Worldwide, more than 2 million children younger than 15 years are infected with HIV, with perinatal transmission the source of most of these infections.1,2 In the developed world, where prenatal testing and safe and effective antiretroviral prophylaxis are widely available, perinatally-acquired HIV has become almost entirely preventable. With early testing and treatment of HIV-infected mothers and their newborns the risk of perinatal HIV transmission can be reduced to less than 2%.3 The pediatric provider plays an essential role in disease reduction. By early identification of HIV-exposed infants, timely virologic testing and provision of postpartum HIV and opportunistic infection prophylaxis, pediatric care providers can intervene to dramatically reduce the risk of infection for the neonate.
Perinatal transmission of HIV denotes infections that are acquired during the intrauterine, intrapartum and postpartum periods. In the United States, the peak years of perinatal HIV transmission occurred in the early 1990s, with 1650 new infections diagnosed in 1991 alone.4 In recent years there has been a dramatic reduction in new HIV infections, with a 95% reduction in the incidence of perinatally acquired HIV from 1992 to 2004 in the United States.4 In 2002, an estimated 144–236 new perinatal HIV infections were diagnosed in the United States.4 These cases represent those women who either refused or were not offered prenatal HIV testing, had suboptimal antiretroviral adherence during pregnancy, presented at term without prenatal care, or experienced rare unexplained treatment failures.
The reduction in new infections in the developed world is a direct consequence of perinatal antiretroviral regimens. In 1994, the Pediatric AIDS Clinical Trials Group released the results of their landmark 076 study, examining the effect of a three-part regimen containing the nucleoside reverse transcriptase inhibitor (NRTI) zidovudine (ZDV). The active treatment arm consisted of maternal oral ZDV therapy beginning at 14–34 weeks gestation, intravenous ZDV in labor, and infant oral ZDV for 6 weeks. The HIV infection rate in the ZDV-treated group was 8% at 18 months versus 26% in placebo group—a remarkable 68% reduction in HIV transmission.5 Based on the study findings, in 1994 the Centers for Disease Control and Prevention and U.S. Public Health Service issued recommendations for the routine use of the three-part ZDV regimen for all pregnant HIV-infected women.6
In July 1995, the U.S. Public Health Service issued recommendations for universal prenatal HIV counseling and consensual testing.7 In 2006, the Centers for Disease Control and Prevention revised its HIV testing recommendations to increase early detection of HIV in pregnancy. The new guidelines focus on implementing HIV screening as a routine part of prenatal care, rather than as an optional test. As such, they recommend “opt-out” testing, whereby all women should receive the test as part of their care unless they specifically decline. The Centers for Disease Control and Prevention also recommends a second screening in the third trimester for women with known risk factors or those in high ...