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In June 1981, the first cases in the United States of what was later called acquired immunodeficiency syndrome (AIDS) were reported.1 Today, approximately 1.2 million people in the United States are estimated to be living with the human immunodeficiency virus (HIV).1 In the general population, the number of new AIDS cases reported annually increased rapidly in the 1980s and peaked in 1992, with an estimated 78,000 cases diagnosed. In 1998, the epidemic stabilized and since then has declined slowly such that fewer than 40,000 AIDS cases are now diagnosed annually.1,2

Among children younger than 13 years, the proportion of all AIDS cases decreased from 1.4% (7668 cases) in 1981–1995 to 0.6% (308 cases) in 2014.1 In 2015, the total number of children reported with newly diagnosed HIV was 120, with numbers limited by the identification of HIV-infected pregnant women and the effectiveness of antiretroviral prophylaxis in reducing mother-to-child transmission of HIV.1,3 The successes achieved in controlling perinatal infection have not been mirrored in other at-risk pediatric groups. The 2015 Youth Risk Behavior Survey reported that 41% of heterosexual and 51% of lesbian, gay, and bisexual (LGB) high school students engaged in sexual intercourse at least once, and 42% and 52% of sexually active heterosexual and LGB students, respectively, had not used a condom during their most recent act of sexual intercourse.4 More than half of all HIV-infected adolescents are estimated to be unaware of their infection.5 This is an area where the pediatric practitioner can make a difference—among adolescents who were tested for HIV, 58% cited their provider’s recommendation as their reason for testing.6

The declining pediatric HIV epidemic in the United States is overshadowed by the global picture of the HIV epidemic. Despite increased access to effective treatment and prevention programs, the number of people living with HIV continues to grow. In 2015, new HIV infections occurred in 2.1 million people while 1.1 million died as a result of AIDS. Although an estimated 150,000 children became newly infected with HIV in 2015, this number represents progress as it is a significant decline from a high of more than 500,000 new child infections in 2005.7

This chapter focuses on the care of the HIV-infected child in the United States. See Chapter 56 for an approach to the HIV-exposed infant, Chapter 58 for a more detailed discussion of infections in HIV-infected children, and Chapter 59 for a discussion on HIV prevention.

The diagnosis of HIV infection depends on the laboratory detection of HIV, or antibody directed against the virus, in a body fluid. This is performed either directly by virologic testing or indirectly by demonstrating the antibody to the virus. The diagnosis of AIDS combines clinical skills with laboratory diagnostics and is based on the detection of one or more AIDS-defining diagnoses in an individual who ...

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