Birkhead and colleagues1,2 report on a remarkable public health accomplishment in this issue of the Journal of Public Health Management and Practice. In a study documented over 2 decades (1988–2008), mother-to-child transmission of human immunodeficiency virus (HIV) exhibited a sharp decline in the number of HIV-infected newborns and the corresponding perinatal transmission rate in New York State.
In 2008 Birkhead reports, only 6 infants were determined to be infected with a perinatal transmission rate of 1.3%. In 1988, New York City was the epicenter of the HIV epidemic with nearly one-third of the nation's total cases of pediatric AIDS. Results of a newborn HIV seroprevalence study initiated in 1988 shocked state health department staff and the public by providing graphic detail about the magnitude of this epidemic.3–5 The study, initiated in 1988, led to projections of 700 HIV-infected infants in 1988, assuming a perinatal transmission rate of 25% to 30%.6 In areas of New York City, 3 of every 10 childbearing women were infected with HIV. By 1997, when universal newborn testing was first done with identifiers, 99 infants were reported to be HIV infected with a reduced transmission rate of 11.5%. Also documented, in these articles, is a 70% decrease in HIV seroprevalence in childbearing women during this 2-decade time period.
Conquering this scourge required a comprehensive public health effort beginning with surveillance, designing a series of interventions with universal application, legislation, public education leading to behavior change, and substantial investment of resources.
In June 1987, late Dr Donald Berns, the then director, Division of Clinical Sciences, Wadsworth Laboratory of the New York State Department of Health, and I attended the Third International Conference on AIDS in Washington, District of Columbia. We were most interested in a presentation by the Massachusetts State Health Department on using blood samples from newborns to estimate the seroprevalence of HIV among childbearing women. Blood specimens submitted for metabolic screening were tested anonymously for an overall seropositivity rate of 0.21%.7 After a visit to the Massachusetts Public Health Laboratory, we met with late Dr David Axelrod, the then New York State commissioner of health. Dr Axelrod recognized the value of obtaining surveillance information to efforts to combat the HIV epidemic. He requested that I, then director of the Center for Community Health at the New York State Department of Health, implement the surveillance effort, including the newborn surveillance study as well as 5 companion studies on other groups at risk: prisoners, family planning clients, runaway and homeless adolescents, sexually transmitted diseases clients with, and intravenous drug users.4
In 1987 to 1988, the first year of the newborn seroprevalence study, a total of 276 709 blood specimens were analyzed for HIV serological status. The highest seroprevalence rates were found in the Bronx (1.70%), Manhattan (1.65%), and Brooklyn (1.31%). Entire neighborhoods in these boroughs had rates exceeding 2%, and 13 zip codes had rates exceeding 3%. The majority of the HIV seropositive individuals were black or Hispanic. The HIV seroprevalence rate increased with age, peaking in the group over 35 years. While HIV seroprevalence was lower in New York State, exclusive of New York City, the problem was important throughout the State. Study results in the period 1987 to 1990 showed rates for 2 regions adjacent to New York City (suburban and Mid-Hudson Valley) to be about one-fifth that of New York City.5
These results framed the public health problem. While focused in certain inner-city neighborhoods, the study demonstrated the universal distribution and vulnerability to this infection for all childbearing women and infants in the state. New York State mounted a methodical, stepwise, and concerted attack with built-in fail-safe mechanisms aimed directly at a reduction in perinatal transmission.
The first necessary step was the discovery in 1994 that the risk of perinatal transmission to the newborn could be markedly reduced with zidovudine prophylaxis during pregnancy, labor, and delivery.8 For antiretroviral prophylaxis to be translated into New York State practice, identification of HIV-infected childbearing women was necessary, preferably as part of prenatal care. A New York State Law passed in 1996 added HIV testing (with identifying information) to the newborn screening program. This step, implemented in 1997, and an expedited testing program, added in 1999, required obstetrical facilities to provide HIV counseling and testing (if this test had not previously been performed in pregnancy). These procedures identified vulnerable children, constituting a “fail-safe” backup mechanism for mothers who had not undergone HIV testing in the prenatal period.
The meat of the intervention was universal prenatal testing—on a voluntary basis or if this failed to occur, then through employment of expedited testing. In 1997, 50% of women received prenatal testing. Five years later, in 2002, an astonishing 95% of women received testing during pregnancy and in 2008, only 3% of women arrived at labor/delivery without a documented prenatal test—and for those expedited testing took place. The availability of prophylaxis, the identification of the population requiring the intervention, and ensuring delivery of antiretroviral prophylaxis explain the astounding success of this public health program in New York State.
The New York State Department of Health has developed a system with fail-safe components that provide for effectiveness in reaching all New York State HIV-exposed births, including near-universal prenatal testing, backup-expedited testing at labor/delivery for those without prenatal testing, and retention of universal newborn screening as a further backup.
The companion article published in this issue by Birkhead and colleagues also outlines a series of programs, policies, and interventions that have been implemented in New York State to address pediatric HIV infection. Without these broad policies and supportive programs, testing mandates and regulations and treatment guidelines would not have been sufficient to fully achieve the goal of reduced mother-to-child transmission. The programs and policies include primary prevention services for women of childbearing age, voluntary HIV counseling and testing with referral to care, HIV/AIDS case management, services for high-risk and HIV-infected women, prenatal care efforts, and family-centered health care.
A welcome, albeit puzzling, factor of high importance in understanding trends in this health issue is the sharpness of the decline of seroprevalence of women in childbearing age in New York State over the 2-decade period. Birkhead correctly refers this as multifactorial. Initially, the high newborn seropositivity study did show the highest prevalence among older women and “aging out” of this cohort may be a factor. The seroprevalence study also showed a significant association between those geographic areas with newborn seropositive and all drug-related hospital discharges. The pattern of intravenous drug use may have changed, with this factor identified in only 6% of all new HIV diagnoses in 2007.1
Surveillance and an extensive and rigorous population-based prevention program have led to a major public health advance in New York State. The communities providing public health care and medical assistance are to be applauded. Yet, so many challenges remain, including prevention of acquisition of HIV infection during pregnancy. A system of interlocking components, including screening and available treatment, melded with policies, supportive programs, a massive investment, and professional initiative is responsible for this success.
1. Birkhead GS, Pulver WP, Warren BL, et al. Progress in prevention of mother-to-child transmission of HIV in New York State: 1988–2008. J Public Health Manag Pract. 2010; 16:481–491.
2. Birkhead GS, Klein SJ, Warren BL, et al. Program and policy interventions for preventing mother-to-child transmission of HIV in New York State. J Public Health Manag Pract. 2010; 16:492–504.
3. Novick LF, Berns D, Stricof R, Stevens R, Pass K, Wethers J. HIV seroprevalence in newborns in New York State. JAMA. 1989; 261:1745–1750.
4. Novick LF. The New York State HIV seroprevalence project: goals, windows, and policy considerations. Am J Public Health. 1991; 81[suppl]:11–14.
5. Novick LF, Glebatis DM, Stricof RL, MacCubbin P, Lessner L, Berns DS. Newborn seroprevalence study: methods and results. Am J Public Health. 1991; 81[suppl]:15–21.
6. Lambert B. AIDS survey shows course of infection The New York Times. July 15, 1988:B1
7. Hoff R, Berardi VP, Weiblen BJ, Mahoney-Trout L, Mitchell ML, Grady GF. Seroprevalence of human immunodeficiency virus among childbearing women: estimating by testing samples of blood from newborns. N Engl J Med. 1988; 318:525–530.
8. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med. 1994; 331:1173–1180.