Correlates of Mother-to-Child Transmission of Human Immunodeficiency Virus in the United States and Puerto Rico

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The most common mode of human immunodeficiency virus (HIV) infection in children is mother-to-child transmission during pregnancy, labor, and delivery. The use of current guidelines can prevent a significant proportion of perinatally acquired HIV infections. Current recommendations for prevention include HIV testing early in pregnancy; combination antiretroviral prophylaxis during pregnancy; administration of zidovudine during labor and to the neonate, planned cesarean delivery before labor when indicated, and avoidance of breast-feeding. Implementation of these recommendations has resulted in a marked decline in the number of perinatally infected infants during the past decade. Failure to use any of these interventions is a missed opportunity for prevention of perinatal HIV transmission. This study explored the association between missed prevention opportunities and mother-to-child transmission in 15 US jurisdictions for birth years 2005 through 2008, while controlling for variables associated with transmission. Data regarding HIV-infected women who gave birth to live infants were obtained from the Enhanced Perinatal Surveillance system. Multivariable logistic regression analysis was used to control for demographic, behavioral, clinical, and missed opportunity variables associated with mother-to-child transmission. HIV infection was diagnosed in 179 infants (2.2%) among the 8054 births to HIV-infected women during the 4-year study period. There was at least one missed opportunity for prevention of mother-to-child transmission in 74.3% of infected infants and 52.1% of uninfected infants. A total of 7757 mother–infant pairs had sufficient data for analysis. The adjusted data showed that the odds of having an HIV-infected infant were higher for women who received late testing (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 1.5–4.0) or no prenatal antiretroviral medications (aOR, 3.5; 95% CI, 2.0–6.4). The odds of having a HIV-infected infant for women who breastfed were >4-fold higher than for those that did not (aOR, 4.6; 95% CI, 2.2–9.8). The odds were >2-fold higher among women with CD4 counts <200 cells per microliter compared with those with CD4 counts ≥500 cells per microliter (aOR, 2.4; 95% CI, 1.4–4.2). Similarly, the odds for women with substance abuse were twice those for women without this risk factor (aOR, 2.0; 95% CI, 1.4–2.9). These findings indicate that further decreasing, or ultimately eliminating, perinatal HIV infections in the United States will require increased attention to the following interventions: an increase in earlier HIV diagnosis, lowering CD4 counts through the use of prenatal antiretroviral medications, substance abuse treatment, and avoidance of breast-feeding. Failure to use any of these interventions represents a missed opportunity for prevention.