Steve Nesheim, M.D.
During the two-plus decades that pediatrician and epidemiologist Steven R. Nesheim, MD, has worked to lower the incidence of mother-to-child transmission of HIV, progress has often occurred at a fast pace. But as elimination of perinatal HIV transmission comes closer into view, progress is likely to shift to a slower, steadier pace.
At the epidemic's peak in 1991, during Dr. Nesheim's tenure at the Department of Pediatrics and as Medical Director of the Pediatric/Adolescent Infectious Disease Program at Emory University's Grady Health System in Atlanta, the number of infants infected with HIV perinatally stood at 1,650.1 But in 1994, when clinical trials showed that timely use of anti-retroviral prophylaxis reduced the risk of HIV transmission from mother to infant, sharp drops in the incidence quickly followed. By 2009, an estimated 151 U.S. infants were infected with HIV transmitted from their mothers, according to data presented by Dr. Nesheim and colleagues at the 2012 Conference on Retroviruses and Opportunistic Infections.2
With elimination of perinatal transmission of HIV on the horizon, the public health, surveillance, and clinical communities began to consider how that goal could be achieved and sustained, according to Dr. Nesheim, who joined the CDC's Division of HIV/AIDS Prevention in 2007. As experts began to discuss the ramifications, Dr. Nesheim realized that the goal of elimination (defined as an incidence of less than 1 per 100,000 live-born infants and a mother-to-child transmission of less than 1%) would not mean that the work required to get there would be over.
While clearly a major public health achievement, eliminating perinatal HIV transmission "is not just a one-time thing...it's a process, not an event," he said. "It won't be trying to reduce incidence from 150 to 80 and then we're done." Instead, "We have to focus on 8,700 pregnancies annually 3 [the approximate number of women with HIV infection who give birth each year] and, from that, reduce the number of infected infants to 80 every year, which is not easy or automatic."
To address this challenge, Dr. Nesheim and colleagues at the CDC began collaborating with numerous stakeholders from the federal government, state and local health departments, clinical experts, and key non-governmental organizations. The two-year effort resulted in the development and implementation of a six-part framework to eliminate mother-to-child HIV transmission (EMCT) in the United States.
The framework takes a comprehensive approach to reaching that goal. It provides a blueprint for implementing proven perinatal HIV prevention and treatment strategies for all HIV-infected women that accomplishes the following:
- Assures that HIV care includes comprehensive reproductive health care, family planning, preconception care services, and HIV testing according to CDC's recommendations
- Conducts comprehensive, real-time case findings of all HIV-infected pregnant women and their exposed infants
- Makes available comprehensive clinical care and social services for women and infants
- Performs detailed reviews of select cases to identify missed prevention opportunities to identify and address local system improvements through quality improvement methodology modeled after the Fetal and Infant Mortality Review (FIMR)
- Conducts research and long-term follow-up to develop safe and effective interventions
- Assures data reporting for HIV surveillance and evaluation of mother-to-child transmission elimination efforts.
The EMCT framework reflects significant input of evidence-based research, coordination, and follow-up. But to Dr. Nesheim, another way to think about it is simply "how to improve on what's being done for pregnant women. If we can get pregnant women in proper care, identify them, get them tested and treated, that alone…will further reduce the number of babies that get infected."
And that, over time, will reduce the number of adolescents and young adults with perinatally acquired HIV, a population Dr. Nesheim is well-acquainted with from his experience as Medical Director of Grady Health System's Ponce De Leon Center. Founded in 1993, the center provides medical and support services and is one of the largest facilities in the United States providing HIV/AIDS care to approximately 5,000 men, women, adolescents, and children.
While the survival and well-being of adolescents born with HIV is remarkable, "they are not just sailing into adulthood unscathed," Dr. Nesheim said. An article he and colleagues at the CDC published in 2011 in Current Opinions in Obstetrics and Gynecology4 confirms that observation. Adolescents who are long-term HIV survivors have three distinct behavioral health challenges: decreased medication adherence, sexual activity that brings risk of pregnancy and transmission, and mental health problems. To benefit fully from treatment advances, they need coordinated, multidisciplinary support services, including medication adherence, reproductive health counseling, and mental health and educational planning.
With the tremendous progress made toward eliminating perinatal HIV transmission, Dr. Nesheim points to HIV testing as the resource that yields the biggest pay-off. "One of the best things people can do is to get tested," he said. Testing and the information it provides puts into motion the interventions that will make perinatal HIV elimination a reality.
Yet attaining this goal will bring distinct challenges, Dr. Nesheim predicts. "We still have thousands of HIV-infected women delivering every year who need preventive efforts," he noted. "We will have to accomplish that in a different way every year with a new group of HIV-infected women."
- Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999;282:531–538. (cited in Mother-to-Child [Perinatal] HIV Transmission and Infection, Factsheets, Centers for Disease Control and Prevention). Available at: http://www.cdc.gov/hiv/topics/perinatal/resources/factsheets/perinatal.htm
- Taylor A, Little K, Zhang X et al. Estimated Perinatal ARV Exposure, Cases Prevented, and Infected Infants in the Era of ARV Prophylaxis: US._CROI, 2012 Seattle. 19th Conference on Retroviruses and Opportunistic Infections.
- Whitmore SK, Zhang X, Taylor A, et al. Estimated Number of Infants Born to HIV-Infected Women in the United States and Five Dependent Areas, 2006. JAIDS. 1 July 2011; 57(3): 218–222.
- Koenig, LJ, Nesheim SR, Abramowitz S. Adolescents with Perinatally Acquired HIV: Emerging Behavioral and Health Needs for Long-Term Survivors. Curr Opin Obstet Gynec 2011, epublished August 11.