Brief Report: HIV-Positive and Breastfeeding in High-Income Settings: 5-Year Experience From a Perinatal Center in Germany.

BACKGROUND: Exclusive breastfeeding is recommended for women living with HIV (WLWH) in low-income-but not in high-income-countries, where milk substitutes are preferred. Some guidelines for high-income countries opted for a shared decision-making process regarding breastfeeding in optimal scenarios with adherence to antiretroviral therapy (cART), suppressed maternal viral load (mVL), and clinical monitoring. Although vertical transmission (VT) risk under cART is estimated below 1% in low-income settings, data from high-income countries are rare. METHODS: We retrospectively analyzed all 181 live births from WLWH at the LMU Munich university hospital perinatal center in Germany between January 2016 and December 2020. We focused on VT, suppressed mVL and optimal scenario rates, breastfeeding frequency, cART regimens, and infant prophylaxis. All women were counseled according to current guidelines, foremost recommending avoidance of breastfeeding. RESULTS: In the 5-year cohort, no VT was observed. One hundred fifty-one WLWH (83.4%) decided not to breastfeed, even in optimal scenarios. Thrity infants (16.6%) were nursed, of which 25 were within an optimal scenario, whereas in 5 cases, breastfeeding was performed with a detectable VL in pregnancy or the postpartum period. All WLWH were treated with cART at delivery, and 91.7% sustained suppressed mVL. Zidovudine infant prophylaxis was given between 2 and 8 weeks but not necessarily over the whole breastfeeding duration and was declined from 5 breastfeeding WLWH. CONCLUSIONS: Although the cohort is too small to assess VT risk through breastfeeding with cART-suppressed mVL, breastfeeding might be an alternative even in high-income countries, but further studies are needed.

Anal cytology as a screening tool for early detection of anal dysplasia in HIV-infected women.

BACKGROUND AND AIM: HIV-infected patients show a high rate of anal dysplasia and anal carcinoma but there is no gold standard for early detection. Therefore, the objectives of this prospective study were: a) evaluation of an anal screening using anal/perianal cytology; b) in case of a positive result to investigate its relation to immune status, clinical symptoms of HIV infection and antiretroviral therapy. PATIENTS AND METHODS: In every HIV-infected woman visiting our gynaecological outpatient clinic, an anal and perianal swab for anal cytology was taken. One experienced cytologist examined all specimens. Relevant details of the HIV-related history such as CDC classification, CD4 count, viral load, actual antiretroviral therapy etc. were documented. RESULTS: Altogether, 104 HIV-infected women were enrolled on this study. The results of 13 (13.5%) anal cytologies were classified as suspicious for low-grade or high-grade anal dysplasia and 6 of these were confirmed in an anal biopsy. A total of 9 out of 13 also had a cervical dysplasia and 12 were positive for high-risk HPV at the cervix. Ten of these women had already experienced clinical symptoms of their HIV infection and 8 showed a nadir of the CD4 count below 200 cells/microl. All but one took a highly active antiretroviral therapy. CONCLUSION: In this pilot study, anal screening using anal cytology showed 13.5% suspected anal dysplasia in HIV-infected women. All performed biopsies revealed the presence of a high-grade anal lesion. The majority of these women already had an advanced disease and/or immune defect related to their HIV infection. In summary, we found anal cytology to be a useful tool to early detect anal dysplasia of high-risk patients such as HIV-infected women. How far this screening method contributes to the prevention of anal cancer has to be evaluated in further investigations.

Pregnant women after physical and sexual abuse in Germany.

BACKGROUND/AIMS: The aim of our study was to evaluate the prevalence of abuse among pregnant women in Germany attending our antenatal outpatient clinic and to observe whether a history of abuse had consequences for women's feelings about their pregnancy. METHODS: 455 women between the 35th and 42nd weeks of gestational age were included and were asked to fill out an anonymous questionnaire concerning their pregnancy, their actual psychological state, and their history of physical/sexual abuse. 600 questionnaires were distributed (return rate 75.8%), 70 women (10.4%) were excluded because of male companionship to ensure their safety in case that they were currently in an abusive relationship with the attending man. RESULTS: 88 women (19.3%) reported a history of sexual and/or physical abuse. Pregnant women after physical and/or sexual abuse significantly more frequently associate negative feelings with their pregnancy than nonabused women. The Hospital Anxiety Depression Scale (HADS) and the SCL-K-9 demonstrated significantly more negative feelings of depression and anxiety, strain, loneliness and less expectation of happiness for their future in abused women. CONCLUSION: Physical and sexual abuse are relevant problems among women in obstetric care that may complicate their pregnancies and make them feel more depressive.

High recurrence rate of cervical dysplasia and persistence of HPV infection in HIV-1-infected women.

AIM: A) evaluation of the recurrence of cervical dysplasia after surgical treatment and of the rate of HPV persistence of HIV-infected women and b) the influence of antiretroviral therapy on the recurrence. PATIENTS AND METHODS: In a retrospective analysis, the follow-up data of HIV-positive women visiting our outpatient clinic regarding results of cervical cytology, cervical HPV detection, cervical biopsy, patient history of dysplasia and antiretroviral therapy were assessed. A total of 388 HIV-positive women had a mean follow-up of 2.7 years and a median of 2.5 outpatient visits. RESULTS: Out of the 344 patients (57.3%) tested for HPV, 197 showed at least one positive HPV result. Of the same group, 136 women had four or more HPV tests which showed that 84 of them (61.8%) had a persistent HPV-infection. Overall, 157/388 had cervical dysplasia and 70 needed surgery. Forty-one of the 70 patients (58.6%) received more than one surgical treatment because of a recurrence, all of this group had persistent HPV. DISCUSSION: The recurrence of cervical dysplasia in HIV-positive women after surgical treatment was found to be very high as was the associated long-term persistence of HPV-infection. HPV persistence represented an excellent marker for relapsing cervical dysplasia.

German-Austrian recommendations for HIV-therapy in pregnancy--common declaration of The German AIDS-society (DAIG), The Austrian AIDS-society (OEAG) as well as The Robert-Koch Institute Berlin (RKI), The German Association of Physicians specialized in HIV Care (DAGNAE), The German Society of Pediatric and Youth Medicine (DGKJ), The German AIDS Pediatric Association (PAAD), The German Society of Obstetrics and Gynecology (DGGG), The National Reference Center for Retroviruses (NRZ), German AIDS Assistance (DAH).

Anti-retroviral therapy during pregnancy--The German/Austrian recommendations to optimise prevention of vertical transmission of HIV and to minimise adverse drug effects. In Germany during the last years about 200 HIV infected pregnant women delivered a baby each year, a number that is currently increasing. To determine the HIV-status early in pregnancy voluntary HIV-testing of all pregnant women is recommended in Germany and Austria as part of prenatal care. In those cases, where HIV infection was known during pregnancy, since 1995 the rate of vertical transmission of HIV was reduced to 1-2%. This low transmission rate has been achieved by the combination of anti-retroviral therapy of pregnant women, cesarean section scheduled before onset of labor, anti-retroviral prophylaxis in the newborn and refraining from breast-feeding by the HIV infected mother. In 1998 an interdisciplinary consensus meeting consisting of gynaecologists, infectious disease specialists, paediatricians, pharmacologists, virologists and members of the German AIDS Hilfe (NGO) updated this combined strategy for the first time. A second update became necessary because of new results in research, approval of new anti-retroviral drugs and changes in the general treatment recommendations for HIV infected adults, which are referred to in the pregnancy guidelines. The updating process was started in July 2000 and was finalized in May 2001. In the updated guidelines recommendations for monitoring of HIV infected pregnant women in prenatal care and for preventive procedures for the newborn in delivery room have been included. The guidelines provide new recommendations on the indication and the starting point for anti-retroviral therapy in pregnancies without complications, drugs and drug combinations to be used preferably in these pregnancies and updated information on adverse effects of anti-retroviral drugs. Also the procedures for different scenarios and risk constellations in pregnancy have been specified. With these current guidelines in Germany and Austria the low rate of vertical HIV-transmission should be further maintained.