[Timely implementation of interventions to reduce vertical HIV transmission: a successful experience in Brazil].
OBJECTIVE
To describe the impact, at the public maternity facility of a university hospital in Brazil, of the rapid implementation of new guidelines recommended by national consensus panels concerning the prevention of vertical HIV transmission.


METHODS
We performed a retrospective study of deliveries by HIV-infected women at the public maternity facility of a university hospital in the city of Campinas, São Paulo, Brazil, from 1990 through 2000. The guidelines utilized at the facility during this period were: (1) from 1990 through 1994, contraindication to breast-feeding and no use of antiretroviral drugs; (2) 1995 and 1996, use of zidovudine (AZT) by the pregnant woman and the newborn; (3) 1997 and 1998, use of AZT according to the ACTG 076 protocol; and (4) 1999 and 2000, multiple antiretroviral agents and elective cesarean delivery. All the antiretroviral drugs were provided for free by Brazil's public health care system. The vertical transmission rate was calculated for each of the four stages, and the risk ratio for congenital transmission was calculated for each stage and for each prophylactic intervention separately (breast-feeding, type of antiretroviral drug, type of delivery).


RESULTS
We studied 197 deliveries at the public maternity facility over that 1990-2000 period. Over the four stages, the rate of vertical transmission decreased: it was 32.3% in the first stage, 25.7% in the second, 2.2% in the third, and 2.9% in the fourth. The most pronounced decrease, observed from the second to the third stage, occurred after introduction of the full ACTG 076 regimen. The use of combined antiretroviral agents increased from 0% in the first stage to 46.4% in the fourth stage. There were no cases of vertical transmission in pregnant women treated with multiple drugs. The risk of vertical HIV transmission was 5 times as great with breast-feeding vs. no breast-feeding (risk ratio = 5.06), 5 times as great with no antiretroviral therapy vs. the full ACTG 076 regimen (risk ratio = 5.29), and 4 times as great with forceps delivery vs. elective cesarean delivery (risk ratio = 4.13).


CONCLUSIONS
The timely adoption of up-to-date interventions recommended by national consensus panels, along with the free provision of antiretroviral drugs, was effective in reducing congenital HIV transmission in this public maternity facility. The interaction between the university hospital health service and the public health service reduced the time needed for implementation of proven, effective interventions, and this experience could serve as an example for other maternal and perinatal health situations.
Amaral
Eliana
E
Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Tocoginecologia, Brasil. elianaa@unicamp.br
Assis-Gomes
Francisco
F
Milanez
Helaine
H
Cecatti
José Guilherme
JG
Vilela
Maria Marluce
MM
Pinto E Silva
João Luiz
JL
D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use; D044966:Anti-Retroviral Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001938:Brazil; D001942:Breast Feeding / Q000009:adverse effects; D002585:Cesarean Section; D015331:Cohort Studies; D004359:Drug Therapy, Combination; D005260:Female; D015658:HIV Infections / Q000151:congenital / Q000188:drug therapy / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control*; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious; D012189:Retrospective Studies; D015215:Zidovudine / Q000008:administration & dosage / Q000627:therapeutic use
D019380:Anti-HIV Agents; D044966:Anti-Retroviral Agents; D015215:Zidovudine