Thanks to prevention efforts, there are now around 150 infants born with HIV infection each year in the United States, down from nearly 2,000 babies at the peak of the epidemic in 1992. Transmission from parent to child is the most common way children are diagnosed positive for HIV – but prevention efforts in pediatric practice for both infants and adolescent youths remain as crucial as ever to eliminate the risk of HIV/AIDS in all kids. Here’s what pediatricians should know and how to help provide prevention resources in your community.
A Brief History of Pediatric HIV/AIDS
According to the Elizabeth Glaser Pediatric AIDS Foundation, the most common way children are infected with human immunodeficiency virus (HIV) is through vertical transmission; that is, when the pregnant or postpartum mother is HIV-positive and the infant comes into contact with bodily fluids via vaginal birth, breastfeeding, or otherwise.
U.S. prevention efforts and intensive research since the 1970s have been successful in lowering perinatal transmission rates. According to the Center for Disease Control & Prevention (CDC), rates have lowered from around 26% to less than 1%: “When the recommended antiretroviral and obstetric interventions are used, a woman who knows of her HIV infection early in pregnancy now has a less than 1% chance of delivering an infant with HIV.” Prevention efforts include antiretroviral therapy for the pregnant parent early in pregnancy. Antiretroviral therapy for infants within hours after birth can reduce transmission by up to half.
Pediatric HIV rates are more prevalent in specific demographics. Black/African American children represented 65% of the diagnosed pediatric HIV infections in 2018, followed by White and Hispanic/Latino populations. HIV is also more prevalent among different gender and sexuality groups, such as transgender people, with people who identify as gay or bisexual at the highest risk.
Pediatricians treat a diverse group of young people. Since the highest risk for HIV/AIDS lies at either end of the age spectrum that pediatricians are most likely to care for – infants and young adults – prevention and treatment efforts by pediatricians remain important to reduce and eliminate HIV infection in the United States and to reduce stigma related to the virus.
Preventing Pediatric HIV/AIDS in Infants
The first pediatric group affected by HIV infection is infants of mothers/parents who are HIV-positive. Pediatricians’ role in this group is preventing transmission and caring for infants whose mothers are being treated with antiretroviral therapies.
The pregnant person’s primary care physician and/or Ob/Gyn should test the mother for HIV and counsel them on appropriate therapies and preventive measures to protect their babies. Pediatricians may have a role in HIV testing and prenatal prevention in cases of adolescent or young adult pregnancy of their patient. Most often, however, pediatricians’ prevention efforts for infants begin almost immediately after birth.
Pediatricians may test infants of HIV-positive parents for HIV within hours after birth if the parent’s doctor did not complete this test. Subsequent virological testing at 1 to 2 months of age, and at 4 to 6 months of age can confirm HIV status for the infant.
Preemptive antiretroviral therapy for all infants appropriate to gestational age is recommended by ClinicalInfo.HIV.gov, a section of the National Institute of Health’s Office of AIDS Research. The specific course and type of antiretroviral therapy is determined by the risk factors of both mother and infant, including how late in the pregnancy HIV was diagnosed, adherence by the mother to antiretroviral therapies, and the infant’s testing status.
Prevention & Care
Prevention efforts for infants include discouraging mothers from breastfeeding altogether, or any action that would expose the infant to bodily fluids, such as pre-chewing food.
According to Stanford Children’s Health, immunizations are safe for children who test HIV-positive. Varicella vaccination, as well as yearly influenza vaccinations, are recommended.
With the therapies and prevention efforts available, most American babies have an excellent chance of avoiding or successfully treating HIV infection. To continue this trend, vigilance is required in testing, prevention efforts, and appropriate therapies for HIV-positive parents and children.
Pediatricians can guide families of infants on the risk factors, timeline, and prognosis for children tested for HIV. Children with HIV tend to get sick more severely, and are at risk for future AIDS. However, HIV can successfully be managed with adherence to therapies and the ongoing guidance of a child’s pediatric team.
HIV Prevention and Care in Youths
Undiagnosed HIV is thought to be a leading cause of HIV spread in young adults, the demographic most affected by new HIV cases every year. To account for this, the American Academy of Pediatrics updated its recommendations for HIV testing in adolescents in late 2021:
“The American Academy of Pediatrics in an updated clinical report recommends that universal and routine screening for human immunodeficiency virus (HIV) be offered to youth ages 15 and older at least once in a health care setting.”
The briefing continues with recommendations for creating a safe environment for testing, which includes considerations for privacy, confidentiality, and tolerance of sexual and reproduction health choices. The clinical report mentioned in the briefing notes that “youth at increased risk, including sexually active youth, should be rescreened at least annually, potentially as frequently as every 3 to 6 months if at high risk.”
Rapid HIV Testing kits allow pediatricians to test and report results in one office visit. Pediatricians may choose to incorporate HIV testing into other sexual health screenings. Maintaining confidentiality and trust during conversations about sexual health and testing are crucial for young patients to understand that their pediatrician’s office is a safe space to express their sexual health needs, drug use, concerns, and questions.
During counseling, pediatricians should educate adolescent patients about safety measures they can take and the protections available to them, including condom use, healthy relationships, and Preexposure Prophylaxis (PreP) treatment for those at risk of HIV. Pediatricians and any over licensed provider can prescribe PreP as a risk-reduction prevention method for HIV – learn more about prescribing PreP from the CDC.
Resources like those on HealthyChildren.org are available for patients and their families to learn about, anticipate symptoms of, and treat HIV in children. You can also learn more about sexual health conversations in our previous post, All About Pediatric Gyn Care.
Treatment of HIV in children varies based on viral load, response to antiretroviral therapies, and more. Common medications for infant antiretroviral treatment include zidovudine, lamivudine, and nevirapine. These drugs are currently not tested for safety in premature newborns younger than 37 weeks gestational age.
Treatment and prevention of HIV is a complex process for patients and physicians. Patients should be evaluated to ensure they are withstanding antiretroviral therapy well and have the resources available to keep them safe and healthy. As the cases of pediatric HIV and AIDS decrease in the United States, fewer incidences may appear at any given pediatric practice, which means that fewer pediatricians are familiar with treating pediatric HIV/AIDS.
For advice and more information on treating HIV/AIDS in infants and children, you can contact the National Clinician Consult Center for peer-to-peer advice on managing specific cases.
Preventive care for pediatric HIV remains as critical as ever to reduce risk of infection for everyone, including infants and children. Diagnosis of adolescent HIV can raise quality of life for HIV-positive patients, and prevent spread. Treatment for HIV-positive infants can reduce viral load and prevention can help infants avoid infection altogether.
Preventive services like HIV testing are some of a pediatrician’s most important work. Whether your practice is working to decrease stigma around services like HIV care and testing or to increase your vaccination attempts, prevention efforts are not only important for patients, but for your practice revenue, too. Learn all about why a focus on preventive medicine pays well, protects communities, and expands value to families in our webinar.