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Between the years 2005 and 2012, 27 infants were identified as HIV-infected. Risk factors for MTCT of HIV identified through the screening questionnaire are presented in Table 1. The majority of women were African–Americans (89%) between 16 and 30 years (63%). Only 44% received prenatal care. Seventy-four percent of women (20/27) knew their HIV status prior to pregnancy, yet only 10 (50%) of them received prenatal care. Illicit substance use was identified in nine (33%), with cocaine and marijuana being the drugs of choice either alone or in combination. Among the 20 women who knew they were HIV-infected during their pregnancy, nine (45%) did not receive combination antiretroviral therapy (cART), and five (25%) did not receive intrapartum zidovudine (ZDV). CD4 T-cell count was available in only nine of 27, with three women documented to have at least 500 cells/μl. HIV RNA at the time of delivery was available in only 10 of 27 women, and, of these, only three had an undetectable plasma level. Of the three mothers, obstetric risk factors or complications probably contributed to perinatal HIV transmission and were therefore not considered as missed opportunities. The first mother gave birth to an infant at 39 weeks gestation, and received prenatal care from 8 weeks gestation and cART throughout her pregnancy with a CD4 T-cell count at the time of delivery of 583 cells/μl. Pregnancy was complicated by placenta previa and premature rupture of membranes of unknown duration. The infant was born by C-section and both the mother and the newborn received prophylaxis with ZDV during labor and for 6 weeks postnatally. The infant was formula-fed, but the HIV DNA PCR was reported as positive at 4 weeks of life. A second mother received appropriate HIV management throughout pregnancy and delivery, but had placental abruption. HIV infection was diagnosed in her infant at 6 weeks of life. The third mother gave birth at 36 weeks gestation to dizygotic twins, in which twin A was infected and twin B was not. She received prenatal care from the third trimester when her HIV RNA level was 123 000 copies/ml and CD4 T-cell count was 277 cells/μl. The mother commenced cART achieving undetectable plasma HIV RNA level at the time of delivery. The newborn was immediately initiated on oral ZDV and formula-fed. HIV DNA PCR at birth was reported as positive and the infant considered to have been infected in utero. HIV genotype assays obtained at the initial postnatal visit reported wild-type virus for all three infected infants.
Twenty-two percent of mothers had premature rupture of membranes, and the most common mode of delivery was C-section (70%). Of the mothers who gave birth vaginally, two had known and detectable HIV RNA plasma level at the time of delivery. The first mother was diagnosed during pregnancy and prescribed cART; however, compliance was poor and the HIV RNA level at time of birth was 231 000 copies/ml. She received intrapartum ZDV, but the infant did not receive postpartum ZDV. An HIV diagnosis was made in the infant at 1 month of age. The second mother tested HIV-positive 1 year prior to her pregnancy, but used illicit substances, reported being homeless and did not receive any prenatal care. HIV RNA level at the time of delivery was 124 890 copies/ml and her CD4 T-cell count was 67 cells/μl. Although she did not receive intrapartum ZDV, oral ZDV was administered as postnatal prophylaxis soon after birth. Her infant was diagnosed with HIV infection at 3 weeks of age.
Of the 27 infants, the mean gestational age was 37 (SD: 2.9) weeks. Eleven percent (n = 3) had a positive HIV DNA PCR at birth and probably acquired HIV infection in utero. Fifty-nine percent were boys, and 67% were prescribed AZT prophylaxis (data on ZDV prophylaxis were unavailable for two participants). Thirty-three percent required neonatal ICU admission. Seventy percent were exclusively formula-fed (no feeding history was available in seven participants), with one mother acknowledging that she had breastfed her baby for 3 months because of undiagnosed maternal HIV infection. Among the whole cohort, the median age for the first positive HIV DNA PCR was 1 month (range: 0–30 months). Stratifying by timing of maternal HIV diagnosis (prepregnancy, during pregnancy through delivery, or postpartum), a prepregnancy or during pregnancy through delivery diagnosis was associated with the infant's first positive HIV DNA PCR at a median age of 1 month compared with 20 months in those mothers who were diagnosed postpartum. Most infected infants were enrolled in HIV care at a median age of 2 months (range: 0–34 months).
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