August 21, 2009

When too much success
can mean going out of business

Aggressive treatment for pregnant women who have tested positive for HIV has resulted in a program so effective, it may no longer be necessary.

Thanks to a protocol pediatrician Warren Andiman has established, not a single baby has been born HIV-positive in New Haven in more than 12 years.

In the mid-1980s, when the Yale Pediatric AIDS Care Program began caring for HIV-infected children, young patients died painful and protracted deaths, often before they celebrated their 10th birthdays. “There’s no way to describe what it was like,” said Warren A. Andiman, M.D., FW ’76, professor of pediatrics and epidemiology and public health and medical director of the Yale Pediatric AIDS Care Program.

But in the ensuing 25 years, the program has been so effective in diagnosing, treating and monitoring pediatric AIDS patients, that it will likely close its doors within the next few years. “We have literally been putting ourselves out of work,” said Andiman, quickly adding that this accomplishment “is the crowning achievement of my career.”

Since opening its doors, in 1986, the Pediatric AIDS Care Program has admitted every baby born to an HIV-infected mother in New Haven, or about 500 babies. During the first decade, about 20 percent of the babies were infected with HIV themselves. As a result of the program’s efforts, the number of HIV-positive babies born to HIV-infected women dropped to zero in 1996 and has never gone up. New Haven’s protocols for preventing mother-to-child transmission have been so effective that the only HIV-positive infants delivered in the city over the past 13 years were born to mothers who had not yet been diagnosed with the disease themselves.

These encouraging developments in the fight against AIDS aren’t unique to New Haven. Today mother-to-child transmission is a rarity in the developed world. Nationwide, the rate is less than two percent. Andiman attributes the dramatic reduction in the number of infants born HIV positive to “will and money.”

In Connecticut, widespread HIV testing allows doctors to identify women who may pass the virus on to their infants. Any pregnant woman in the area who tests positive for HIV gets referred to Yale’s High-Risk Maternity Program or a parallel program at the Hospital of St. Raphael. Both programs work closely with the Yale Pediatric AIDS Care Program to institute measures that will protect the fetus from being born HIV-positive. Typically, the mother is given antiretroviral drugs during her pregnancy. Other measures include administering AZT to mothers during labor and to newborns. Under certain circumstances, performing a Caesarean section and discouraging breastfeeding can reduce the chances of HIV being passed on from mother to child.

Connecticut mandates that women be offered HIV testing while they are pregnant and again during labor. If a woman refuses, the newborn can still be tested over her objections, although, almost all mothers welcome testing.

During the pregnancy of an HIV-positive woman, older children and sex partners are also tested and given treatment, if necessary. The woman will be connected with the adult AIDS clinic, and social workers will help her address and remediate a range of related practical and emotional issues, such as housing, drug treatment, enrollment in entitlement programs such as Medicaid, making provisions for an adequate food supply through programs such as WIC, and making certain that each baby has a primary care pediatrician. “It’s a sort of seminal period, a moment when all kinds of worthwhile stuff can happen,” said Andiman.

When the Yale Pediatric AIDS Care Program closes, Andiman says the remaining 30 patients will be transitioned to internal medicine practitioners or to the Pediatric Infectious Diseases Clinic, depending on their ages. “It's reached the point where AIDS can be treated as an infectious disease just like many other infectious diseases", he said.

—Colleen Shaddox

Photo by John Curtis

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