Reproductive health of adolescent girls perinatally infected with HIV 11th Annual Maternal and Child Health Epidemiology Conference December 7, 2005

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Reproductive health of adolescent girls
perinatally infected with HIV11th Annual
Maternal and Child Health Epidemiology
ConferenceDecember 7, 2005

• Susan Brogly, Heather Watts, Nathalie Ylitalo,
• Eduardo Franco, George Seage III, James Oleske,
• Michelle Eagle, Russell Van Dyke

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BACKGROUND

• Rate of pregnancy in perinatally HIV infected
  girls and effectiveness of antiretroviral therapy
  (ART) in preventing 2nd generation perinatal HIV
  transmission unknown
• High rate of cervical human papilloma virus (HPV)
  infection and squamous intraepithelial lesions
  (SIL) in women adolescents infected with HIV
  through drug and sexual behaviors
• This has not been studied in perinatally HIV
  infected adolescent girls

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OBJECTIVES

• To estimate the rate of pregnancy, genital
  infections, and cervical dysplasia in a US cohort
  of perinatally HIV infected adolescent females
• To identify the demographic and HIV disease
  related characteristics associated with these
  outcomes

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STUDY POPULATION

• Source population PACTG 219C cohort
• 1,305 perinatally HIV-infected girls
• Study population
• 453 perinatally HIV-infected girls ?14 years of
  age
• From 73 clinics in 23 states and Puerto Rico
• Median follow-up 29.2 months (10th, 90th 4.9,
  72.7) from their 14th birthday
• 160 (35.3) known to be sexually active

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DATA COLLECTION

• Every 3 months histories of clinical diagnoses,
  pregnancy ART use collected
• Annual pelvic examinations taken in sexually
  active girls
• Frequently screened for genital infections
  (condyloma, Chlamydia, trichomoniasis, syphilis,
  gonorrhea) at this time
• Annual cervical Papanicolaou (Pap) smear
  examinations taken in sexually active girls
• Pap smears fixed using spray preservative and
  sent to the local institutions laboratory for
  review
• Diagnoses of ASCUS, LSIL, HSIL made according to
  the Bethesda system for cytological specimens

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STATISTICAL ANALYSIS

• Estimated the incidence rate of
• Pregnancy
• Genital infections (condyloma, Chlamydia,
  trichomoniasis, syphilis, gonorrhea)
• Abnormal cervical cytology
• Differences characteristics of girls with and
  without above outcomes assessed with Fisher exact
  and Kruskal-Wallis tests

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INCIDENCE OF 1st PREGNANCY
25.6/1,000 pyrs (17.4-36.4) 14 to 23
years 34.9/1,000 pyrs (23.0-50.8) 15 to 19 years
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CHARACTERISTICS BY PREGNANCY STATUS
Characteristic Pregnant (N31) Non-pregnant (N422)
Median age 16.9 (15.4, 19.8) 16.2 (14.4, 19.6)
Race/ethnicity Black Hispanic White/other 9 (29.0) 17 (54.8) 5 (16.1) 243 (57.6) 118 (28.0) 61 (14.5)
Living conditions With biologic parent(s) With adoptive parents (s) With other adult(s) Foster care/residential facility On own 12 (38.7) 1 (3.2) 5 (16.1) 1 (3.2) 12 (38.7) 124 (29.4) 89 (21.1) 164 (38.9) 22 (5.2) 23 (5.5)
Genital infection 9 (29.0) 23 (5.5)
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CHARACTERISTICS CONTD
Characteristic Pregnant Non-pregnant
CD4 lt 15 15 to 24 ? 25 5 (21.7) 8 (34.8) 10 (43.5) 90 (21.3) 96 (22.8) 236 (55.9)
HIV RNA viral load (copies/mL) lt1,000 1,000 to lt10,000 ? 10,000 10 (43.5) 11 (47.8) 2 (8.7) 210 (49.8) 86 (20.4) 126 (29.9)
ART prophylaxis In utero exposure 1st 6 weeks of life 0 (0.0) 0 (0.0) 3 (0.7) 2 (0.5)
Currently on ART 24 (77.4) 366 (86.7)
Currently on HAART (girls on ART only) 13 (54.2) 307 (83.0)
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PREGNANCY OUTCOMES

• 1st pregnancies (N31)
• 23 live births (1 set of twins) 3 spontaneous
  abortions 6 therapeutic abortions
• 2nd pregnancies (N3)
• 2 live births 1 therapeutic abortion
• All mothers on ART during pregnancy
• Infant infection status (N25)
• 1 HIV-infected, 23 uninfected, 1 unknown
• HIV transmission rate 4.0 (95 CI 0.10-20.35)

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GENITAL INFECTIONS
Infection No. of cases No. of subjects Cumulative incidence () at 60 months (95 CI)
Condyloma 10 438 4.17 (1.15-7.19)
Chlamydia 9 452 3.17 (0.86-5.48)
Trichomoniasis 8 451 4.62 (0.76-8.48)
Gonorrhea 6 452 1.99 (0.24-3.74)
Syphilis 1 453 0.40 (0.00-1.18)
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CERVICAL CYTOLOGY

• 84 (18.5) girls had Pap smears - 51.9 of 160
  girls known to be sexually active
• 41.7 1 Pap smear, 15.5 2 Pap smears, and 42.9
  3 Pap smears
• 39 (46.4) had cervical abnormalities
• 1st abnormal cytologic diagnosis ASCUS (N16),
  LSIL (N21), HSIL (N2)
• Cumulative incidence of SIL at 12 months 21.97
  (4.86-39.08)
• Among 20 girls with intervention, 5 cervical
  abnormalities cleared, 2 regressed to less severe
  SIL, 8 persisted, and 5 progressed to more severe
  SIL

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LIMITATIONS

• Some spontaneously or therapeutically aborted
  pregnancies may not have been identified
• Could have underestimated the pregnancy rate
• Screening for genital infections was not
  performed routinely as part of the 219C protocol
• Estimated rates represent minimum rate of genital
  infections
• Analysis of cervical cytology restricted to girls
  with Pap smears likely included girls with
  high-risk sexual behavior
• Could have overestimated the rate of abnormal
  cervical cytology

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CONTRIBUTION

• Despite the relatively low number of births, ART
  appears effective in preventing 2nd generation
  perinatal HIV transmission
• 16 of girls pregnant before 20th birthday 46
  had abnormal cervical cytology
• 50 of the girls known to be sexually active had
  Pap smears
• Underscores the importance of obtaining sexual
  histories, recommending routine Pap smears,
  conservative cytological follow-up, education
  on safer sexual practice in this population