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Worldwide, it is estimated that 2.5 million children younger than 15 years are infected with human immunodeficiency virus type 1 (HIV-1), with more than 2.2 million HIV-1-infected children in Africa alone.1 In 2006, some 330,000 children died from HIV-1 infection. Many millions have been orphaned as a result of the HIV-1-related deaths of their parents. In the United States, rates of new pediatric HIV infections increased from 1982 until 1995. Since 1995, the use of antiretroviral agents to prevent mother-to-child-transmission of HIV-1 has significantly reduced perinatal transmission. Rates of new HIV-1 infections in children younger than 15 years in the United States have declined from a high of 2500 per year in the early 1990s to approximately 100 to 200 per year.2 The number of HIV-1-infected infants and children in the United States is currently estimated to be 10,000.2

More than 95% of HIV-1-infected infants and children acquire their infection vertically, during gestation, especially later gestation, or during labor and delivery. An increasing proportion of women with HIV-1 contracted their infection through heterosexual contact, although injection drug use and substance abuse still play a significant role because injection drug use is prevalent in about one third of all HIV-1-infected women of childbearing age.2 Ethnic minorities and individuals with low income are markedly overrepresented among HIV-1-infected women and HIV-1-infected infants and children in the United States.2 Child sexual abuse and transfusion of contaminated blood products result in an exceedingly small number of HIV infections in children in the United States. Adolescents participating in adult risk behaviors (sexual activity and injection drug use) are increasing and represent the largest number of new pediatric infections.2

The timing and mechanism of perinatal HIV-1 transmission are not completely understood. Evidence of HIV-1 in fetal tissue is found in approximately 30% of first- and early second-trimester abortions by women who are HIV-1 infected. It appears likely that in the preantiretroviral era, the majority of infants were infected in the peripartum period, either through transplacental passage of virus (late pregnancy or at the time of labor) or by exposure to HIV-1 during birth. Because antiretroviral therapy has been successful in reducing perinatal HIV-1 transmission, particularly late in pregnancy and at the time of delivery, transmission earlier in pregnancy now represents the more common period of transmission. Postnatal transmission through breast-feeding is well documented,3 and this fact underlies the recommendation that mothers with HIV-1 infection should not breast-feed if safe, alternative infant nutrition is available. Mixed feeding (combination of breast and formula) carries a higher risk for transmission than breast-feeding alone.4 In areas where a safe alternative is not available, breast-feeding exclusively should be maintained until the infant can obtain adequate nutrition without breast-feeding.

Of children born to HIV-1–infected women not receiving antiretroviral treatment, 13% to 40% will be infected.5 Many maternal and obstetric factors that contribute to the risk of perinatal transmission have been identified. Prematurity, ...

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