cohort were receiving an appropriate level of gynaecological care. They established that 58% of sexually active girls had had a documented Pap smear during follow-up and 95% had had a pelvic examination. The mean age for first Pap smear was 16.7 years.

Of the girls who had a Pap smear, 30% had abnormal cervical cells on their first examination and a further 18 had abnormalities detected during subsequent examinations. Treatment was provided for these abnormalities to 21 girls. In ten of these girls the cervical abnormality either persisted or progressed. Treatment was not provided to 14 girls, and in six of these the cervical abnormalities persisted and progression was observed in one.

“To our knowledge”, write the investigators, “this is the first study to evaluate the reproductive health of a large cohort of perinatally HIV-infected adolescent girls…the need for enhanced provision of reproductive health services such as contraceptive counselling and cervical cytological screening is evident.”

The investigators compared the findings to studies looking at rates of pregnancy and sexual health in similarly aged girls who were either HIV-negative or infected with HIV sexually during adolescence. This showed that the pregnancy rate of 34 per 1000 person-years for 15 – 19 year olds in the study was significantly lower than the 87 per 1000 person years seen in a large US study including similarly aged HIV-negative girls.

At 3%, the rate of mother-to-child transmission of HIV was similar to that observed in the US Woman and Infants Transmission Study. However, the investigators note that a small Indian study looking at pregnancy outcomes for adolescents who were perinatally infected with HIV found that none of the girls in that study transmitted HIV to their infants.

Rates of sexually transmitted infections were lower than those seen in the REACH study that had a study population comprised of individuals infected with HIV during adolescence. Nevertheless, the incidence of sexually transmitted infections was higher than that seen in both a Canadian and US study with a similarly aged, HIV-negative population.

“A considerable proportion of adolescents in our cohort engaged in unprotected sex despite close and frequent contact with HIV clinics”, conclude the investigators, who add, “education on safer sexual practices is needed in this population.”