Prevention of vertical transmission of HIV infection in Рerm region: problems and prospects

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Introduction

Human immunodeficiency virus (HIV) is one of the most serious medical and social problems [1]¹. In recent years, there has been an increase in the proportion of socially wellbeing part of the population among HIV-infected people. A significant aspect of the fight against the HIV/AIDS epidemic is the prevention of vertical transmission of HIV, since transmission of the virus from mother to child remains one of the most pressing ways of spreading the infection. Currently, more than 10 thousand children and adolescents in Russia live with HIV, and the vast majority of them are infected with HIV from their mothers vertically [2]. Therefore, it is important to start treatment before conception, which helps prevent vertical transmission of the virus during pregnancy, childbirth and breastfeeding. This is especially important due to the fact that effective treatment can reduce the viral load and improve the immune status of the mother, which in turn reduces the risk of infection of the fetus [3; 4]. This problem is especially acute in regions with high incidence rates, such as the Perm region. The relevance of this topic is due to the fact that, despite successful HIV prevention and treatment programs, vertical transmission continues to be a significant threat to the health of children in the region.

The aim of the study is to analyze the situation with vertical transmission of HIV in the Perm Territory for 2020–2024, identify factors that prevent the risk of vertical transmission of infection from being minimized, and assess existing prevention programs and their effectiveness.

Materials and Methods

The method of statistical analysis of the indicators of the federal state statistical observation forms No. 2 "Information on infectious and parasitic diseases" and No. 61 "Information on the disease caused by the human immunodeficiency virus" in the Perm Territory for 2020–2024, the accounting and reporting forms of the State Budgetary Healthcare Institution "Perm Regional Center for the Prevention and Control of AIDS and Infectious Diseases" and data from the Ministry of Health of the Perm Territory was applied.

Results and Discussion

Perm Territory ranked 14th among the constituent entities of the Russian Federation in terms of the incidence rate (64.2 per 100 thousand population), according to data for 2023². For the period from 1987 to 2024, 49,225 people with HIV infection were registered in the Perm Territory, including 32,328 currently living. In 2024, 1,530 new cases of HIV infection were identified, which is 50 less than in 2023. An analysis of the gender of people diagnosed with HIV infection for the first time in their lives showed that in 2024, there was an increase in cases of the disease in women in the Perm Territory (Fig. 1).

Fig. 1. HIV detection by gender for 2020–2024, %

The total number of HIV-infected women as of 2024 was 14,177, of which the majority (75.6 %) were of reproductive age. The “feminization” of the infection is largely associated with sexual transmission of the virus (Fig. 2). This circumstance can certainly aggravate the problem of vertical transmission of HIV infection.

Fig. 2. The proportion of men and women by HIV transmission routes in 2024, %

For women living with HIV who are of reproductive age, planning pregnancy is a key step in preventing vertical transmission of the virus. Effective prenatal HIV prevention includes several important aspects, with a primary focus on early initiation of antiretroviral therapy (ART). Initiation of ART prior to current pregnancy remains the leading factor in reducing perinatal HIV transmission³. In the Perm Territory, the overwhelming majority (92.3 %) had their diagnosis confirmed before pregnancy of the 388 HIV-positive patients who gave birth in 2024 (Table 1). However, only 71 % of women received ART before pregnancy and had an undetectable viral load at their first visit, with the recommended rate being 90 %. Overall, the Perm Territory has seen a satisfactory level of testing pregnant women for HIV antibodies over the past four years. In 2024, the coverage of pregnant women with HIV testing using the ELISA method (upon registration for prenatal care at a women's clinic and upon admission to an obstetric hospital for childbirth) was 100 %.

Table 1. Number of births in HIV-infected women in 2021–2024

It is known that the most important factor influencing the probability of HIV transmission from mother to fetus and child is the level of viral load during pregnancy and childbirth, so it is important to achieve its undetectable values as early as possible. Initially, when registering for pregnancy, 97.8 % of HIV-positive pregnant women who gave birth in 2024 were tested for viral load, with a standard indicator of 100 % (Table 2).

Table 2. Viral load levels in pregnant women registered for prenatal care at antenatal clinics for 2021–2024

Achieving an undetectable viral load is key to preventing vertical transmission of the virus from mother to child. An undetectable viral load in 90.0 % of women before delivery is the main criterion for providing medical care to pregnant women infected with HIV [7].

In 2024, a total of 341 (92.2 %) women were tested for viral load at 34–36 weeks of pregnancy, in 72.7 % of cases the viral load was undetectable (less than 50 copies/ml), in 91.5 % of cases the viral load was up to 1000 copies/ml. In 93 (27.3 %) women the viral load was detectable, which indicates either ineffective antiretroviral therapy during pregnancy or insufficient adherence of patients to its implementation. The reasons for ineffective chemoprophylaxis (CP) during pregnancy may be both irregular intake and unauthorized discontinuation of medications, as well as the start of therapy in the late stages of pregnancy. Currently, the recommended time to start ART in HIV-positive patients is before pregnancy or at 13 weeks of pregnancy. If this condition is met, the risk of perinatal transmission of HIV infection is reduced to minimum values. The beginning of ART at 14–27 weeks increases the risk of HIV transmission from mother to child by 2.3 times, from the 28th week and later – by 4.5 times [7]. The proportion of women who started taking ART before pregnancy or before 14 weeks of gestation was 81 % in the Perm Territory in 2023 (Table 3).

Table 3. Initiation of ART for HIV-infected pregnant women depending on the gestational age for 2021–2024

In general, the coverage of HIV-positive women and newborns with chemoprophylaxis in the Perm Territory in 2024 was quite high and corresponded to the standard indicators (Fig. 3). At the same time, the coverage of chemoprophylaxis at the stage of pregnancy (stage I) in comparison with the data of 2022–2023 remained practically unchanged and, as in previous years, was lower than the coverage of newborns.

Fig. 3. Coverage of chemoprophylaxis of HIV-infected pregnant women and newborns in Perm Region for 2021–2024, %

In total, 8,612 children were born to HIV-infected mothers in the Perm Territory from 1998 to 2024. In 2024, 391 children were born (Fig. 4).

Fig. 4. Number of children born to HIV-infected mothers in Perm Region for 1998–2024, abs.

There is a positive trend in reducing the risk of infection of children born to HIV-positive mothers in the Perm Territory. If in 2014 the proportion of children infected with HIV was 5.2 %, then in 2022 this figure dropped to 2.1 %, and in 2024 – to 1.2 %. This indicates a high level of effectiveness of preventive measures and an improvement in the quality of medical monitoring of patients. The total number of children with HIV infection registered at the dispensary was 327, of which 38 children were born to women who were seronegative during pregnancy. In a third of cases, the presence of HIV infection in mothers was detected a month after childbirth and later. Due to the late diagnosis of HIV infection in the mother, measures to prevent vertical transmission of HIV to HIV-infected children were not carried out. Also, more than a third of the children were breastfed, which significantly contributed to the transmission of HIV infection from the mother.

Thus, despite satisfactory testing of pregnant women for antibodies to HIV infection in the Perm Territory, insufficient explanatory work is being carried out among HIV-infected patients. This leads to the failure to fully implement preventive measures aimed at preventing vertical transmission of HIV. The primary coverage of viral load testing among registered pregnant women was 97.8 %, and at 34–36 weeks of pregnancy – 92.2 %, with the standard indicator being 100 %. During a repeat examination at 34–36 weeks of pregnancy, detectable viral load was detected in 27.3 % of cases, which indicates that stage I of chemoprophylaxis was not carried out effectively enough. Strengthening information and outreach work and supporting HIV-positive women in following recommended medical protocols can significantly reduce the risk of mother-to-child transmission of the virus.

Conclusions

1. There is a positive dynamic in reducing the risk of vertical transmission of HIV from mothers to children in the Perm Territory. Thanks to effective preventive measures such as early diagnosis, antiretroviral therapy and medical monitoring of pregnant women, it has been possible to significantly reduce the number of infected children.
2. However, despite satisfactory testing of pregnant women for HIV antibodies, there is a need to strengthen educational work among HIV-infected patients. This will help to increase awareness and compliance with all preventive measures aimed at minimizing the risk of vertical transmission of infection. Therefore, it is important to pay attention not only to medical aspects, but also to educational programs for women.
3. The importance of cooperation between doctors of various specializations (infection specialists, obstetricians and gynecologists) and social workers is undeniable. Joint work of specialists allows achieving comprehensive approach to treatment and prevention, as well as preventing possible refusals of treatment, which reduces the risk of transmission of infection from mother to child.
4. Regular assessment and monitoring of the effectiveness of the activities will help to promptly make adjustments, thereby increasing their effectiveness. It is also important to analyze each case of HIV transmission from mother to child in order to identify the causes and eliminate possible gaps in the organization of assistance.

¹ World Health Organization. Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, Guidelines Review Committee. “Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach”, available online: https://www.who.int/publications/i/item/9789240031593 (accessed on 4 October 2022).

² Reference of HIV infection in the Russian Federation in 2023, available at: http://www.hivrussia.info/wp-content/uploads/2024/09/spravka-vich-v-rossii-2023-god.pdf

³ Clinical guidelines "HIV infection in pregnant women". M. 2021, available at: https://cr.minzdrav.gov.ru/preview-cr/717_1.

About the authors

Yu. V. Rakitina

Author for correspondence.
Email: yuvlara2014@gmail.com
ORCID iD: 0009-0003-6040-5800

DSc (Medicine), Acting Head of the Department of Obstetrics and Gynecology No. 2

References

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2. Fig. 1. HIV detection by gender for 2020–2024, %

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3. Fig. 2. The proportion of men and women by HIV transmission routes in 2024, %

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4. Fig. 3. Coverage of chemoprophylaxis of HIV-infected pregnant women and newborns in Perm Region for 2021–2024, %

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5. Fig. 4. Number of children born to HIV-infected mothers in Perm Region for 1998–2024, abs.

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