World AIDS Day - 2007

Today is World AIDS Day and the headlines on all the newswires sadden me tremendously, partly because of the devastating toll this epidemic is taking on women and children around the world, but also because we seem to be losing the battle even on our own turf. To those of you who have followed my comments for awhile, you know my interest in AIDS in women during pregnancy goes way back to before we knew what caused it. More than 33 million individuals worldwide are infected with HIV and in parts of Africa, one of every 10 babies is born with HIV and will die before age 2. What a sad commentary this is at a time when we as human beings should know better and could fix the problems if we spent as much time worrying about humanity as we did killing each other in the “name of god”, or for the sake of oil, and wanting to execute school teachers who affectionately and unwittingly name their classroom Teddy bear after a religious leader whom will not be mentioned here lest I risk incurring a similar sentence.

If the same energy, fervor, and unity could be placed into learning to respect and live together, most of the world’s problems could be addressed, life would NOT be any less exciting, and we could spend our time enjoying the rich diversity of culture and nature this fine and relatively forgiving (but currently stressed) Mother Earth provides us. Of course part of that would require world leaders (political and religious) who actually had an interest in improving the welfare of their people, rather than their own self-interests, and another part would require elevating women to the status of equals around the globe. Unfortunately, the tremendous “male EGO” responsible for much of the world’s irrationality (and the spread of HIV to young women) is not going to allow either of these events to happen anytime soon, so don’t hold your breath. Forgive the soapbox soliloquy. I just can’t help myself sometimes, but let’s get back to the facts…

According to The Washington Post, new government estimates of the number of Americans who become infected with the AIDS virus each year are 40-50 percent higher than previous calculations suggested. For more than 10 years, the U.S. Centers for Disease Control and Prevention (CDC) has estimated the number of new infections annually to be approximately 40,000, but new estimates may put that number in the range of 55,000 to 60,000. The number of new cases of HIV infection diagnosed among 15-to-19-year-olds in the United States, which was 1,001 in 2001, and stable for several years after that, has jumped 20 percent to 1,213 cases in 2005 in the final data analysis from that year. There has also been an increase in new HIV infections among young people aged 20 to 24 from 3,184 in 2001 to 3,876 in 2005. The problem of course is that at least 25% of individuals who have HIV are completely asymptomatic and unaware of their infections and yet are responsible for more than 70% of the new infections annually. Youth, and the relatively prolonged ‘natural history’ of HIV, make denial much easier.

It does not surprise me that the number of newly infected teens and young adults is suddenly on the rise. At our institution in Greenville, South Carolina, we care for almost 3,000 women per year in our obstetrical clinic - most are Medicaid or uninsured. Despite great efforts to provide a high-quality service, in the five years since coming here, we have witnessed a steady resurgence in teen pregnancy rates, especially in the 11-17 age groups (mostly the result of sexual activity with older males), a progressive increase in conceptions within a year of a previous delivery, a steady rise in the Hispanic population (from 5% to 25% of our patients, and mostly ‘undocumented’), a growing trend toward ‘late entry to prenatal care’, particularly among our Hispanic women, one of the country’s highest rates of sexually transmitted infections (including HIV), a relative lack of interest in ongoing contraception, including a completely cavalier attitude toward the use of condoms, a rise in substance abuse, especially methamphetamines, and cuts in programs that might help all of the above.

The cost of converting HIV infection to a chronic and ‘treatable’ condition has not just been the cost of the extended therapy with expensive medications which have made that a reality, but a reduction in the emphasis (for whatever reasons – political, finanacial, religious, etc.) on the significance of the HIV epidemic and in attention to the impact to the overall cost to the health care system. Unfortunately, the most vulnerable and unaware members of society, young women, are the ones who will suffer the brunt of that neglect. Although it is true that both young men and women in the black community have not benefitted as much from the advances made in HIV care, the number of new infections has dropped for black Americans between 2001 (20,868 cases) and 2005 (18,121 cases). However, black men are still six times more likely than white men to contract HIV, and black women are 20 times more likely to acquire the virus compared to white women. But, I expect with the increase in the social acceptability of interracial relationships, and the relative naivete of young women, who are easily entrapped into ‘unsafe sex’ practices by their partners, I would imagine we will soon be seeing a significant shift in the demographics of the heterosexual epidemic.

In my business, of course, we not only have to worry about the pregnant woman’s health with regard to HIV, but also that of her unborn child. In the ideal world, we would prevent the woman from contracting the virus to begin with. But, since things are not ideal, we still have a tremendous opportunity to reduce maternal morbidity and to prevent transmission to the baby. With the introduction of rapid, reliable, and relatively inexpensive test kits for HIV, we have the opportunity to do so by repeated screening during pregnancy and even in women who are not diagnosed with HIV until presentation for delivery. Although again, ideally, antiretroviral therapy should be started much earlier in pregnancy, a significant reduction in transmission rate is possible, given the opportunity to administer prophylactic doses of therapy prior to delivery and/or by proceeding to elective cesarean delivery if ‘viral load’ is unknown and the patient consents to the same.

So, this World AIDS Day -2007, even though I am saddened by the statistics, I am also comforted by the knowledge that we have the resources and the opportunities to make things right…and perhaps some day we will.

Labels: AIDS, HIV infection in women

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