When Cambridge University Press decided to undertake the publication of the second edition of the Handbook of Pediatric Care, they told us that they were very enthusiastic about the book, but that they thought that, while the handbook was too large to be a true “handbook,” they still valued and appreciated the more comprehensive content of the book. The Press therefore asked us, for the second edition, to both shorten the material to a more manageable size to make a new handbook and to augment the material in the handbook to make an even more comprehensive Textbook of Pediatric HIV Care. We hope that we have achieved these goals in these two books, a second edition of the Handbook of Pediatric HIV Care and the first edition of the Textbook of Pediatric HIV Care.

Our goals for both books are to provide the clinician with the information needed to provide excellent care to children infected with HIV. Neither book is meant to be an exhaustive treatise on the subject of pediatric HIV disease, covering all the many societal and policy issues that are involved necessarily in a complete discussion of HIV and children. Rather, we aim to provide helpful management information for the frontline clinician. While we have focused on the management of pediatric HIV disease, we believe that effective management requires a solid understanding of the basic and applied virology, immunology, and pathophysiology of the disease, so that the practitioner can thoughtfully and rationally apply the management information supplied in the other chapters.

Introduction

Over the past several years, major successes have been achieved in prevention of mother-to-child transmission (MTCT) of human immunodeficiency virus type 1 (HIV). However, these successes have occurred primarily in those countries with the greatest resources and the lowest burden of HIV infection among women and children. Significant challenges remain, particularly in those countries with more limited resources and a greater population burden of HIV infection. Each day an estimated 2000 infants become infected with HIV, virtually all residing in resource-poor settings [1]. MTCT of HIV can occur during pregnancy, at the time of labor and delivery, and postnatally (through breastfeeding) [2]. Rates of MTCT of HIV have been calculated in studies conducted around the world in the absence of interventions to decrease transmission [3]. Overall, most studies reported a transmission rate in the range of 25%–30% and higher transmission rates were observed in resource-poor settings (13%–42%) than in resource-rich settings (14%–25%). In this chapter, risk factors for MTCT of HIV will be reviewed briefly. In addition, interventions for the prevention of MTCT of HIV will be discussed, both those already shown to be efficacious and those under study. Finally, strategies to prevent MTCT of HIV will be addressed.

Risk factors for, and interventions to prevent, mother-to-child transmission of HIV

Numerous risk factors for MTCT of HIV have been identified or are under investigation [4].

Introduction

When we were in training to be pediatricians we diagnosed and treated some of the first children infected with HIV seen in our hospitals. We watched as most of them died quickly, within the first year or two of life, and we saw many of their parents die too. Over the following few years we witnessed the wards of our hospitals fill with children infected with HIV, at least in part because the growing epidemic was not viewed as a serious threat to the population as a whole, a threat that needed to be confronted with the determination and the resources appropriate to the magnitude of that threat.

As the epidemic expanded we initially had few effective therapies, either for HIV infection itself or for the opportunistic infections that complicate the disease. The numbing morbidity and mortality of HIV infection in children grew; we continued to see our patients and their parents die. Slowly, we saw more effective treatments for opportunistic infections and for HIV infection itself come into use. We saw the development of serological tests to diagnose HIV infection, of the first antiretroviral agents and agents for the prevention and treatment of opportunistic infections, of more effective antiretroviral agents, of methods to employ antiviral agents in effective combinations that can drive the viral load to low levels, of assays to determine viral load and methods to use the viral load assays to measure the effectiveness of antiretroviral therapy, of methods to assess whether a patient's virus is resistant to antiretroviral agents and approaches to select optimum combinations of antiretroviral agents, and of therapeutic approaches that dramatically decrease the likelihood that an infected mother will transmit HIV to her newborn.