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Inicio Enfermedades Infecciosas y Microbiología Clínica (English Edition) Congenital HIV infection after failure of serological screening. Importance of i...
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Vol. 37. Issue 9.
Pages 619 (November 2019)
Vol. 37. Issue 9.
Pages 619 (November 2019)
Scientific letter
DOI: 10.1016/j.eimce.2018.09.006
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Congenital HIV infection after failure of serological screening. Importance of implementing a second screening for HIV infection during the third trimester of pregnancy
Infección congénita por el VIH con cribado serológico gestacional negativo. Importancia de la implementación de la segunda prueba en el tercer trimestre de gestación
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Javier García-Abellána, Sergio Padillaa, María Isabel Serranob, Mar Masiáa,
Corresponding author
marmasiac@gmail.com

Corresponding author.
a Unidad de Enfermedades Infecciosas, Hospital General Universitario de Elche, Universidad Miguel Hernández, Elche, Alicante, Spain
b Servicio de Pediatría, Hospital General Universitario de Elche, Elche, Alicante, Spain
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HIV infection is still a severe childhood health problem in less developed countries.1 Although the incidence of new infections has decreased in recent years, 160,000 new cases are still occurring on an annual basis.1,2 In a setting such as ours, with easy accessibility to the healthcare system and to antiretroviral therapy (ART), the perinatal HIV transmission rate can be reduced to less than 1%.3 However, even today cases are still being reported, as demonstrated by the six new diagnoses due to mother-to-child transmission recorded in 2016 in Spain, of whom two were of Spanish origin and the rest from other countries, with no data on the prevention protocols applied in the latter (two from Sub-Saharan Africa, one from Latin America and another from Eastern Europe).4

Recently, in the latest consensus document from the Grupo de Estudio de Sida [AIDS study group (GeSIDA)] and the Sociedad Española de Ginecología y Obstetricia [Spanish Society of Gynaecology and Obstetrics, (SEGO)], the pregnancy screening protocol has been modified. It is now recommended to do an HIV serological measurement in the third trimester, in addition to the routine one in the first trimester. In high-risk cases, another measurement can also be added in the second trimester.5 However, the North American guidelines from the Centers for Disease Control and Prevention (CDC) only recommend repeating the test in the third trimester in pregnant women with a high risk of contracting HIV, defined as those who receive care in areas with a high incidence of HIV infection.6 The performance of this second measurement is considered cost-effective, given that the cost of ART far exceeds the cost in the measurement of a second test, which is currently around two dollars per measurement.7,8

Not carrying out the second test in the third trimester may lead to errors in the diagnosis of infections acquired during pregnancy which may be passed on to the foetus. In our centre, we recently cared for a male newborn aged 27 days who was brought to the paediatric emergency department due to malnutrition and epistaxis which had started two days beforehand. He was also partly rejecting food, with no other symptoms. The pregnancy was monitored in the mother's local hospital. The first semester serological tests (HIV, syphilis, hepatitis B and C viruses), which were performed in the eighth week of pregnancy, were negative. The baby was delivered through a normal vaginal delivery with amniorrhexis of 46h at week 38+4 of pregnancy. The newborn baby weighed 2775g (15th percentile). He was admitted at 3 days old due to weight loss and symptomatic hypoglycaemia which were attributed to poor feeding technique by the parents. He was readmitted at 27-days-old with a clinical picture of malnutrition, weighing 2570g (percentile <3) with a size of 50cm (3rd percentile).

In the study of malnutrition causes in the infant which included, among others, screening for metabolic diseases, congenital heart diseases, blood diseases and congenital infections, a serological test and an HIV viral load measurement were ordered which were positive (RNA HIV-1 6,654,360copies/ml). HIV-1 infection was also confirmed in both parents, which they were unaware of until that time.

The risk of primary HIV infection is greater during pregnancy due to the fact that, as a result of hormonal changes which occur during pregnancy, there are alterations in the vaginal mucosa and in the immune system, which promote the acquisition of the virus.9 Furthermore, in these cases, the risk of perinatal transmission increases up to eight times, hence the importance of obligatory compliance with the third trimester screening programmes in all pregnant women.10

With this letter, we want to warn of the risk of failure with the first-semester prenatal screening programme, and report a new case of mother-to-child transmission of HIV in our setting, which also displayed an atypical presentation. This case, along with others published in the literature,10 would potentially be preventable if the recommendation for a second serological test in the third trimester was compulsory and was not performed on an optional basis, as it has been up to now.

References
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Global AIDS monitoring 2017: indicators for monitoring the 2016 United Nations Political Declaration on HIV and AIDS.
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M.G. Fowler, M. Qin, S.A. Fiscus, J.S. Currier, P.M. Flynn, T. Chipato, et al.
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N Engl J Med, 375 (2016), pp. 1726-1737
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F. Canals, M. Masiá, F. Gutiérrez.
Developments in early diagnosis and therapy of HIV infection in newborns.
Expert Opin Pharmacother, 19 (2017), pp. 13-25
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Área de Vigilancia de VIH y Comportamientos de Riesgo. Vigilancia Epidemiológica del VIH y sida en España 2016: Sistema de Información sobre Nuevos Diagnósticos de VIH y Registro Nacional de Casos de Sida. Plan Nacional sobre el Sida-S.G. de Promoción de la Salud y Epidemiología/Centro Nacional de Epidemiología - ISCIII. Madrid. Nov 2017.
[5]
Documento de consenso para el seguimiento de la infección por el VIH en relación con la reproducción, embarazo, parto y profilaxis de la transmisión vertical del niño expuesto. Grupo de expertos de la Secretaría del Plan Nacional sobre el Sida (SPNS), Grupo de Estudio de Sida (GeSIDA)/Sociedad Española de Ginecología y Obstetricia (SEGO) y Sociedad Española de Infectología Pediátrica (SEIP). Marzo 2018.
[6]
Laboratory testing for the Diagnosis of HIV infection: updated recommendations. Centers for Disease Control and Prevention and Association of Public Health Laboratories.
[7]
C.D. Pilcher, J.T. McPherson, P.A. Leone, M. Smurzynski, J. Owen-O’Dowd, A.L. Peace-Brewer, et al.
Real-time, universal screening for acute HIV infection in a routine HIV counseling and testing population.
JAMA, 288 (2002), pp. 216-221
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L.S. Wilson, R. Basu, M. Christenson, L. Hensic, C. Paoli, D. Wara, et al.
Pediatric HIV costs across three treatment eras from 1986 to 2007.
Pediatrics, 126 (2010), pp. 541-549
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L. Brabin.
Interactions of the female hormonal environment, susceptibility to viral infections, and disease progression.
AIDS Patient Care STDS, 6 (2002), pp. 211-221
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J. Wertz, J. Cesario, J. Sackrison, S. Kim, C. Dola.
Acute HIV infection in pregnancy: the case for third trimester rescreening.
Case Rep Infect Dis, 2011 (2011), pp. 340817

Please cite this article as: García-Abellán J, Padilla S, Serrano MI, Masiá M. Infección congénita por el VIH con cribado serológico gestacional negativo. Importancia de la implementación de la segunda prueba en el tercer trimestre de gestación. Enferm Infecc Microbiol Clin. 2019;37:618–619.

Copyright © 2018. Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica
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