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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 In the decades since, the human immunodeficiency virus (HIV) epidemic in the United States has resulted in more than 900,000 individuals diagnosed with AIDS, as reported to the Centers for Disease Control by the end of 2004.2 In 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 approximately 40,000 AIDS cases have been diagnosed annually.
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Among children younger than 13 years, the proportion of all AIDS cases decreased from 1.4% (7668 cases) in 1981–1995 to 0.2% (341 cases) in 2001–2004.3 The number of children reported with newly diagnosed AIDS dropped to 48 in 2004, primarily because of the identification of HIV-infected pregnant women and the effectiveness of antiretroviral prophylaxis in reducing mother-to-child transmission of HIV.2,4 The successes achieved in controlling perinatal infection have not been mirrored in other at-risk pediatric groups. The 2005 Youth Risk Behavior Survey reported that 47% of high school students engaged in sexual intercourse at least once and 37% of sexually active students had not used a condom during their most recent act of sexual intercourse.5 More than half of all HIV-infected adolescents are estimated to be unaware of their infection.6 In a survey of 18–24-year-old men who have sex with men (MSM), 14% were found to be HIV-infected and 79% of these HIV-infected MSM were unaware of their infection.7 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.8
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These national achievements are, however, overshadowed by the global picture of the AIDS epidemic. Despite increased access to effective treatment and prevention programs, both the number of people living with HIV and the number of deaths due to AIDS continue to grow. In each day of 2006, new HIV infections occurred in 1450 children and 10,400 adults while 1000 children and 7000 adults died as a result of AIDS.9 The social fabric of nations is being altered by HIV, a virus that has resulted in 12 million AIDS orphans in Africa alone.
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This chapter will focus on the care of the HIV-infected child in the United States. See Chapter 52 for an approach to the HIV-exposed child, Chapter 54 for a more detailed discussion of infections in HIV-infected children, and Chapter 55 for a discussion on postexposure prophylaxis.
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The diagnosis of HIV infection depends on the laboratory detection of human immunodeficiency virus, 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 ...