They show up in a doctor's office or a clinic or a hospital
ward with infections that hang on and on. Doctors try one
thing, then another, but the babies stay sick.
Sometimes, their first serious illness is also their last. They
are children at the mercy of HIV, the human immunodeficiency
virus that causes AIDS.
Concerned that these HIV-infected babies and their mothers need
earlier care than they are getting, Los Angeles doctors who
specialize in pediatric AIDS are calling for routine voluntary
testing of all pregnant women in Los Angeles County for
infection with the AIDS virus.
Not just prostitutes or poor women whose sexual partners use
drugs, but, for example, middle-class women who had several
partners before marrying.
It is an idea whose time has come, these doctors say, because
for the first time--through a network of federally established
drug trials--doctors can offer mothers and children treatments
that they hope will slow the progression of the devastating
"To find just one mother at this early stage and do something
about it would save so much in the long run," said Dr. Yvonne
Bryson, a UCLA professor who directs the Los Angeles Pediatric
AIDS Consortium. "If we could prevent transmission to the baby,
the actual cost and human cost couldn't be compared."
The Consortium, a coalition of Los Angeles hospitals and the
County Department of Health, will begin trials within the next
month to test whether giving the anti-viral drug AZT to
newborns will prevent the AIDS virus from establishing itself
in the children.
The drug is already being given to older children who are
infected but asymptomatic, and to pregnant women to try to
prevent transmission to their children. Other drugs also are
Currently, a third to half of the children born to HIV-infected
mothers come down with AIDS. It usually appears within the
first year of life, and death occurs sooner in children than in
To Bryson, testing women routinely for AIDS is the best way to
assure that they and their babies get the best possible health
care--even if no one can offer them a cure for the fatal
disease that has killed more than 68,000 Americans--1,059 of
them children--since 1982.
But the idea of routinely testing all pregnant women for HIV
infection does not come without controversy, even in areas of
the country where the childhood AIDS problem is much greater
than in the Los Angeles area.
In Miami, which has twice as many HIV-risk births every year
(as does Los Angeles), Dr. Mary O'Sullivan is concerned that
asking women to be tested for infection with the AIDS virus is
asking them to take the chance of serious social discrimination
if the test comes back positive.
"Why isolate them out just because they're pregnant? Do you
have any proof that what you have to offer is going to decrease
the incidence of infection in the newborn?" asked O'Sullivan,
professor of pediatrics at the University of Miami.
And drug trials in pregnant women are not far enough along to
answer that question.
State AIDS office epidemiologist Frank Capell takes a middle
ground. He suggests that public health dollars might be best
spent in pushing HIV testing only in the specific urban areas
where the number of HIV-infected, or seropositive, women is
"The seropositives we saw in L.A. County were not just randomly
distributed," Capell said. "Probably three-fourths of the
county had no seropositive women at all."
The epidemiologist oversaw a study of every California birth
during three-month period last year. Using blood samples
routinely taken from babies to screen for genetic diseases, the
study found evidence of HIV-infected mothers mainly in the
poorer, high drug-use areas of Los Angeles, San Francisco and
While the overall incidence rate in pregnant women in Los
Angeles County was about 1 in 1,000--a rate considered
high--among black women it was 1 in 344. Among Latino women it
was 1 in 1,232.
Nationwide, the highest rates in the nation are in drug-abusing
communities in northeastern cities--as high as 1 in 25.
Los Angeles County's overall rate is high enough to justify
recommending screening for every woman in the county, not just
in public health clinics but also in private doctors' offices,
said Dr. Laurene Mascola, deputy chief of acute communicable
disease control for the L.A. County Department of Health.
"I personally think that if there's a disease you can screen
for and have some impact on the outcome for fetus and mother,
you should do it," Mascola said. "It's not as 100% as syphilis,
where you can give a shot of penicillin and prevent the
disease. But we are actively trying different strategies to
reduce the risk."
U.S. Centers for Disease Control guidelines say doctors or
clinics should routinely conduct HIV tests in pregnant women in
certain at-risk groups: intravenous drug users, recipients of
blood transfusions before 1985, prostitutes, women who have had
multiple sexual partners, and women who have a partner who is
bisexual, a hemophiliac or who otherwise fits an at-risk
And the CDC recommends that if the incidence among pregnant
women is 1 or more in 1,000, routine testing of pregnant women
in that area should be considered.
But in public health clinics that serve poor black women or
Latinos, adding routine AIDS testing is an issue of money. Even
if the $2 cost of the initial test is covered by state funds,
the clinics are so overburdened that they would find it
difficult to take on the education and counseling effort that
would be needed if all 38,000 pregnant women they see in a year
were to be tested, Mascola said.
Except for those participating in a study overseen by Mascola,
women at the clinics are specifically offered the test only if
they identify themselves as falling into a risk-factor group,
But many women at the clinics--and in the community at
large--don't realize they may be at risk for AIDS.
"Half of our HIV-positive women don't acknowledge any risk
factors. Their partners are at risk and don't tell them,"
This would include a partner who was previously bisexual or an
intravenous drug user, since both those groups are at high
Mascola's pilot program tells women about their possible AIDS
risk factors and offers testing; three-quarters of the women
choose to take the test. The program found nine women infected
with HIV out of 7,579 tested in the first 10 months of 1989,
Those nine were referred for special care for themselves and
their babies, she said, but it is the other 7,570 who she hopes
will benefit most from the program's educational component.
Similarly, other women of childbearing age in the county need
to recognize that protecting themselves from AIDS also is
protecting future children from it, public health officials
Repeatedly in the Los Angeles Pediatric AIDS Consortium,
doctors see families in which the first sign that HIV might be
a problem is when the baby's infection is diagnosed many months
"The children of these mothers are born normal. They look fine,
and so they disappear into the system," Bryson said. She noted
the case of one woman who was six months pregnant with her
second child before doctors determined that her first child,
her husband and she were all infected by HIV.
The AIDS virus is spread through blood, sexual activity
(including intercourse without condoms) and from mother to
child before or during birth. Breast milk from an infected
woman also contains HIV.
Public health officials advise the use of condoms, and tell
women that they should question a potential partner about AIDS
risk factors before engaging in sexual activity.
So far, the AIDS Consortium has identified about 200 children
in Los Angeles County infected with HIV. If the 1 per 1,000
infection rate in pregnant women holds up, that would mean at
least 60 HIV-infected babies will be born each year here.
DE WOMEN--HEALTH; BABIES--HEALTH; DIAGNOSTIC TESTS; ACQUIRED
IMMUNE DEFICIENCY SYNDROME; VIRUSES; HUMAN IMMUNO DEFICIENCY
VIRUS; CHILDREN--HEALTH; PREGNANCY; INFECTIONS; HEALTH
EDUCATION; SEX EDUCATION