Policies in 1994
O f the 55 centres in the 1994 survey, four had no experience o f caring fo r HIV-infected
pregnant women and thus the follow ing data on interventions relate to 51 centres. A ll
centres routinely advised HTV-infected women not to breastfeed and in over a third (19,
37%), no other intervention to reduce the risk o f mother-to-child transmission was
available. Although results o f the ACTG 076 trial were released in early 1994 (Connor et al, 1994), before the survey started, in 30 (59%) centres zidovudine was not prescribed at all, or only fo r clinical indications, i.e. for immunosuppressed (CD4 count less than 200
cells/mm^) and/or symptomatic women. A total o f nine (16%) centres had a policy o f
performing elective caesarean sections on HIV-infected women and in 12 (24%) centres,
disinfection o f the birth canal (w ith either chlorhexidine or benzalkonium chloride) was a
routine procedure (Table 4.4).
Policies in 1997
By the time o f the second survey, prevalence o f routine zidovudine use had increased
significantly from 41% to 98% (%^=27.9, p<0.02), w ith only one centre (Sofia) not
in itia l survey, inform ation was collected on the precise antiretroviral therapy regimen
adopted: in 38 (90%) centres all three components o f the ACTGK)76 protocol (i.e.
pregnancy, intrapartum and neonate therapy) were routinely provided, w ith two centres
only administering the pregnancy component and two prescribing zidovudine in
pregnancy and to the infant, w ithout intrapartum therapy.
Zidovudine therapy in pregnancy was reported to start at a median o f 14 weeks (range,
12 to 34 weeks), w ith 10 centres not starting therapy u ntil the th ird trimester. In the 39
centres where intrapartum use o f zidovudine was part o f the usual regimen, this was
given intravenously in 35 centres (including one w ith a policy o f universal elective
caesarean section w ith zidovudine given intravenously during the procedure), orally in
two and by either route o f administration in the remaining two. The duration o f
prophylactic treatment o f the infant was six weeks in 36 (90%) o f the 40 centres
providing this part o f the regimen, 10 days in two centres, 28 days in one and one month
to six weeks in another.
An important change seen in the follow -up survey was the introduction o f combination
antiretroviral therapy to reduce the risk o f mother-to-child transmission: other antiretroviral
drugs w ith zidovudine were routinely used in nine centres, including three where
combination therapy (zidovudine and 3TC or ddl) was routinely prescribed to all infected
women and in one case, to the neonates for six weeks. In the remaining six centres (from
Sweden, the U K , Germany, France and Austria), one or more subgroups o f women were
routinely offered zidovudine and 3TC (and rarely zidovudine and ddl or ddC): those
previously treated w ith zidovudine (2 centres), women w ith symptomatic disease, severe
place in pregnancy (1 centre). In one centre offering 3TC and zidovudine, i f zidovudine
intolerance developed, zidovudine was substituted w ith d4T (stavudine).
To estimate the extent o f zidovudine uptake among pregnant women, respondents were
asked to indicate the approximate proportion o f women currently receiving zidovudine to
reduce vertical transmission. In 32 o f the 33 centres which cared fo r H IV -infected
pregnant women in 1996, it was estimated that three-quarters or more o f the women
identified to be H IV -infected received zidovudine, and in the remaining centre half were
estimated to have received zidovudine. O f the 18 centres, where a quarter to a h a lf o f
women identified as H IV -infected did not receive zidovudine therapy, one or more
reasons fo r this were specified: refusal o f therapy was the most common reason given (15
cases), in addition to late obstetric booking/lack o f antenatal care (8), non-compliance (1)
and contra-indication or discontinuation o f therapy because o f side effects (1).
Although the effectiveness o f caesarean section remains unproven, the percentage o f
centres offering routine elective caesarean section fo r all HIV-infected women increased
from 19% (8 centres) in 1994 to 26% (11 centres). There was an even greater change at the
centre level whereby over a quarter (11) o f centres changed their caesarean section policies:
four o f the eight centres routinely offering this procedure in 1994 no longer did so by 1997,
w hile an additional seven centres had adopted a policy o f offering elective caesarean
sections to all HIV-infected women. In an additional 18 (42%) centres, a subgroup o f
women were offered this intervention: 10 centres were participating in the Mode o f
D elivery T rial (Newell et al, 1997b), w ith consenting women allocated to vaginal or caesarean section delivery randomly, seven centres had a policy o f offering caesarean
(e.g. history o f long labour and early rupture o f membranes, cervico-vaginal infection) and
in the remaining centre the policy was to offer the procedure to women who refuse
antiretroviral therapy.
Cleansing o f the vagina and cervix o f HIV-infected women in labour was routine in nine
(21%) centres. The agents most commonly reported were benzalkonium.chloride and
chlorhexidine. Although the number o f centres w ith a policy o f routine disinfection o f the
birth canal was the same in 1997 as in 1994, three o f the nine centres w ith this policy in
1994 stopped providing this intervention by the second survey, w ith an additional three
in itia tin g a new policy o f vaginal lavage. A ll centres had a policy o f advising H IV -
infected women not to breastfeed.
These policies have been confirm ed by results from the ECS, which have shown a
gradual but significant increase in zidovudine use to reduce vertical transmission from
24% (59/248 deliveries) in 1994 to 62% (103/211) in 1995 and 76% (69/91) in 1996
( X ^ = 9 5 . 3 , / 7 < 0 . 0 2 ) . This has been associated w ith a significant temporal decline in the
vertical transmission rate from an estimated 19% in 1993 to 6% in 1996 (p<0.02);
however, the confidence intervals around these estimates are wide in 1995 and 1996 due
to small numbers and this trend needs further confirm ation. Over the same period o f
tim e, the elective caesarean rate has stayed stable at approximately 31%.