Implementa\ue7\ue3o oportuna de interven\ue7\uf5es para reduzir a transmiss\ue3o vertical do HIV: uma experi\ueancia brasileira bem-sucedida

Objective. To describe the impact, at the public maternity facility of a university hospital in Brazil, of the rapid implementation of new guidelines recommended by national consensus panels concerning the prevention of vertical HIV transmission. Method. We performed a retrospective study of deliveries by HIV-infected women at the public maternity facility of a university hospital in the city of Campinas, S\ue3o Paulo, Brazil, from 1990 through 2000. The guidelines utilized at the facility during this period were: (1) from 1990 through 1994, contraindication to breast-feeding and no use of antiretroviral drugs; (2) 1995 and 1996, use of zidovudine (AZT) by the pregnant woman and the newborn; (3) 1997 and 1998, use of AZT according to the ACTG 076 protocol; and (4) 1999 and 2000, multiple antiretroviral agents and elective cesarean delivery. All the antiretroviral drugs were provided for free by Brazil\u92s public health care system. The vertical transmission rate was calculated for each of the four stages, and the risk ratio for congenital transmission was calculated for each stage and for each prophylactic intervention separately (breast-feeding, type of antiretroviral drug, type of delivery). Results. We studied 197 deliveries at the public maternity facility over that 1990\u96 2000 period. Over the four stages, the rate of vertical transmission decreased: it was 32.3% in the first stage, 25.7% in the second, 2.2% in the third, and 2.9% in the fourth. The most pronounced decrease, observed from the second to the third stage, occurred after introduction of the full ACTG 076 regimen. The use of combined antiretroviral agents increased from 0% in the first stage to 46.4% in the fourth stage. There were no cases of vertical transmission in pregnant women treated with multiple drugs. The risk of vertical HIV transmission was 5 times as great with breast-feeding vs. no breast-feeding (risk ratio =3D 5.06), 5 times as great with no antiretroviral therapy vs. the full ACTG 076 regimen (risk ratio =3D 5.29), and 4 times as great with forceps delivery vs. elective cesarean delivery (risk ratio =3D 4.13). Conclusion. The timely adoption of up-to-date interventions recommended by national consensus panels, along with the free provision of antiretroviral drugs, was effective in reducing congenital HIV transmission in this public maternity facility. The interaction between the university hospital health service and the public health service reduced the time needed for implementation of proven, effective interventions, and this experience could serve as an example for other maternal and perinatal health situations. Portugu\ueas Objetivo. Descrever o impacto da implementa\ue7\ue3o oportuna de novas condutas recomendadas por consensos cl\uednicos nacionais dirigidos \ue0 preven\ue7\ue3o da transmiss\ue3o vertical de HIV na maternidade de um hospital universit\ue1rio p\ufablico no Brasil. M\ue9todo. Realizou-se um estudo retrospectivo de coorte dos partos de mulheres infectadas pelo HIV atendidos na institui\ue7\ue3o de 1990 a 2000. As condutas adotadas nesse per\uedodo foram: 1) at\ue9 1994, amamenta\ue7\ue3o contra-indicada, sem uso de drogas anti-retrovirais; 2) de 1995 a 1996, uso de zidovudina (AZT) pela gestante e pelo rec\ue9m-nascido; 3) de 1997 a 1998, uso de AZT conforme protocolo ACTG 076; e 4) de 1999 a 2000, terapia anti-retroviral m\ufaltipla e ces\ue1rea eletiva. Em todos os per\uedodos, a distribui\ue7\ue3o das drogas foi gratuita. Foram calculadas as taxas de transmiss\ue3o nas quatro fases e as raz\uf5es de risco de transmiss\ue3o cong\ueanita para as fases e para cada interven\ue7\ue3o profil\ue1tica (amamenta\ue7\ue3o, tipo de terapia anti-retroviral, tipo de parto). Resultados. Foram estudadas 197 gesta\ue7\uf5es. Houve redu\ue7\ue3o na transmiss\ue3o vertical da primeira para a quarta fase, de 32,3 para 25,7, 2,2 e 2,9%. A maior queda, observada na terceira fase, ocorreu ap\uf3s a introdu\ue7\ue3o do esquema completo do ACTG 076. O uso de terapia anti-retroviral combinada aumentou de 0% na primeira fase para 46,4% na quarta fase. N\ue3o houve nenhum caso de transmiss\ue3o vertical nas gestantes tratadas com m\ufaltiplas drogas. O risco de transmiss\ue3o vertical foi 5 vezes maior com amamenta\ue7\ue3o do que sem amamenta\ue7\ue3o (raz\ue3o de risco =3D 5,06), 5 vezes maior sem terapia anti-retroviral contra uso do esquema ACTG completo (raz\ue3o de risco =3D 5,29) e 4 vezes maior para parto com f\uf3rcipe contra ces\ue1rea eletiva (raz\ue3o de risco =3D 4,13). Conclus\ue3o. A ado\ue7\ue3o oportuna de interven\ue7\uf5es atualizadas, recomendadas por consenso nacional de especialistas, com provis\ue3o gratuita de drogas, mostrou-se eficiente para reduzir a transmiss\ue3o cong\ueanita do HIV