Screening for Sexually Transmitted Infections in Antenatal Care Is Especially Important Among HIV-Infected Women.

The article by Adachi et al. titled “Chlamydia and gonorrhea in HIV-infected pregnant women and infant HIV transmission” is in this issue of Sexually Transmitted Diseases. Its data are from the HIV Prevention Trials Network (HPTN) 040 protocol, a unique study that provided definitive clinical trials data to document the benefits of postexposure prophylaxis with antiretroviral (ARV) medications for babies whose HIV-infected mothers had received no ARV therapy either antenatally or intrapartum. The HPTN 040 study was supported by the National Institutes of Health and was conducted from 2004 to 2010 in Brazil (68% of enrolled mothers-infants), South Africa (30%), and Argentina and the United States (<2.0%). The investigators wisely recognized the opportunities for discovery within this study and obtained data on sexually transmitted infections (STIs) including Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). The parent HPTN 040 study was designed to see whether combinations of ARVs would work better than zidovudine (ZDV) alone for postexposure prophylaxis in exposed infants whose HIVseropositive mothers had not received ARVs. The 1684 infants enrolled were formula fed and were randomized into a ZDV-alone group (the global standard at that time), a 2-drug group (ZDVand nevirapine [NVP]), and a 3-drug group (ZDV, nelfinavir, and lamivudine). Intrapartum transmission occurred in 4.8% (95% confidence interval [CI], 3.2–7.1) of infants in the ZDV group versus 2.2% (95% CI, 1.2–3.9; P = 0.046) in the ZDV/NVP group, and 2.4% (95% CI, 1.4–4.3) in the 3-drug group. The total HIV transmission rate (antepartum and intrapartum) was 8.5%, highest in the ZDV only group (P = 0.03 for the comparisons with the 2and 3-drug groups). On multivariate analysis, ZDV monotherapy, higher maternal viral load, and maternal illicit drug use were associated significantly with MTCT. Hence, there may have been children in the HPTN 040 who remind us of the initial outcome thought to have been seen in so-called Mississippi baby, that is, children infected with HIV who were prevented or even cured by early use of ARVs. Syphilis data from HPTN 040 were published previously. Serological evidence of syphilis without documented treatment was noted in 10.3% (n = 171) of 1664 HIV-infected pregnant women. Fully 1.4% of their 1684 infants (n = 24) were dually HIVand syphilis infected. Compared with HIV-infected women, syphilis-HIV–coinfected women were more likely to be nonwhite (adjusted odds ratio [AOR], 2.5; 95% CI, 1.5–4.2), to have consumed alcohol during pregnancy (AOR, 1.5; 95% CI, 1.1–2.1), and to have had maternal-to-child HIV transmission (MTCT; AOR, 2.1; 95% CI, 1.3–3.4). Compared with HIV-infected or HIV-exposed infants, syphilis-HIV–coinfected infants were significantly more likely to be born to mothers with venereal disease research laboratory titers at least 1:16 (AOR, 3; 95% CI, 1.1–8.2) and higher viral loads (AOR, 1.5; 95% CI, 1.1–1.9). Of 6 venereal disease research laboratory–positive newborns with symptomatic syphilis, 2 died and 2 more were HIV infected. Complementing this analysis, Adachi et al. have now provided multivariable assessment of potential contributions ofCTand NG bacterial coinfections on the risk of MTCT from the same HPTN 040 study. The rigor and size of the HPTN 040 STI analysis are impressive compared with most prior work published on this subject. Fully 81.5% of the 1684 women enrolled in the parent study had valid urine samples using the Xpert CT/NG assay on the GeneXpert platform, for a sample size of HIV-infected women with 1373 valid test results. Clinical conduct and laboratory/data quality control were superb, typical of studies conducted within the National Institutes of Health HIV/AIDS networks (the HPTN and IMPAACT networks, in this case). Prevalence was high, 18.1% for CTand 4.6% forNG based on the molecular platform diagnosis. Along with the previously reported syphilis prevalence of 10.3%, one can speculate that more than 20%