Advertisement
JOGC

HIV/AIDS is Not Over

      As Canada and the world struggles to recover from the SARS-CoV-2 pandemic, it is important to remember that the HIV/AIDS epidemic is not over, despite significant advances in diagnosis and treatment over the last few decades.
      In the eighties, in Canada, HIV/AIDS was understood as a disease that predominantly affected gay men, people who inject drugs, patients with hemophilia, and immigrants from Haiti. It took many years to recognize that women were also being infected, and affected, by HIV/AIDS and that infants too were vulnerable to the disease.
      I was a chief resident in obstetrics and gynaecology 30 years ago when I watched my dear friend and medical school classmate Dr. Peter Jepson-Young, then one of Canada’s most well known AIDS activists, succumb to the disease. At the time, I was acutely aware that our community was not recognizing the burden of HIV/AIDS for women, particularly pregnant women. There was little dedicated care for women with HIV, and the medical establishment was only beginning to recognize the specific care needs of pregnant women living with HIV.
      Around this time, in 1990 to be exact, our pediatric colleagues Dr. Jack Forbes and the late Dr. Susan King had the foresight to launch what became the Canadian Perinatal HIV Surveillance Program (CPHSP), which continues today as a great example of pan-Canadian perinatal disease surveillance.
      As an infectious diseases fellow at the University of Washington in the early nineties, I had the opportunity to enroll women into what would become the most pivotal trial in the area of HIV transmission in pregnancy. The protocol was ACTG 076—a double-blind, placebo-controlled trial of zidovudine versus placebo. It was bold to suggest treating women in pregnancy with a relatively new antiretroviral medication. In February 1994, the trial had a planned interim review, and on the Tuesday after the U.S. President’s Day long weekend, the data came pouring out of the fax machine at our women and children’s HIV clinic in Seattle. It was truly astonishing! This was the first example of HIV treatment as prevention.
      Women on zidovudine had only an 8% transmission rate to their infants compared with a 25% transmission rate in the placebo group.
      • Connor E.M.
      • Sperling R.S.
      • Gelber R.
      • et al.
      Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group.
      We immediately called our patients in to get them on open-label zidovudine, and, when I returned to our comprehensive women's and children's HIV centre, the Oak Tree Clinic, in Vancouver, later that year, we began to prescribe the same prophylaxis here. That was the beginning of a progressive increase in the complexity of treatment of HIV in pregnancy that has now advanced to the point where we can assure women with HIV that they can have a safe pregnancy with a <1% risk of transmitting HIV to their infant.
      • Forbes J.C.
      • Alimenti A.M.
      • Singer J.
      • et al.
      A national review of vertical HIV transmission.
      Sadly, this was not the end of the story when it came to preventing HIV transmission in pregnancy. There are many parts of the world where timely diagnosis and treatment is not accessible, and even Canada has seen increasing rates of transmission in the last few years—up to 3% in 2021

      Singer J, Sauve L, Bitnun A, et al. The effect of the COVID-19 pandemic on access to HIV Treatment and vertical transmission: results from the Canadian Perinatal HIV Surveillance Program [abstract]. In: The 24th International AIDS Conference (AIDS 2022). July 29 to August 2, 2022; Montréal, QC.

      —caused by barriers to diagnosis and care. Our new goal should be eliminating infection: 0% infants diagnosed with HIV. And 100% of pregnant women in Canada should be able to access optimal therapy for themselves and their infants.
      We must also recognize that there are many women living with HIV in Canada today, an estimated 15 000,
      Government of Canada
      People living with HIV in Canada: infographic. Government of Canada.
      and that women make up approximately 30% of new infections.
      Public Health Agency of Canada
      HIV in Canada: 2019 surveillance highlights. Government of Canada.
      These women will need ongoing care as they age with a disease that, although controllable, is nonetheless associated with accelerated biologic aging. These patients require tailored gynaecologic care.
      HIV/AIDS is not over, and we must remain vigilant and attentive to what is needed to ensure we move more rapidly toward the global goal of ending the AIDS epidemic. As obstetricians and gynaecologists, we have a real and important part to play in this narrative, and I urge you to remember that HIV/AIDS has not yet been conquered.

      References

        • Connor E.M.
        • Sperling R.S.
        • Gelber R.
        • et al.
        Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group.
        N Engl J Med. 1994 Nov 3; 331: 1173-1180
        • Forbes J.C.
        • Alimenti A.M.
        • Singer J.
        • et al.
        A national review of vertical HIV transmission.
        AIDS. 2012 Mar 27; 26: 757-763
      1. Singer J, Sauve L, Bitnun A, et al. The effect of the COVID-19 pandemic on access to HIV Treatment and vertical transmission: results from the Canadian Perinatal HIV Surveillance Program [abstract]. In: The 24th International AIDS Conference (AIDS 2022). July 29 to August 2, 2022; Montréal, QC.

        • Government of Canada
        People living with HIV in Canada: infographic. Government of Canada.
        (Available from:)
        • Public Health Agency of Canada
        HIV in Canada: 2019 surveillance highlights. Government of Canada.
        (Available at:)

      Linked Article

      • Le VIH/sida est encore présent
        Journal of Obstetrics and Gynaecology Canada Vol. 44Issue 12
        • Preview
          Pendant que le Canada et le monde peinent à se remettre de la pandémie de SARS-CoV-2, il est important de se rappeler que l’épidémie de VIH/sida n’est pas terminée malgré les importants progrès en diagnostic et en traitement réalisés ces dernières décennies.
        • Full-Text
        • PDF