[procaare] Re: Pregnancy May Not Imperil HIV Negative Sex Workers (2)

["Julian Meldrum" <procaare@healthnet.org>]

Re: Pregnancy May Not Imperil HIV Negative Sex Workers (2)
- Julian Meldrum, UK
*********************

The Indian study which was publicised through this forum is part of a body of research on
persistently-HIV-negative but heavily-exposed people and needs to be seen in that context.
Unfortunately, I don't think it is relevant to the question of how negative women in
relationships with HIV positive men can safely bear children.

To understand the study, you first need to ask: why should pregnancy be seen as a risk to
such women?

We know that immune responses which control malaria may be disrupted or suppressed when a
woman becomes pregnant, especially in a first pregnancy, resulting in placental malaria: a
major disease risk both for a woman and her child.

Previous research on persistently-seronegative heavily exposed women suggests that a
similar kind of immunity may be operating to protect them against HIV. In particular,
HIV-specific cellular immunity, with or without mucosal HIV antibodies, in the absence of
antibodies or virus circulating in their blood.

The implication is that these women may, in fact, have been infected with HIV but their
immune system is able to contain and control that infection, perhaps in a very small
population of cells in their mucosal tissues. Or perhaps the virus is eliminated from
their bodies.

In which case, would they suffer increased vulnerability to HIV once they became pregnant?
If the virus is present, would it be able to break out and cause illness for the mother
and/or her baby?

I think this is the main question this research speaks to: the answer appears to be, 'no',
but would be more convincing if there was also clear
evidence within the research study that the women concerned did, indeed, have specific
immune responses to HIV (as has been demonstrated in some other heavily-exposed sex
workers, notably in Kenya).

The questions that were asked about differences in strains of the virus can also perhaps
be answered, if only to explain why the research did not go in that direction.

Much of the Indian HIV epidemic is due to subtype C strains of HIV, but in this setting it
would not be possible to distinguish between the strains to which seronegative women were
exposed and those which infected the other women.

Also, the strains in one person can be replaced completely with slightly different
strains, especially just after the earliest period of infection when they are most
infectious and immune responses to HIV are most powerful. So if you tracked down the
previous partners of these women, the virus present in their bodies now might not be the
same as the one that the women had been exposed to.

Finally, the strains which get transmitted may not be those present in the largest
quantity in the body of the person who transmits the virus.

The women in Nairobi, Kenya, who similarly remained HIV negative despite repeated exposure
to HIV were mostly exposed to subtypes A and D and A/D recombinants.

The full abstract of the Indian study follows below:

Title: Course and Outcome of Pregnancy in 54 Persistently HIV-1-Seronegative Sex Workers
and Their Infants
Authors: Rachana M. Chibber, M.D., Ashok Khuranna, MBBS, M.D., Mohammed H. Al-Sibai, MBBS,
Ph.D., Abdul-Aziz Abdulla Al-Mulhim, MBBS, M.D., and Sajid S. Shahul, MBBS

Objective: To determine the course and outcome of pregnancy in 54 persistently
HIV-1-seronegative pregnant commercial sex workers
(prostitutes).

Study Design: Five hundred twenty-three initially HIV-1-seronegative prostitutes in
Manipur, India, were studied between 1990 and 1999. Two hundred forty (46%) women
seroconverted to HIV-1 during the study period. HIV-1 polymerase chain reaction with env,
nef and vif gene primers was done on 98 persistently seronegative sex workers, who
remained seronegative after three years of follow-up. Fifty-four of these women became
pregnant (study group). The course and outcome of pregnancy were studied prospectively in
54 persistently HIV-1-seronegative women and compared with those in matched
HIV-1-seronegative women from the general population coming for routine antenatal
checkups.

Results: In the 54 seronegative women (study group) who became pregnant, there were 52
singleton, term vaginal deliveries and two emergency cesarean sections for fetal distress.
All 54 infants had negative viral cultures for HIV-1 at birth. The women remained
seronegative throughout pregnancy, as did the control group. All 54 infants were
breast-fed and remained well.

Conclusion: A small proportion of highly exposed individuals may have natural protective
immunity to HIV, may be resistant to HIV-1 and may have successful outcomes of pregnancy.
(J Reprod Med 2002;47: 1016-1020)

=====

Julian Meldrum
International Editor
E-mail: julian@nam.org.uk
www.aidsmap.com

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