Perinatal HIV transmission results in hundreds of HIV-infected infants in the US every year, most of which are entirely preventable. By 2005, almost 8500 children had been diagnosed with AIDS who were infected perinatally. Of these, an estimated 4800 had died. [i] In the early 1990s at the peak of the incidence, a 25% mother-to-infant HIV transmission rate caused the infection of an estimated 1650 infants annually in the US. However, in 1994, the Pediatric AIDS Clinical Trials Group 076 demonstrated that treatment with zidovudine (AZT) substantially reduced perinatal HIV transmission rates when administered during pregnancy and labor and in the newborn. [iii] In response, the US Public Health Service released its recommendation in 1995 for universal HIV testing of all pregnant women, and use of AZT by those infected. [iv] Later studies also demonstrated the dramatic effectiveness of using cesarian section as the mode of delivery. [v] Studies show that these treatment strategies, when combined with routine HIV testing of all pregnant women, can reduce the risk of perinatal HIV transmission to less than 2 percent. [vi]

Despite these successes in prevention and treatment, the number of newborns infected with HIV remains unacceptably high, especially considering the preventability of transmission. Missed opportunities for perinatal HIV prevention account for more than half of the cases of HIV-infected infants. [vii] One missing link lies in prenatal care. A 1998 report by the Institute of Medicine states that even though women are generally receptive to HIV testing, not enough women are tested, either because they never receive prenatal care or because providers fail to offer or strongly recommend the test. [viii] In 2004, the CDC declared that until all HIV-infected pregnant women are tested for HIV infection during prenatal care, the promise of the elimination of perinatal HIV transmission cannot be realized.

Clear strategies have been identified for making the final push to eliminate perinatal HIV transmission. The challenge lies in the implementation. Necessary prevention strategies will include incorporating HIV prevention methods into routine prenatal care, reaching women with reported illicit drug use, and fitting models and methods to different geographical, economic, and cultural settings.

Hospitals play a critical and unique role in eliminating perinatal HIV transmission in the US. Studies emphasize the importance of clinicians' commitment to HIV testing, identifying the potential benefits of hospital-sponsored physician education programs. [x] Medical record data point to higher HIV testing rates associated with "opt-out" voluntary testing policies adopted by hospitals. [xi]Perhaps most importantly, routinely offering rapid HIV testing to women whose HIV status is unknown during labor and delivery provides the opportunity to reduce transmission even among women who do not seek care until labor begins. [xii] In 2004, the CDC issued a recommendation that all hospitals adopt a policy of routine rapid HIV testing by using an opt-out approach for women whose HIV status is unknown when presenting to labor and delivery. [xiii] Even intervention limited to the neonate in the immediate postnatal period, combined with avoidance of breast feeding, lowers the risk of transmission.

In 2006, the CDC expanded their recommendations for HIV screening to include all adults aged 13-64 in all health care settings. Repeat screening in the third trimester is recommended for women in certain high-risk categories. [xiv] These recommendations include the use of opt-out testing.

[i] CDC. HIV/AIDS Surveillance Report, 2005. Vol. 17. Rev. ed. Atlanta: US Department of Health and Human Services, CDC; 2007: 1-54.

[ii] Connor EM et.al. (1994) Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with Zidovudine Treatment. New England Journal of Medicine. 331:1173-1180.

[iii] Connor et.al.

[iv] Centers for Disease Control and Prevention. (1995 July 7) US Public Health Service Recommendations for Human Immunodeficiency Virus Counseling and Voluntary Testing for Pregnant Women. MMWR. 44 (No. RR-7).

[v] The International Perinatal HIV Group. (1999 April 1) The Mode of Delivery and the Risk of Vertical Transmission of Human Immunodeficiency Virus Type 1 - A Meta-Analysis of 15 Prospective Cohort Studies. New England Journal of Medicine. 340(13):977-987.

[vi] Dorenbaum A, et.al. (2002) Two Dose Intrapartum/Newborn Nevirapine and Standard Antiretroviral Therapy to Reduce Perinatal HIV Transmission: A Randomized Trial. Journal of the American Medical Association. 288:189-198.

[vii] Peters V, Liu KL, Dominguez K, et.al. (2003 May) Missed Opportunities for Perinatal HIV Prevention Among HIV-Exposed Infants Born 1996-2000, Pediatric Spectrum of HIV Disease Cohort. Pediatrics. 111 (5 Part 2):1186-91.

[viii] Institute of Medicine. (1999) Reducing the Odds: Preventing Perinatal Transmission of HIV in the United States. Committee of Perinatal Transmission of HIV. Washington, DC: National Academy Press.

[ix] Lampe M, Branson B, Paul S, et. al. (2004 January) Rapid HIV-1 Antibody Testing during Labor and Delivery for Women of Unknown HIV Status: A Practical Guide and Model Protocol. Centers for Disease Control and Prevention.

[x] Nichols SA, Bhatta MP, et.al. (2002 December) Prenatal HIV Counseling, Testing, and Antiretroviral Prophylaxis by Obstetric and Family Medicine Providers in Alabama. American Journal of Medical Science. 324(6):305-9.

[xi] Centers for Disease Control and Prevention. (2002 November 15) HIV Testing Among Pregnant Women - United States and Canada, 1998-2001. MMWR: 51(45):1013-1016.

[xii] Lampe et.al.

[xiii] Lampe et.al.

[xiv] CDC. Revised recommendations for HIV testing of adults, adolescents, and pregrant women in health-care settings. MMWR 2006;55(RR-14):1-17.