HIV Among Pregnant Women, Infants and Children in the United States

Prevention Challenges

The reduction in perinatal HIV infections in the United States represents an important achievement in public health. However, perinatal transmission of HIV continues to occur -- and infant infections can be associated with interruptions of care at any stage of pregnancy for HIV-infected women and their infants.
The following challenges can be categorized as missed opportunities in preventing perinatal HIV transmission:

• Enhanced primary HIV prevention strategies for women and girls continue to be needed and evaluated to prevent new infections in these populations, which will in turn, prevent perinatal HIV infections.
• Few HIV medical care providers routinely provide preconception care or family planning services to their patients with HIV, which may result in unintended pregnancies.
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• Other missed opportunities for perinatal HIV prevention include lack of the following: appropriate prenatal care, prenatal HIV testing (see bullet below), prenatal antiretroviral medication, Cesarean delivery for women with a viral load greater than 1,000 copies/mL, and education on avoidance of breastfeeding. Among the mothers of HIV-infected infants reported to CDC from 2003-2007, only 62% had at least one prenatal visit, 27% were diagnosed with HIV after delivery, and only 29% received some antiretroviral medication during pregnancy.
• HIV testing. Because approximately 18% of all people with HIV do not know their HIV status, many women who are infected with HIV may not know they are infected. The Centers for Disease Control and Prevention (CDC) recommends routine, opt-out³ HIV testing for all persons aged 13-64 years in health care settings, including women during every pregnancy. If women are tested and diagnosed with HIV infection before or early in their pregnancy, they can be given medication to improve their own health and reduce the risk of transmitting HIV to their infant.

Other factors also pose prevention challenges, including:

• Substance abuse, mental illness, and HIV-related stigma present barriers to prenatal care in women living with HIV. Increasing accessibility to prenatal care services is crucial to sustain and maximize the decline in perinatal HIV infections.
• Socioeconomic issues associated with poverty, including limited access to high-quality health care, housing, and HIV prevention education, may directly or indirectly increase the risk factors for HIV infection.
• Lack of awareness that pre-chewing of food for infants is a transmission risk.
• Of the more than 140,000 HIV-serodiscordant heterosexual couples (one partner is HIV-infected and the other is not) in the United States, about half of them want additional children; and many of these couples have limited access to safe conception methods and services.

What CDC Is Doing

• CDC published Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings in 2006. To further reduce the number of children who are infected with HIV perinatally, these recommendations called for routine opt-out HIV testing for all pregnant women, with repeat HIV testing in the third trimester for women who meet certain criteria.
• CDC, the Council of State and Territorial Epidemiologists, and the American Academy of Pediatrics have recommended universal HIV perinatal exposure reporting to ensure that HIV-infected pregnant women receive all necessary interventions to safeguard their health and that of their infants.
• CDC has proposed a framework to eliminate mother-to-child HIV transmission (EMCT) in the United States to guide efforts by federal agencies and other national, state, and local organizations. In this framework, EMCT is defined as a transmission rate of less than 1% among infants born to HIV-infected women and less than 1 transmission per 100,000 live births.
• CDC is collaborating with the François-Xavier Bagnoud Center (FXBC) to organize and lead a group of stakeholders and experts from maternal and child health, HIV/AIDS, policy, research, and surveillance fields to eliminate mother-to-child HIV transmission in the United States using the EMCT framework.
• CDC, the American College of Obstetricians and Gynecologists, CityMatCH, and the National Fetal and Infant Mortality Review Program developed a continuous quality improvement methodology for local systems to identify and address missed prevention and treatment opportunities. The Fetal and Infant Mortality Review (FIMR)/HIV Prevention Methodology is underway in nine sites, and an FIMR/HIV Prevention Methodology National Resource Center provides information and technical assistance to any community interested in conducting the methodology.
• CDC has worked to educate obstetricians, gynecologists, nurse midwives, and other health care professionals on the importance of perinatal HIV testing and counseling through the One Test. Two Lives. campaign. CDC has also conducted educational sessions for health care professionals and sponsored a special supplement titled "Achievements, Issues, and Challenges: Prevention of Mother-to-Child HIV Transmission in the United States and in Resource-Limited Settings" in the American Journal of Obstetrics and Gynecology. For more information, visit www.cdc.gov/actagainstaids/ottl/index.html.

Footnotes

1. The remaining 25% are categorized as "other," which includes hemophilia, blood transfusion, and risk factor not reported or not identified.
2. Hispanics/Latinos can be of any race.
3. Opt-out HIV testing: Pregnant women are told that an HIV test will be included in the standard group of prenatal tests (that is, tests given to all pregnant women), and that they may decline the test. Unless they decline, they will receive an HIV test.