Eurosurveillance

ECDC

Assessment of Prevention of Mother-to-Child Transmission of HIV Infection in the Republic of Karelia, 1999-2006

 Rediger
  Published: 30.01.08 Updated: 30.01.2008 15:40:23

Mironova Viktoria, Rozhkova Inna, Kholina Nina

State Institute of Health, Republican Centre on Prevention and Control of AIDS and Infectious Diseases

The Republic of Karelia is part of the North-Western Federal Region and has a total population of 703 080.  Prevalence of HIV in the Republic of Karelia is lower than that in the Russian Federation and the North-Western Federal Region. However, in some of the territories that border on Finland and Murmansk oblast (the towns of Kostomuksha and Sortavala, and Loukhsky district), where intravenous drug use and commercial sex are common, and the prevalence of HIV infection is relatively high.

Fig. 1. Prevalence of HIV-infection per 100 000 population on January 1, 2006 in districts of the Republic of Karelia. (For comparison: The prevalence is 55/100 000 in the Republic of Karelia, 344/100 000 in the North-Western Federal Region of Russia, and 227/100 000 in the whole of Russia.)

 

 

 

 

 

 

 

 

 

 

 

 The first case of HIV infection in Karelia was reported in 1995, and until 1998 only single cases were observed. The incidence began to rise from 1999, when the first injecting drug users began to be infected. The largest number of HIV-infected persons was notified in 2005, at 82 new cases.

Table 1. Notified cases of HIV infection in the Republic of Karelia, 1995 - 2006

 

Years

1995-1999

2000

2001

2002

2003

2004

2005

2006

Total

Cases of  HIV infection

21

54

66

52

41

64

82

58

438

Detection notification (per 100 000 population)

 

7.6

9.3

7.3

5.8

9.0

11.6

8.2

62.3

Since the first case was reported and up to January 1, 2007, 438 cases of HIV infection were notified, giving a figure for HIV prevalence of 62.3 per 100 000 population (for permanent residents the figure was 54.9). Of these 438, 33.8% were females and 66.2% were males. The majority of the infected (65.5%) were young people between 20 and 29 years old.
HIV cases in Karelia were found in almost all social groups: unemployed, workers, engineers, teachers, health-care workers and students. As regards educational level, two-thirds had not completed secondary school, or had completed secondary school and vocational training, and one-third had higher or technical education.
Out of the cases where information on probable transmission mode was available, 53.2% were injecting drug users.
Transmission routes have changed in recent years.  While parenteral transmission was prevalent at first, sexual (heterosexual) transmission had become the main transmission mode in 2006. This had resulted in a change in the gender distribution: the ratio of HIV-infected females and males was close to 1:1 in 2006.

Fig. 2. Change in gender distribution of HIV-infected persons in the Republic of Karelia as of  January 1, 2007

 

 

 

 

 

 

 

 

 

 

 The proportion of women (for all years of registration) was 33.8% of all HIV-infected persons; 95% of them were of reproductive age.

Table 2. Distribution of reported HIV-infected women by age at time of infection

 

Age (years)

0-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50 and more

Total 

No

1

22

57

36

15

6

3

5

3

148

  %

0.7

14.9

38.5

24.3

10.1

4.1

2.0

3.4

2.0

100.0

 

 

 

In the last few years there has been a rise in reported cases of HIV infection among pregnant women both in Karelia and in the Russian Federation in general. This has increased the risk of mother-to-child transmission (MTCT).

Table 3. Registered cases of HIV infection among pregnant women (tested upon pregnancy registration and at the examination preparatory to abortion)

 

Years

2002

2003

2004

2005

2006

No of women tested

24 894

23 534

24 052

24 930

22 653

No of seropositives

5

5

10

5

7

Incidence rate (per 100 000 tested)

16.1

21.2

41.6

20.1

30.9

The number of children born to HIV-infected women has risen as the proportion of HIV-infected women of reproductive age has increased. During the whole period of reporting of HIV infection among females, 74 (50%) of the HIV-infected women were pregnant and in 43 cases (29%) pregnancy resulted in delivery.
The first delivery by an HIV-positive woman in Karelia occurred in 1999. On average 8-10 children are born annually to HIV-infected mothers in Karelia.

As regards the social and educational characteristics of HIV-infected mothers, 72% of the women were unmarried and 48% were unemployed, 69% had secondary education, 17% had incomplete secondary education, 11% had higher education and 3% were university students.

Out of the 43 women who gave birth to children, 14 (32%) had been diagnosed with HIV infection prior to pregnancy, 27 (62%) had been diagnosed during pregnancy and 2 (4.6%) had been diagnosed after delivery. In the last two years a number of HIV-infected women underwent more than one pregnancy and delivery (3 women had second deliveries and 1 woman had a third delivery). In half of the cases the pregnancy was unwanted.

Perinatal prophylaxis against HIV infection is carried out according to procedures regulated by normative documents issued by the Ministry of Public Health. The procedures are as follows.

  1. Mandatory testing of pregnant women for HIV infection during the first and third trimesters of pregnancy, free of charge.
  2. Mandatory counselling at the Republican AIDS Centre before and during pregnancy.
  3. Chemoprophylaxis during pregnancy and delivery and for newborns.
  4. Rational delivery procedures at the Republic Perinatal Centre.
  5. Artificial feeding of newborns.
  6. Postpartum counselling and regular follow-up of the child.

Chemoprophylaxis is given according to the standard for prevention of MTCT approved by the Ministry of Public Health of the Russian Federation:

  1. From the 28th week of pregnancy: azidothimidine 800 mg/kg/day.
  2. Two hours before birth: intravenous injection of Retrovir 2 mg/kg/hour, followed by 1 mg/kg/ hour until the end of delivery.
  3. Newborns: Retrovir syrup 2 mg/kg/day up to 6 weeks (dose correction depending on weight).
  4. Women with progressive HIV, viral load > 200 000 copies/ml and CD4  < 300 cells/ml: combination therapy with Combivir 1 tablet x 2 per day.

Since determination of the viral load was not used in Karelia until 2007, the choice of therapy was based on CD4 indicators, the history of the infection and its clinical development over time. Combination therapy was only necessary for two women; the others followed the normal protocol.

Caesarean section was performed in 35 (81%) of the 43 deliveries from HIV-infected mothers. Chemoprophylaxis during pregnancy and delivery was given to 29 women (67.4% of all the pregnant women). Thirty-eight of the newborns received chemoprophylaxis (88.3%).

In 2 cases of late detection of HIV infection in 2004-2005, chemoprophylaxis for mother and child was not administered because the HIV infection was diagnosed more than 3 days after delivery. The first case was a woman from St. Petersburg, whose pregnancy had not been followed up in her home community. Delivery took place in a small town in Karelia and the woman was admitted to hospital in the first stage of delivery. Since she did not notify the obstetrician of her condition, and since the hospital had no rapid tests available at that time, the positive HIV diagnosis was not made until she and her newborn child were tested later at the Republican AIDS Centre. In the second case the newborn also did not receive chemoprophylaxis because the testing had to be postponed due to lack of a rapid test. Nowadays rapid tests are available at all medical centres in Karelia.

Afterwards all children were followed up for the first 12 months by district physicians or physicians at the Republican AIDS Centre in accordance with procedures regulated by the normative documents.   By the age of 12 months the antibodies no longer reflect the mother’s status due to disintegration and the children were withdrawn from the regular clinical follow-up programme. Since 2007 the PCR diagnostic test has been carried out throughout Karelia. The test allows the diagnosis of HIV infection to be confirmed or eliminated in the early stages.

By the beginning of 2007, 23 HIV-negative children out of the 43 born to HIV-infected mothers had been withdrawn from the regular follow-up programme and 14 children with uncertain status were being followed up. One of the 2 children who did not receive chemoprophylaxis immediately after birth left for St. Petersburg with its mother and we have no data about this child. Another child was removed from the regular follow-up programme after 12 months of follow-up.

Table 4. Chemoprophylaxis for vertical transmission of HIV infection in the Republic of Karelia

 

Deliveries

Chemoprophylaxis, women

Chemoprophylaxis, children

1999

1

0

0

2002

8

6

8

2003

5

5

5

2004

10

9

9

2005

8

7

7

2006

11

11

11

Thus by the beginning of 2007 no perinatal infection was to be found among newborns in the Republic of Karelia. This was due to the measures taken by the State Institution of Health, Republican AIDS Centre, the obstetricians and the district paediatricians, which ensured a high level of follow-up of HIV-infected pregnant women and newborns from HIV-infected mothers.


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