HIV IN PREGNANCY IN THE CITY OF MUMBAI
Duru Shah*, Safala Shroff**, Kedar Ganla**
*Associate Professor of Obstetrics and Gynaecology; **Clinical Research Associate, Kwality House, Kemps Corner, Above Chinese Room, Mumbai 400 026. India.
Objective : To study the prevalence of HIV positive pregnant women in the semi-private sector in the city of Mumbai, and compare the findings and the prevalence with that of a general hospital. The obstetric outcome of the sero-negative and sero-positive group was also compared.
Design : A prospective comparative study.
Setting : Antenatal clinics of semi-private hospitals.
Participants : 1000 women attending the antenatal clinics of semi-private hospitals (upper middle class strata of society), between 20-28 weeks of gestation in the years 1994-1995.
Methods : The women were screened for HIV by ELISA all women who tested positive by ELISA were subjected to Western Blot to confirm the HIV status.
The results were then compared to the incidence of HIV sero-positivity in pregnant women attending a University Teaching Hospital (lower middle class strata of society) in Mumbai over the same period.
Results : Of 1000 women tested, a total of 8 were confirmed as positive, giving an incidence of 0.8% in our study in the year 1995. The obstetric outcome of these patients did not differ significantly from those of sero-negative women. The incidence of prematurity, stillbirth or IUGR was not affected by the presence of HIV infection. In majority, HIV transmission was heterosexual. At the University Teaching Hospital over the same period, out of 20578 pregnant women who were tested for HIV sero-positivity, the incidence of HIV sero-positive women was 0.81%, similar to the semi-private hospitals.
Conclusion : The fact that the women in the semi-private sector also had the same sero-positivity as a University Teaching Hospital should make us aware that this disease is not limited to the lower socioeconomic strata of society. By screening the antenatal population attending semi-private clinics in the city of Mumbai, we have been able to confirm that HIV infection has permeated through all the socioeconomic strata of society and needs to be attacked at all levels. As obstetricians, if we can detect HIV sero-positivity in pregnant mothers by making HIV testing mandatory for all patients and by offering preventive measures and drug therapy to prevent the increasing incidence of paediatric AIDS, we will be able to reduce the incidence of AIDS in children.
The struggle against sexually transmitted diseases constitutes a priority of public health in developing countries. HIV is the most dreaded disease of them all. The HIV epidemic in India has been growing stealthily over the past 10-12 years. More and more women are being infected through their infected partners all over the world, with an increasing proportion of cases attributed to heterosexual transmission and a few through blood transfusions, bone allografts, tissue transplants and occasionally through injections of immunoglobulins prepared from pooled sera.  More disturbing is the knowledge of mother to child transmission of the disease. In a nutshell the impact of the HIV on human life has been devastating.
Public awareness has been too little and too late to stop a major epidemic. In India serosurveillance has shown that HIV infection is present in all states in urban and rural areas. It is estimated that 2-3 million are sero-positive in India (over 50% ofthem being mother and child) .
With increasing number of women infected worldwide great efforts are being made towards detection of this disease in pregnancy and reduction of perinatal transmission. Antenatal screening of HIV, though not mandatory has been gaining ground as a part of antenatal care.
To study the prevalence of HIV positive pregnant women in the semi-private hospitals in the city of Mumbai, and compare with the prevalence of a general hospital. The obstetric outcome of the sero-negative and sero-positive group was also compared.
1000 women attending the antenatal clinics of semi-private hospitals were screened for HIV by ELISA using the Bio-Chem® kit, between 20-28 weeks of gestation in the years 1994-1995. All patients who tested positive by ELISA were subjected to Western Blot using the Gene Labs® kit to confirm the HIV status. All patients were followed till delivery. (All those who participated in the study did so voluntarily, having given their informed consent).
The results were then compared to the prevalence of HIV sero-positivity in pregnant women attending a University Teaching Hospital in Mumbai over the same period. The women in the semi-private hospitals were from the upper middle class strata of society whilst those from the University Teaching Hospital were from the lower middle class strata of society.
Of 1000 women tested, a total of 8 were confirmed as positive, giving an incidence of 0.8% in our study in the year 1995. The obstetric outcome of these patients did not differ significantly from those of sero-negative women. The incidence of prematurity, stillbirth or IUGR was not affected by the presence of HIV infection.
Also, the obstetric outcome of the sero-positive patients of both the semi-private hospital and the general hospital were comparable. Over 90% delivered between 38 and 40 weeks of gestation and over 60% were primigravidas. In the semi private strata the average birth weight was 3.2 kg and in the University Teaching Hospital it was 2.7 kg.
In majority, HIV transmission was heterosexual. The husbands of these 8 patients also tested positive, 6 of them having been involved with commercial sex workers (CSW’s). One of the patients had received a blood transfusion in the past, whilst in one patient no factor could be identified.
At the University Teaching Hospital over the same period, out of the 20578 pregnant women who were tested for HIV sero-positivity, the incidence of HIV sero-positive women was 0.81%, similar to the semi-private hospitals. There was no increased risk of obstetrical or neonatal complications in the HIV positive mothers as compared to the sero-negative women.
The HIV and AIDS epidemic merits its designation as a pandemic. As of early 1993, a cumulative total of 611,589 cases of AIDS were reported by the World Health Organisation (WHO); however because of less than complete diagnosis and reporting, the WHO estimates that a total of 2.5 million cases of AIDS had actually occurred. As of early 1993 the WHO estimates that there have been approximately 13 million infections, of which 1 million have been children. HIV continues to spread causing nearly 16,000 new infections a day in the world. By the year 2000 the WHO predicts that there will be 30-40 million cumulative infections in the world, of which 90% will be in developing countries and almost half will be among women. By that time the male : female ratio of new infections will be close to1:1. [2,3,4,5]
South-east Asia has now become the epicentre of the HIV/AIDS pandemic. It has been predicted that by 2000 AD, the majority of the new infections will occur in South-East Asia. [5,6]
Data for 1986 under the Indian Council for Medical Research (ICMR) and continued by National AIDS Control Organization since 1993 suggests a sharp increase in the presence of HIV.  However these studies were conducted on "convenience samples" including both high and low risk people who were not epidemiologically designed to represent the population prevalence of HIV in India (Table 1).
TABLE 1 Prevalence of HIV in India Period No. of tested No. positive* Prevalence per 1,000 1986-1987 56934 145 2.5 1988-1989 307343 1505 4.9 1990-1991 864110 4764 5.5 1992-1993 706447 7034 10.0
*Confirmed by Western Blot (Directorate General of Health Services, Government of India).
By the end of July 1998, 78904 HIV infections and 6386 AIDS cases had been reported to the National AIDS Control Organization from various states in India.  However it has been estimated that the prevalence of HIV infection in the sexually active age group of 15-49 years may be 0.6-1.0% and India may currently have between 3 and 5 million HIV-infected persons, the largest burden faced amongst all the countries in the world.  The disease has spread rapidly and by 1997 Maharashtra, Tamil Nadu and Manipur together accounted for over three-fourths of AIDS cases and over two-thirds of HIV infections with Maharashtra reporting almost half the number of cases in the country.  A sentinel surveillance carried out by the National AIDS Control Organization (NACO) between February 1 and March 31, 1998, amongst 4800 women attending antenatal clinics in 12 centres in Maharashtra found 116 women to be sero-positive for HIV giving a high prevalence rate of 2.4% (2.0-2.9).  (Table 2).
HIV in Mumbai, India
A recent study reports the prevalence of HIV as 1.9% among women who were attended to for suspected pelvic inflammatory disease (PID), infertility or laparoscopic tubal ligation. 
HIV is spreading at a rapid rate in the world. Though it is stabilizing in certain developed countries, the rise of infection in the developing world, especially Asia with its huge population is ominous. The theme of the 12th World AIDS Conference held at Geneva between June 28 and July 3 1998 was "Bridging the Gap". Most presentations in epidemiology showed that the gap between high and low prevalence countries is being bridged by the virus.  Developing countries face the brunt of this disease due to many factors such as an overwhelmingly large population, a striking unmet need for contraception, a need to address social issues such as unemployment, rapid urbanization, migration, and the status of women.
A recent review of literature reveals that the impact of HIV/AIDS is particularly great on women in developing countries for four reasons.  (1) Stereotypes related to HIV/AIDS have meant that women are blamed for the disease, the consequences being : delayed diagnosis and treatment, stigmatization, loss of income and violation of human rights.  Women are at increased risk for reasons related indirectly and directly to their gender.  Psychological and social burdens are far more greater on the women than men in a similar situation. These include : problems related to pregnancy and motherhood and rejection as marital partners.  Women’s frequently low socioeconomic status and lack of power make it difficult for them to undertake preventive measures.
TABLE 2: Sentinel surveillance for HIV infection (Feb 1-March 31, 1998) STD ANC State No. of Sites No. Tested Total +ve % age No. Tested Total +ve % age Andhra Pradesh ANC-3 STD-1 700 144 20.5
1200 19 1.58
Andaman andNicobar ANC-2 STD-1 59 0 —
(97.5% upper C.I; 6.1)
318 0 —
Arunachal Pradesh ANC-1 STD-1 85 0 —
(97.5% upper C.I; 4.2)
220 1 0.5
Assam ANC-4 STD-3 470 6 1.2
1550 0 —
Chandigarh ANC-1 STD-2 214 13 6.07
NA C.I; 0.2) Daman and Diu ANC-2 STD-2 11 0 —
270 2 0.3
Delhi ANC-2 STD-1 250 9 36
800 4 0.25
Goa ANC-2 STD-2 114 18 15.7
735 5 0.68
Gujarat ANC-4 STD-4 455 56 12.3
1334 7 0.52
Harayana ANC-1 STD-1 41 1 2.43
182 0 —
Himachal Pradesh ANC-1 STD-3 686 0 —
824 1 0.12
Karnataka ANC-3 STD-3 743 72 96
516 12 2.2
Kerala ANC-3 STD-5 445 12 2.6
117 1 0.08
Maharashtra ANC-12 STD-8 1762 473 26.8
4800 116 2.4
Madhya Pradesh ANC-6 STD-4 413 9 2.1
2398 0 —
Meghalaya ANC-1 STD-2 52 0 —
400 1 0.25
Manipur ANC-5 STD-3 1160 52 4.4
2026 24 1.2
Nagaland ANC-4 STD-1 311 15 4.8
1284 11 0.8
Orissa ANC-2 STD-2 201 1 0.25
395 0 —
Punjab ANC-2 STD-2 403 7 2.5
123 0 —
Rajasthan ANC-3 STD-2 249 14 5.6
1200 1 0.05
Sikkim ANC-2 STD-1 15 0 —
773 1 0.12
Tamil Nadu ANC-4 STD-6 1120 108 9.6
1516 17 1.1
Tripura ANC-1 STD-1 172 0 —
400 0 —
Uttar Pradesh ANC-2 STD-4 723 16 2.2
2179 4 0.1
West Bengal ANC-2 STD-3 775 18 2.3
800 5 0.63
(Unless indicated specifically all figures in brackets are 95% Confidence Intervals (C.I)). Source : National Aids Control Organisation NACO, 1998.
Women in India are particularly at risk due to the dominance of heterosexual transmission in the epidemic, the high rate of sexually transmitted diseases and then social vulnerability and social constraints for negotiating ‘safer sex’ practices within their partners.  In India the lower level of knowledge and awareness among the women about HIV/AIDS is of serious concern. [14,15] Hence more programmes are needed for women in general, incorporating sero-positive women wherever possible.
The major risk factor for antenatal mothers, who represent the population of normal healthy women of childbearing age, is the extra marital relationship of their husbands. The transmission of HIV in India is mainly heterosexual, from men infected by CSW’s, who transmit it to their unsuspecting wives and probably to their future generation. As the years have gone by the incidence is increasing and has been reported to be between 1% and 4% from various centres. The HIV prevalence has been reported to have risen rapidly amongst high risk groups between 1986 and 1994, prevalence of HIV infection has risen from 1.6% to 40% in sex workers, 1.4% to 40% in STD clinics and 0 to 70% in intravenous drug users in various studies. [16-18]
By screening the antenatal population attending private clinics in the city of Mumbai, we have been able to confirm that HIV infection has permeated through all the socioeconomic strata of society and needs to be attacked at all levels. The only major obstacle towards implementation of routine antenatal screening of HIV is its cost. One cannot estimate the monetary value of life, however many studies on cost effectiveness of antenatal screening of HIV and zidovudine treatment for infected women and their infants reveal that without intervention and with life time medical care, costs were much higher as compared to the cost of intervention (counseling, testing and zidovudine therapy). Also the intervention would prevent many paediatric HIV infections and could save medical care costs of up to millions of dollars! [19,20] Offering the HIV test and allowing the women to make their own choice regarding whether to accept it is being followed in most clinics. The American College of Obstetricians and Gynaecologists recommend screening for HIV in areas of high prevalence, but has not yet advocated HIV testing in all pregnancies.  Many studies have shown that women have high acceptability rates of voluntary HIV counseling and testing (VCT) where a particular effort in implementing VCT programmes has been made. [22,23] We recommend routine antenatal screening of HIV because a failure to self-report risk factors for HIV infection has been reported in many studies. [24-26] If we follow the recommendations of CDC for counseling and testing for HIV antibody in women of childbearing age (Public Health Service Guidelines) and screen only the high risk population, then many sero-positive women would be missed because they do not self-acknowledge risk factors. Hence routine antenatal testing would help identify HIV sero-positivity in low as well as high risk group. Further more on routine screening, heterosexual transmission emerged as an important cause of infection in our study which was found to be consistent with other studies, who also reported that over 70% sero-positive women would have not been identified due to failure to report risk factors of HIV infection.  The fact that the women in the semi-private sector also had the same sero-positivity as a University Hospital should make us aware that this disease is not limited to the lower socioeconomic strata of society.
Perinatal transmission of HIV has been of special concern. It was the highlight of the 12th world Conference in Geneva, 1998. More than 90% of cases of HIV in children result from perinatal infection, and 7000 children are born annually to women infected with HIV.  The reduction of perinatal transmission of HIV after the use of zidovudine has been studied by many and found to be effective.  Connor et al suggests that the rateof transmission may be reduced to 8% by giving zidovudine before and during labour and to the newborn soon after birth.  The trial ACTG 076 was a randomised placebo controlled trial of zidovudine which showed a 25% vertical transmission rate in the placebo arm compared with 8% in the zidovudine arm of the study (p < 0.0005). 
Breastfeeding contributes an excess risk of transmission of 14% (95% CI 7-21).  Although induced abortion and effective post partum contraception among HIV infected women will reduce perinatal transmission, a more effective strategy is prevention of infection in those likely to become pregnant and prevention in women likely to become infected. Routine antepartum testing and assessment of risk factors for infection would enable us to identify and counsel high-risk pregnant women who are not yet infected.
As obstetricians, if we can detect HIV sero-positivity in pregnant mothers by making HIV testing mandatory for all patients and by offering antiviral therapy to prevent the increasing incidence of paediatric AIDS, we will be able to reduce the incidence of AIDS in children.
While knowledge and tools for preventing HIV transmission are available in the world, prospects for HIV/AIDS control in India appears to be gloomy unless major efforts are made towards reduction of poverty, ignorance and control of sexually transmitted diseases.
This study has been supported by a financial grant from The Indian College of Surgeons.