In the US, HIV probably occurred in children almost as early as in adults but was not clinically

recognized for several years. Thus far, about 10,000 cases have been reported in children and
young adolescents, representing only 1% of total cases. In 2018, < 100 new cases were
diagnosed in children < 13 years of age (1).
More than 95% of HIV-infected US children acquired the infection from their mother, either before
or around the time of birth (vertical transmission). Most of the remainder (including children with
hemophilia or other coagulation disorders) received contaminated blood or blood products. A few
cases were the result of sexual abuse. Vertical transmission has declined significantly in the US
from about 25% in 1991 (resulting in > 1600 infected children annually) to ≤ 1% in 2018 (resulting
in only about 100 infected children annually). Vertical transmission has been reduced by using
comprehensive serologic screening and treating of infected pregnant women during both
pregnancy and delivery and by providing short-term antiretroviral prophylaxis to exposed
newborns.

However, the total number of HIV-infected US adolescents and young adults (13 to 24 years of
age) continues to increase despite the marked success in decreasing perinatal HIV infection. This
paradoxical increase is a result of both greater survival among perinatally infected children and
new cases of HIV infection acquired via sexual transmission among other adolescents and young
adults (in particular, among young men who have sex with men). Reducing transmission of HIV
among young men who have sex with men continues to be an important focus of domestic HIV
control efforts as is continuing the reduction of vertical transmission.

Worldwide, about 1.7 million children have HIV infection (4% of the total caseload worldwide).
Each year, about 160,000 more children are infected (9% of all new infections), and about 100,000
children die. Although these numbers represent a daunting amount of illness, new programs
created to deliver antiretroviral therapy (ART) to pregnant women and children have reduced the
annual number of new childhood infections and childhood deaths by 33 to 50% in the past few
years (1). However, infected children still do not receive ART nearly as often as adults,
and interrupting vertical transmission  and providing treatment to HIV-infected children remain the
two most important goals of global pediatric HIV medicine.

Transmission of HIV
The infection risk for an infant born to an HIV-positive mother who did not receive ART during
pregnancy is estimated at 25% (range 13 to 39%).

Risk factors for vertical transmission include

 Seroconversion during pregnancy or breastfeeding (major risk)

 High plasma viral RNA concentrations (major risk)

 Advanced maternal disease

  Low maternal peripheral CD4+ T-cell counts

Prolonged rupture of membranes is no longer thought to be an important risk factor.

Cesarean delivery before onset of active labor reduces the risk of mother-to-child transmission
(MTCT). However, it is clear that MTCT is reduced most significantly by giving combination ART,
usually including zidovudine (ZDV), to the mother and neonate (see Human Immunodeficiency
Virus (HIV) Infection in Infants and Children : Prevention ). ZDV monotherapy reduces MTCT from
25% to about 8%, and current combination ART reduces it to ≤ 1%.
HIV has been detected in both the cellular and cell-free fractions of human breast milk. The
incidence of transmission by breastfeeding is about 6/100 breastfed children/year. Estimates of
the overall risk of transmission through breastfeeding are 12 to 14%, reflecting varying durations of
breastfeeding. Transmission by breastfeeding is greatest in mothers with high plasma viral RNA
concentrations (eg, women who become infected during pregnancy or during the period of
breastfeeding).