Foreword: Perinatal Viral Infections

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Viral pathogens are best described as tiny but mighty. These simple, yet diverse organisms impact every living system, influencing history and every aspect of obstetric care. The recent human immunodeficiency virus (HIV), Zika, and Ebola pandemics demonstrate that viral infections remain a formidable cause of infectious morbidity and mortality within pregnancy. Management of viral infections in pregnancy presents both an opportunity and challenge for the practicing obstetrician. Providers have interrelated responsibilities (1) to reduce viral infection during pregnancy, (2) optimize pregnancy outcome on behalf of the woman and neonate, and (3) safeguard and advocate for the health of our patient, a woman who is pregnant. Opportunities to improve maternal and child health are accompanied by our commitment as a woman’s health advocate. Critical challenges during prenatal care are to respect our patient’s autonomy and avoid unintentionally subjugating maternal health out of concern for fetal well-being.
When first invited to guest edit this symposia, enthusiasm prevailed. Colleagues attest to my fascination with viruses, so the opportunity to share my passion in partnership with experts in the field was welcomed. Furthermore, many characterize the interdisciplinary treatment of HIV infection in pregnancy a resounding success and paradigm for managing other viral infections in pregnancy. Treatment has reduced mother to child HIV transmission (MTCT) to well below 1%. Maternal health has likewise improved; whereby secondary to effective treatment, HIV infection evolved from a terminal diagnosis to a chronic health condition. These achievements enable HIV-infected women to enjoy a pregnancy experience and outcome more closely aligned to that experienced by “low risk” women than patients with chronic conditions such as diabetes and hypertension. My role as a practicing obstetrician during this advancement of care has been rewarding. Yet, review of HIV treatment development from my perspective as a female obstetric provider, while contemplating how to best manage hepatitis C infection during pregnancy, elicited an ethical paradox. Validating my beliefs included considering my responsibilities as a woman’s health/rights advocate in the context of reproductive justice. Reproductive justice combines reproductive rights with social justice, the concept of fair and just relations between an individual and society.
My first encounter with reproductive injustice occurred in the early 1990s following publication of a groundbreaking study demonstrating that highly active antiretroviral therapy (HAART) was superior to monotherapy. When I asked a study investigator about offering HAART to pregnant women, he told me it was too risky to be undertaken secondary to “unknown fetal risks.” HAART was not proscribed to pregnant women for several years.1,2 Pregnant women and their infants could not benefit from state of the art treatment, later confirmed to improve maternal health and further reduce MTCT. This delay perpetuated reproductive injustice. Entering clinical practice in the 1990s I was aware of, but peripheral to the heated ethical debate regarding Pediatric AIDS Clinical Trial Group Protocol number 076 (PACTG 076). This sentinel study demonstrated that antepartum, intrapartum and postpartum zidovudine treatment (azidothymidine=AZT) decreased MTCT.3,4 I later learned firsthand about anonymous death threats received by PACTG 076 investigators (colleagues) secondary to “concern” about the unknown effect of AZT on the fetus. Coercive threats such as these, occurring when antiretroviral therapy was recommended for HIV-infected individuals (adults and children), promote reproductive injustice. Perinatal HIV treatment guidelines or “Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States,” are regularly updated.

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