Original paper
Epidemiological aspects of pregnant women with human immunodeficiency virus in Brazil

Introduction
The human immunodeficiency virus (HIV) was first identified in 1983 with the serological diagnosis achieved mainly by the Enzyme Linked Immunoassay (ELISA) and Western Blot methods [1, 2].
An important improvement in the treatment of the disease occurred in 1994 with the 076 protocol of the Aids Clinical Trial Group (PACTG 076) showing that the use of zidovudine (AZT) by pregnant women reduces vertical transmission by 67% [3, 4]. Currently, anti-retroviral therapy reduces the maternal plasma viral load to undetectable levels and also reduces transmission of HIV to the baby [5].
In this period the technical and financial difficulties and the approach to the disease and acceptance by patients were widespread in Brazil. However, the Brazilian government took effective measures in the pre-natal period that allowed a reduction in the vertical transmission of HIV by making testing routine and providing zidovudine combined with other anti-retroviral agents to infected pregnant women [5].
The aim of the current study is to report on preliminary epidemiological data in the evaluation of pregnant women with HIV and improvements in the approach to the disease in Brazil.

Material and methods
A prospective study was performed of pregnant women who attended the prenatal outpatients’ clinic of Hospital de Base in Săo José do Rio Preto, Brazil between May 1995 and May 1997, when HIV-positive individuals being identified. After consenting to participate, 4653 pregnant women were tested for HIV as a routine examination in the first prenatal consultation. Epidemiological aspects were noted including age, ethnic background, number of gestations, marital status, type of delivery, and the patients’ knowledge about the disease including: forms of transmission, diseases associated with positive cases, and the difficulties in and evolution of the approach to the disease in Brazil. Serological tests were made employing the ELISA method (DADE-BEHRING) and if positive, the test was repeated; if the second result was also positive, the Western Blot method (Bio-Merieux) was utilized to confirm the diagnosis. Data were inputted in the GraphPad InStat computer program, and statistical analysis used percentages with means and standard deviation.

Results
HIV tests were positive in 48 (1.03%) of the pregnant women; the mean age was 24.3±0.6 years. 35 (72.9%) of the individuals were married and 13 (27.1%) had been pregnant one to four times previously. 52.0% knew they were HIV positive, and in 23 (48.0%), diagnoses was made during the consultations for this pregnancy. In 25 (52.0%) the form of transmission was unknown; events and gravid diseases occurred in 4 (31.2%) cases. In 38 (79.2%) cases delivery occurred before the 36th week of gestation, with delivery being vaginal in 38 (79.2%) cases, and in 8 (16.7%) there were puerperal complications (Table I).

Discussion
The current study presents epidemiological data and reports events in one of the main routine evaluation centers for HIV in Brazil. The inclusion of anti-HIV testing was important to reduce the stigma related to the examination. In the USA, from 1995, performing the test was recommended for every pregnant woman who wanted to do so; however, in Brazil, testing became routine from November 1997 [6].
The highest prevalence of positive tests (72.9%) was for married women, a marital status considered stable, showing that marriage is not without risks in the sexual relationships of a couple, and thus protection needs to be used. Another aspect that was identified was that 52% of the women knew they were infected and still became pregnant, and so mechanisms to protect babies from vertical contamination are essential. This study showed that 42% of the women did not know they were infected, and testing at the start of pregnancy prevented vertical transmission with special care for the pregnant woman. The antiviral medication routinely employed reduces the risk of vertical transmission [6, 7]. The greatest prevalence of positive tests was in patients who had had more than two gestations; the mean number of gestations was 3.3±0.3. The fact that these patients became pregnant again is a motive for reflection showing the necessity to intensify family planning programs and educational campaigns discussing vertical transmission. Illegal drugs and promiscuity were other risk factors identified in this study. Gestational events, such as opportunist infections, are more common in this population than in healthy women.
The 12th World Congress on AIDS in July 1998 showed that the most common form of transmission was sexual contact, with an increase in the number of affected heterosexuals since the 1990s. The second most common form of transmission is by intravenous drug use using syringes contaminated with the HIV virus [5, 8]. Over the last few years, access to drugs to control the disease has been free of charge, prevention programs and routine testing of pregnant women have extended the lives of patients, and there is better control of vertical transmission.

Conclusions
The routine examination to test for HIV during pregnancy allows the identification of women who are unaware of infection by the virus and performance of medicinal prevention for these gravidas.


References
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