Missed Opportunities for Congenital Syphilis and Hiv Perinatal Transmission Prevention

Oportunidades perdidas na prevenção da sífi lis congênita e da transmissão vertical do HIV ABSTRACT OBJECTIVE: To estimate the prevalence of missed opportunities for congenital syphilis and HIV prevention in pregnant women who had access to prenatal care and to assess factors associated to non-testing of these infections. METHODS: Cross-sectional study comprising a randomly selected sample of 2,145 puerperal women who were admitted in maternity hospitals for delivery or curettage and had attended at least one prenatal care visit, in Brazil between 1999 and 2000. No syphilis and/or anti-HIV testing during pregnancy was a marker for missed prevention opportunity. Women who were not tested for either or both were compared to those who had at least one syphilis and one anti-HIV testing performed during pregnancy (reference category). The prevalence of missed prevention opportunity was estimated for each category with 95% confi dence intervals. Factors independently associated with missed prevention opportunity were assessed through multinomial logistic regression. RESULTS: The prevalence of missed prevention opportunity for syphilis or anti-HIV was 41.2% and 56.0%, respectively. The multivariate analysis showed that race/skin color (non-white), schooling (<8 years), marital status (single), income (<3 monthly minimum wages), having sex during pregnancy, history of syphilis prior to the current pregnancy, number of prenatal care visits (<6), and last prenatal visit before the third trimester of gestation were associated with an increased risk of missed prevention opportunity. A negative association with missed prevention opportunity was found between marital status (single), prenatal care site (hospital) and fi rst prenatal visit in the third trimester of gestation. CONCLUSIONS: High rates of non-tested women indicate failures in preventive and control actions for HIV infection and congenital syphilis. Pregnant women have been discontinuing prenatal care at an early stage and are failing to undergo prenatal screening for HIV and syphilis. 852 Missed opportunities in congenital syphilis prevention Rodrigues CS et al Infectious diseases transmitted from mother to child during pregnancy and during labor are still an important and preventable cause of morbimortality among newborns. Maternal syphilis may result in fetal and neonatal death, fetal hydropsy, intrauterine growth retardation, as well as preterm infants. It is estimated that 40% of pregnancies in women with non-treated primary or secondary syphilis evolve into fetal loss or neonatal death. 4 In recent years, an increase in syphilis prevalence in developing and industrialized countries has been seen, especially primary and secondary syphilis in childbearing women, with a …

Infectious diseases transmitted from mother to child during pregnancy and during labor are still an important and preventable cause of morbimortality among newborns.Maternal syphilis may result in fetal and neonatal death, fetal hydropsy, intrauterine growth retardation, as well as preterm infants. 5,9It is estimated that 40% of pregnancies in women with non-treated primary or secondary syphilis evolve into fetal loss or neonatal death. 4In recent years, an increase in syphilis prevalence in developing and industrialized countries has been seen, especially primary and secondary syphilis in childbearing women, with a consequent increase in the rate of neonatal syphilis. 2,16SUMO OBJETIVO: Estimar a prevalência de oportunidade perdida de prevenção a sífi lis e HIV entre gestantes que tiveram acesso ao pré-natal e fatores associados a não-testagem para esses agravos.

CONCLUSÕES:
Altas percentagens de gestantes não testadas apontam falhas na prevenção e controle da infecção pelo HIV e da sífi lis congênita pelos serviços de saúde.As gestantes continuam interrompendo o cuidado pré-natal precocemente e não conseguindo realizar os procedimentos de triagem para HIV e sífi lis.In 1993, the Brazilian Ministry of Health developed a plan for the elimination of congenital syphilis in accordance with proposals formulated by the World Health Organization and the Pan American Health Organization.The goal was to achieve an incidence rate equal to or lower than 1 case/1,000 newborns.a Despite easy and inexpensive diagnosis and treatment, syphilis prevalence was still between 3.5 and 4.0% in 1999 according to the Brazilian Ministry of Health.a In addition, a national multicenter study carried out in 2000 among puerperal women admitted for labor or curettage in public maternities showed a syphilis seroprevalence of 1.7% and a strong association with not being tested for HIV and syphilis. 10IV vertical transmission is still of public health concern, although it has decreased in several countries.a Despite universal availability of HIV testing, including rapid tests, and prophylactic medication in Brazil, children are still getting infected.Data from the Brazilian National STD/AIDS Program show that HIV vertical transmission accounted for 83.6% of AIDS cases among children under 13 years of age between 1983 and 2004.In 2004, the number of reported new cases was still of concern (n=450).b In addition, a surveillance study based on sentinel maternities with parturient women conducted in the fi ve regions of Brazil showed an HIV infection prevalence of 0.6%.c It is well known that an elevated proportion of congenital syphilis cases and HIV perinatal transmission is found among women who had low prenatal care attendance, which suggests that full opportunities for maternal infection diagnosis and treatment may be potentially lost. 11A study by Warner et al 18 (2001) shows that each syphilis case in pregnant women should be considered as a potential case of HIV infection and, at the same time, as a potential opportunity for prevention through counseling.Peters et al 7 (2003) concluded that prenatal care and anti-HIV testing prior to delivery are the greatest opportunities for prevention of HIV vertical transmission.The actions developed for the prevention of both, HIV vertical transmission and congenital syphilis, are thus strongly similar and related to adequate prenatal and delivery assistance.

DESCRITORES: Sífi lis
In 2000 the Brazilian Ministry of Health launched a large national program which aimed at guaranteeing improved quality of care to women and children during pregnancy, delivery and puerperium.It included allocating fi nancial resources to towns and maternity wards and specifi c recommendations for HIV and syphilis prevention such as HIV and syphilis testing and treatment. 13spite Brazilian government investment in this area and the availability of prevention and treatment actions, there is limited knowledge to what extent women who have access to prenatal care are indeed receiving adequate attention, including counseling, the recommended number of visits, and specifi cally the opportunity for HIV and syphilis testing.
In this perspective, the present study aimed at determining the prevalence of pregnant women who missed prevention opportunities during prenatal care and to assess factors associated to non-testing to these infections.

METHODS
This cross-sectional study is part of a larger national multicenter study, which was developed in 1999 and 2000 d with the support of the National STD/AIDS Program and the Brazilian Ministry of Health Maternal and Child Health Program.A random probability sample of pregnant women was selected proportionally to the number of deliveries estimated per state and by the number of maternities in each one of 24 states.The detailed methodology has been previously published. 10iefl y, 3,233 pregnant women admitted for labor or curettage were randomly selected upon admission to the maternity ward according to a pre-defi ned schedule.An interview and blood collection for syphilis diagnosis were carried out after delivery or curettage.Sociodemographic, behavioral and obstetric data were obtained by structured interview.Data from current hospitalization and prenatal care were also obtained from medical charts to complete the database.For the analysis, only those women who had had at least one prenatal care visit were included, yielding a fi nal sample size of 2,145 pregnant women.Venereal Disease Research Laboratories (VDRL) test and anti-HIV testing during the current pregnancy was used as a marker for the assessment of missed prevention opportunities.Women tested for HIV only, syphilis only (VDRL) or neither of them was compared to those tested for both (reference category).
The prevalence of missed prevention opportunities for VDRL and anti-HIV testing was defi ned as: • VDRL: the number of pregnant women who had not been VDRL tested during pregnancy divided by the total of pregnant women in the sample; • anti-HIV: the number of pregnant women who had not been anti-HIV tested during prenatal care divided by the total of pregnant women in the sample.
A descriptive analysis was performed and differences in proportions were assessed by chi-square test.Significance level was set at 0.05.The magnitude and the independent effect between selected variables and missed prevention opportunities were estimated through odds Sociodemographic variables showed high proportions of non-white (64%), with ≤8 years of schooling (72%), single (59%), homemaker (60%), with monthly income <3 monthly minimum wages (45%) and age ≤23 years old (54%).Sexual initiation was at an early age (mean=17.1 years old), while 41% had their fi rst pregnancy at age <18 years and 69% were ≥18 years old at fi rst delivery, 91% had at least one sexual intercourse during pregnancy and only 2% reported previous syphilis infection.Most women (58%) attended prenatal care at a health care center.Yet 20% had less than four prenatal visits and 37% had a late prenatal care start, i.e., after the fi rst trimester of gestation.Among women who had started prenatal care after the fi rst trimester, 38% had one to three prenatal visits.For 9% of the women, the last prenatal visit occurred before the third trimester of pregnancy, 73% of which had one to three visits.
Table 1 shows the distribution of subjects according to the tests performed and sociodemographic, behavioral and prenatal care variables, which showed association at p≤0.20.Missing one or both tests during the current pregnancy was statistically associated (p<0.05) with race (non-white), lower schooling (≤8 years), marital status (single), occupation (homemaker), lower monthly family income (<3 monthly minimum wages) and younger age.Similarly, younger women at fi rst delivery and those with less than seven prenatal visits missed one or both tests.It is of concern that women tested for VDRL (15%) or anti-HIV only (23%) and women who had not been tested for either test (33%) had less than four prenatal visits.In addition, both late prenatal care start and early discontinuation (last prenatal visit before third trimester) of prenatal care were higher among women who had not been tested by either test (42% and 16%, respectively).
The multivariate analysis (Table 2) showed that not being tested for VDRL and anti-HIV was positively and signifi cantly associated with race (non-white), lower schooling (≤8 years) and monthly family income, no previous syphilis infection, fewer number of prenatal visits and early discontinuation of care.A dose-response trend was seen for family income, number of prenatal visits and time of the last visit.Not being tested for VDRL and anti-HIV was also negatively associated with receiving prenatal care at the hospital where delivery occurred.Independent positive and signifi cant associations with not being anti-HIV tested were found for lower schooling (≤8 years), being single, having sex during pregnancy and having the last prenatal visit in the second trimester.Testing for VDRL was positively and signifi cantly associated with race (non-white), monthly family income and number of prenatal visits, and was negatively associated with marital status (single) and time of the fi rst prenatal visit (third trimester).
The p-values of Pearson's chi-square test for all three individual logistic regressions were not signifi cant, indicating good overall fi t of the model 3

DISCUSSION
The proportion of pregnant women tested for VDRL and anti-HIV during their prenatal care visits was low, with a consequent high prevalence of missed prevention opportunities (41.2% and 56.0%, respectively).This fi nding corroborates another study conducted by the Brazilian Ministry of Health which also showed a low rate (52.0%) of parturients being tested for HIV and learning of their results during the same prenatal care. 15Schrag et al 12 (2003) have found a high proportion of women being tested for syphilis but a rather smaller proportion of HIV testing during prenatal care in the United States from 1998 to 1999.Warner et al 18 (2001) have also found 60.0% of missed prevention opportunities for diagnosis and treatment of syphilis during pregnancy in Atlanta (US) from 1990 to 1993.The high prevalence of missed prevention opportunities found in the present study indicates a gap in the adoption of prevention measures and proper intervention by the health services.The failure to diagnose and treat syphilis early in the pregnancy may lead to fetal loss, premature delivery and congenital syphilis, many times asymptomatic and non-diagnosed. 5,9Similarly, early HIV infection diagnosis with the use of antiretroviral drugs during pregnancy and labor and the use of zidovudine by the newborn may reduce the rates of vertical transmission to less than 2%. 1 Agency for International Development (USAID) have found that at least 50% of women reported four or more prenatal care visits in 33 of 45 countries. 19e increased risk found between not being tested and early discontinuation of prenatal care may be explained by the smaller number of visits and the lack of immediate test request in the fi rst visit.The Brazilian Ministry of Health currently recommends that VDRL and anti-HIV testing should be carried out in the fi rst prenatal visit, regardless of when it begins. 11These fi ndings show the importance of better organization of health care services.In addition, the importance of expanding access, stimulating early access and the establishment of a satisfactory bond between pregnant women and prenatal care providers have been shown to positively impact on the reduction of congenital syphilis and HIV vertical transmission. 12,17e negative association found between receiving prenatal care at the hospital where delivery occurred and not being tested may indicate that prenatal screening is facilitated in settings where laboratory infrastructure is better and more easily accessible.In many primary care settings serological tests are not performed locally, but rather in distant and centralized facilities, causing patients to miss appointments or fail to return for their test results, which can, in turn, result in treatment being delayed or missed. 6e increased risk found between no previous history of syphilis and not being tested for VDRL during the current pregnancy may indicate a biased perception of less vulnerability by health professionals, and consequently, a smaller number of test requests during prenatal care.This is corroborated by a study carried out in Bolivia which indicated that prenatal care physicians usually did not request syphilis testing when they believed pregnant women did not have any risk behavior for sexually transmitted infections. 14e study results indicate serious failures in prevention actions for HIV infection and congenital syphilis control.Pregnant women are still having a late start and early discontinuation of their prenatal care, thus reducing the likelihood of taking appropriate diagnostic and treatment actions.Investments made and the efforts developed at the three governmental levels for the reduction of HIV vertical transmission and syphilis control, especially congenital syphilis, may not have been as effective.Considering that all pregnant women in the present study had access to at least one prenatal care visit, improving the organization of these services are necessary in order to increase effectiveness of syphilis and HIV control programs.Reach-out programs at the community level should be promoted, in particular among underprivileged populations.Early recruitment and the establishment of adequate bonds with prenatal care providers should also be emphasized.It is also necessary to develop strategies for health professionals in order to assure the minimum number of tests required by the Brazilian Ministry of Health.In addition, timely and adequate treatment for those tested positive for syphilis and prophylaxis for those tested positive for HIV and their exposed children should be of extreme concern and priority.Such actions, which are known to have a positive impact on the reduction of congenital syphilis and HIV infection prevalence, should be immediately sought, implemented and evaluated at all levels of care, from primary -where most women seek prenatal care -to tertiary -where women are referred to for delivery and curettage.