AIDS Among Children --
United States, 1996

As of September 30, 1996, a total of 566,002 acquired immunodeficiency syndrome (AIDS) cases, including 7472 cases among children aged less than 13 years (1%), had been reported to CDC by state and territorial health departments. Most children reported with AIDS acquired human immunodeficiency virus (HIV) infection perinatally from their mothers (1). During 1988-1993, an estimated 6000-7000 children were born each year to HIV-infected women; an estimated 1000-2000 of these children were infected annually (2). In 1994, results of clinical trials demonstrating effective therapy for reducing perinatal HIV transmission indicated a two-thirds decrease in such transmission associated with zidovudine (ZDV) therapy for HIV-infected pregnant women and their newborns. The Public Health Service (PHS) issued recommendations in 1994 for ZDV treatment to reduce perinatal HIV transmission, and in 1995 for routine HIV counseling and voluntary testing for all pregnant women in the United States (3,4). This report summarizes the epidemiology of AIDS in children in the United States reported cumulatively from 1982 through September 1996, presents rates for 1995 (the most recent year for which census estimates are available), and describes a recent decrease in the rate of perinatally acquired AIDS.*

AIDS Among Children

Of the 7472 children reported with AIDS, 58% were non-Hispanic black, 23% were Hispanic, 18% were non-Hispanic white, and 1% were of other racial/ethnic groups. During 1995, the rates of reported AIDS cases per 100,000 children were 6.4 for non-Hispanic blacks, 2.3 for Hispanics, 0.4 for non-Hispanic whites, 0.4 for American Indians/Alaskan Natives, and 0.3 for Asians/Pacific Islanders. Among all U.S. children with AIDS, 6750 (90%) acquired HIV perinatally, 370 (5%) through receipt of contaminated blood transfusions, and 231 (3%) through receipt of contaminated blood products for coagulation disorders; 121 (2%) had no reported risk factor. Among children with perinatally acquired AIDS, the median age at diagnosis was 18 months. Approximately 80% of all children with AIDS had AIDS diagnosed before age 5 years. The highest numbers of cases were reported from New York (1901), Florida (1199), New Jersey (661), California (524), Puerto Rico (347), and Texas (296); combined, these cases accounted for 66% of all AIDS cases reported among children.

Risk exposures for HIV infection among the mothers of the 6750 children with perinatally acquired AIDS included injecting-drug use (IDU) (41%), sexual contact with a partner with or at risk for HIV/AIDS (34%), and receipt of contaminated blood or blood products (2%); for 13%, no risk was specified.

Trends in Perinatally Acquired AIDS

To examine trends in the incidence of AIDS among children born to HIV-infected mothers, the number of perinatally acquired AIDS cases diagnosed each quarter from 1986 through March 1996 was estimated using standard statistical adjustments that account for delays in reporting cases to CDC and estimates of behavioral risk among persons reported without a risk (1). The estimated number of children with perinatally acquired AIDS peaked at 905 during 1992, followed by a decline in incidence.

From 1992 through 1995, the estimated annual number of perinatally acquired AIDS cases declined 27%, from 905 to 663. During this time, the estimated annual number of cases declined 39% among non-Hispanic white, 26% among non-Hispanic black, and 25% among Hispanic children. The proportionate decrease in the number of children with perinatally acquired AIDS from the six areas reporting the highest number of cases was greater than the decrease for all remaining areas and for all areas combined.

HIV Infection Among Children

To enhance the usefulness of surveillance systems to characterize affected populations and to improve the targeting of resources for prevention and care, 28 states require confidential reporting of children with HIV infection without a diagnosis of AIDS as well as those with AIDS (1). Through September 1996, these states reported 29% (2155) of all children with AIDS and 1447 children with HIV infection. During 1995, these states reported 228 AIDS cases among children and 302 children with documented HIV infection who had not developed AIDS. During 1995, these states received 1464 additional reports of children who were born to HIV-infected mothers but who require follow-up with providers to determine their HIV-infection status. Among the six reporting areas with the highest cumulative number of children with AIDS, only New Jersey and Texas require reports of HIV infection among children.

Reported by state, territorial, and local health departments. Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, CDC.

Editorial Note: The findings in this report document a decline in the incidence of perinatally acquired AIDS before and after the release of PHS recommendations for HIV counseling and voluntary testing for pregnant women and for ZDV therapy to prevent perinatal transmission (3,4). The recommendations were issued to promote the adoption of these HIV-prevention strategies as standard medical practice in the United States. Because the number of HIV-infected women who gave birth each year was stable during 1989-1994 (5), this decline suggests that the decrease in perinatal HIV transmission rates probably reflected the effect of perinatal ZDV therapy. Increasing proportions of women may be accepting voluntary prenatal HIV testing and using ZDV to prevent perinatal transmission (6,7).

Because the incidence of perinatally acquired AIDS declined slightly before the PHS recommendations on ZDV therapy were issued in 1994, other factors may have contributed to the decrease in perinatally acquired AIDS cases during this period. For example, the proportion of HIV-infected childbearing women who received ZDV therapy before and during pregnancy for treatment of their HIV disease was increasing (8). Among children, increased use of prophylaxis to prevent AIDS opportunistic infections may have delayed the development of these conditions. However, the incidence of Pneumocystis carinii pneumonia, the most common AIDS-defining condition among children, has not decreased substantially among young children (9,10).

AIDS surveillance conducted in all reporting areas provides a standardized means to monitor AIDS incidence in children as a measure of the effectiveness of perinatal prevention efforts. To further characterize implementation of counseling, testing, and treatment for HIV-infected mothers and their children, CDC and other federal agencies are initiating facility-based program evaluations in selected high-incidence areas. These studies also will examine factors that may contribute to a change in perinatal HIV transmission rates (e.g., changing obstetrical practices and womens' attitudes toward and adherence to ZDV and other preventive therapy). In states that conduct confidential HIV reporting for children, timely assessment of HIV-prevention measures in mother-infant pairs (e.g., prenatal care and prenatal and neonatal ZDV therapy) will measure changes in perinatal HIV transmission rates statewide and permit refinement and redirection of prevention efforts. The Council of State and Territorial Epidemiologists has recommended that all states implement HIV infection reporting for children and consider reporting of all children of indeterminate HIV status who were born to infected mothers.

In the United States, HIV and AIDS disproportionately affect non-Hispanic black and Hispanic women and their children. This disparity probably reflects socioeconomic factors, access to and use of medical services, or differences in behaviors associated with HIV transmission risks among women. Health-care providers in the public and private sectors should implement comprehensive integrated-service delivery programs to ensure that all women have access to HIV counseling and voluntary testing and to services for related health needs (e.g., antiretroviral therapy, substance-abuse treatment, and social and support services).

The ZDV regimen recommended in the United States is not an affordable prevention strategy in many countries where HIV prevalence rates among women are highest. Worldwide, an estimated 8.8 million women and 800,000 children have HIV/AIDS; most of these persons reside in sub-Saharan Africa where resources for health services infrastructure are limited (World Health Organization, unpublished data, 1996). CDC and other organizations are collaborating with ministries of health in Africa and Asia to evaluate the effectiveness of shorter and simplified ZDV regimens, other antiretroviral medications, and other interventions for reducing perinatal HIV transmission. However, because ZDV treatment or other potential interventions are not universally effective in preventing perinatal transmission, primary prevention of HIV infection among children will continue to require preventing new HIV infections among women in the United States and other countries.

References

1. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, 1996:3-4, 30-3. (Vol 8, no. 1).
   
2. Davis SF, Byers RH, Jr, Lindegren ML, Caldwell MB, Karon JM, Gwinn M. Prevalence and incidence of vertically acquired HIV infection in the United States. JAMA 1995;274:952-5.
   
3. CDC. Recommendations of the U.S. Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR 1994;43(no. RR-11).
   
4. CDC. U.S. Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR 1995;44(no. RR-7).
   
5. Davis SF, Steinberg S, Jean-Simon M, Rosen D, Gwinn M. HIV prevalence among U.S. childbearing women, 1989-1994 [Abstract]. Vancouver, British Columbia: XI International Conference on AIDS, 1996.
   
6. Lindsay MK, Peterson HB, Feng TI, Slade BA, Willis S, Klein L. Routine antepartum human immunodeficiency virus infection screening in an inner-city population. Obstet Gynecol 1989;74:289-94.
   
7. Thomas P, Singh T, Lindegren ML, Saletan S, Brooks A, Forlenza S. Patterns of zidovudine (ZDV) use in pregnant HIV-infected women in New York City (NYC) [Abstract]. Vancouver, British Columbia: XI International Conference on AIDS, 1996.
   
8. Simonds RJ, Nesheim S, Matheson P, et al. Declining mother-to-child HIV transmission following perinatal zidovudine recommendations, United States [Abstract]. Vancouver, British Columbia: XI International Conference on AIDS, 1996.
   
9. Lindegren ML, Byers R, Fleming P, et al. A decline in the incidence of perinatally acquired (PA) AIDS in the United States [Abstract]. Vancouver, British Columbia: XI International Conference on AIDS, 1996.
   
10. CDC. 1995 Revised guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with or perinatally exposed to human immunodeficiency virus. MMWR 1995;44(no. RR-4).

* Single copies of this report will be available until November 22, 1997, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023.