Women diagnosed with HIV during pregnancy in Ukraine are now more likely to have acquired HIV through sexual transmission than through injecting drug use, and by 2004 the majority of women who acquired HIV through sexual transmission were not aware of any direct sexual contact with injecting drug–using partners, according to findings from a pan-European comparison of mother-to-child HIV transmission rates published in the June 26th edition of the journal AIDS.
The HIV epidemic fully emerged in Eastern Europe during the mid-1990s, with highest incidence rates in the Russian Federation and Ukraine, driven by injecting drug use. By 2004 HIV prevalence had reached 1% in Ukraine, according to UNAIDS, and a substantial epidemic of mother-to-child HIV transmission was emerging.
Researchers from the European Collaborative Study (ECS) compared 20 years of data on mother-to-child transmission (MTCT) of HIV-1 in Western Europe with data now available from the first Ukraine cohort of HIV-infected pregnant women and their babies (2000-2004).
The prospective cohort study included 5,967 mother-child pairs, of which 4,537 (76%) were enrolled in western European centres during the period 1985-2004. The remainder of cases were collected during 2000-2004 in Poland (179 cases – 3%), and in Ukraine (1,251 cases – 21%). Data were collected on mother and infant characteristics as well as type of delivery.
Despite the still growing number of infected women, triple combination antiretroviral therapy, elective Caesarean Section (CS) delivery and no breastfeeding have contributed to reducing and stabilising MTCT to around 250 cases per year in western Europe during the period 2000-2004. In comparison Ukraine recorded 2,115 cases of mother-to-child transmission in 2004 alone.
In the Ukrainian cohort, nevirapine (sdNVP) was administered intrapartum to 793 (63%) women, of whom 503 (40%) also received zidovudine (ZDV) monotherapy as a short course regimen starting at a median of 35 weeks of pregnancy; 208 (17%) women received ZDV monotherapy alone, and 27 (2%) received highly active antiretroviral therapy (HAART). Elective caesarean section (CS) was performed in only 33% of cases.
Similar PMTCT protocols were implemented in western/central Europe before the introduction of HAART, with only 17% of deliveries being by elective CS during the period 1990-1994, but with an increase to 66% CS and 72% of women on HAART in 2000-2004. Mother-to-child transmission decreased significantly in western Europe, from 16.1% in 1992-93 to 1.7% in 2002-2003 (X2 trend = 0.76; p
The transmission rate seen among women exposed to HIV through injecting drug use in Ukraine in the 2000-2004 period was similar to the rate seen in western Europe amongst all women in the period prior to the introduction of perinatal antiretroviral therapy (pre-1994) (15.4% vs 19.8%), suggesting poorer access to treatment and antenatal care for this group of women in Ukraine.
Ukrainian women are, however, still 83% less likely to be diagnosed before pregnancy than women in western Europe (AOR 0.17; 95% CI 0.15-0.21).
Diagnosis of mother-to-child HIV infection was based on the development of AIDS and HIV-associated mortality in children born at least 18 months before the time of the analysis (twelve children), persistence of HIV antibodies beyond 18 months (24 children), or detectable virus in two or more blood samples taken on different occasions (six children).
Mother-to-child transmission rates were 4.2% in the Ukrainian centres among women on sdNVP and/or short course ZVD (95% CI 1.8 – 8.0). In western Europe in 2000-2004 mother-to-child transmission rates in women on HAART were 1% (95% CI 0.4-1.9). Women on HAART were more than 90% less likely to transmit infection than those untreated and 75% less likely than women on mono or dual therapy (AOR 0.25; 95% CI 0.12-0.54).
The investigators conclude that in Ukraine making HAART universally available and integrating HIV services into the primary healthcare system would reduce mother-to-child transmission. However, they note that the low levels of transmission seen in Ukraine when using sdNVP and AZT highlights the fact that “a reduction in MTCT rates to very low levels without widespread access to HAART is possible in non-breastfeeding, non-trial settings.”,
European Collaborative Study. The mother-to-child HIV transmission epidemic in Europe: evolving in the East and established in the West. AIDS 20: 1419-1427, 2006.