In February 1994, the Pediatric AIDS Clinical Trial Group Protocol 076 demonstrated that zidovudine (ZDV) could reduce the risk of mother-to-child HIV transmission from 25% to 8% [1]. As a result, a United States Public Health Service (USPHS) task force issued recommendations in August 1994 for the use of ZDV to reduce perinatal HIV transmission [2]. These guidelines were updated in July 2008 and include treatment options for HIV-infected pregnant women and for infants born to HIV-infected women. The guidelines also include recommendations for the medical monitoring of pregnant women and of infants who receive ZDV [3]. In July 1995, the USPHS published recommendations for HIV counseling and voluntary testing for all pregnant women, which include advice to health care professionals on educating women about the importance of knowing their HIV status and the steps to preventing mother-to-child transmission [4]. Revised recommendations for HIV testing for adults, adolescents, and pregnant women in healthcare settings were published in 2006. The 2006 HIV testing recommendations seek to provide more opportunities for pregnant women to be tested for HIV. The recommendations were revised to include the following: HIV screening as part of the routine panel screening for all pregnant women unless they decline; repeat HIV testing during the third trimester in areas with high HIV or AIDS incidence and in facilities with one or more cases per 1,000 of HIV in pregnant women diagnosed in a year; and rapid HIV testing during delivery for all pregnant women without documented HIV test results [5].

After the HIV counseling and testing recommendations were published in 1995, CDC began conducting enhanced perinatal surveillance activities in 7 states to monitor the effect of the guidelines. Prevention indicators were assessed for the years before, during, and after the implementation of the guidelines (1993, 1995–1996). These indicators included receipt of prenatal care, HIV testing before or during pregnancy, and administration of ZDV to the mother antepartum and intrapartum and to the infant after birth. Data showed that an increased number of pregnant women and infants received ZDV after the recommendations were published. The proportion of infants infected with HIV decreased from 16% of those who did not receive ZDV to 8% of those who received ZDV [6].

In 1999, the Institute of Medicine issued a report entitled Reducing the Odds: Preventing Perinatal Transmission of HIV in the United States. In this report, the committee described factors that lead to perinatal HIV transmission. They include the lack of prenatal care, HIV testing, and antiretroviral therapy (ART) for HIV-infected women and HIV-exposed infants [7]. Also in 1999, Congress appropriated $10 million per year for activities aimed at reducing perinatal HIV infection. These activities included enhanced perinatal HIV surveillance, funded in 24 state and local health departments (Figure 1); perinatal HIV prevention programs, funded in 16 state health departments; and partnerships with 6 national organizations (Figure 1).

CDC implemented activities to further reduce perinatal HIV transmission in areas with high HIV prevalence. The Enhanced Perinatal Surveillance (EPS) project was created as an extension of routine HIV surveillance activities. The overall goals of EPS are to (a) monitor the implementation of the USPHS recommendations for counseling and voluntary testing of pregnant women, the use of antiretrovirals to prevent perinatal HIV transmission, and the effect of implementation on the trends of HIV disease among children; (b) to establish a surveillance system to collect data that enable states to respond to selected requirements of the Ryan White CARE Act; and (c) to assist in timely evaluation of perinatal prevention efforts.

This report includes data from the 24 areas conducting EPS for live births during 2000 through 2003 (Figure 1). As of December 2003, a total of 10,008 singleton births had been reported to EPS. The report, comprising data for birth years 2000–2003, is organized in 3 sections: (a) demographic, behavioral, and clinical information on HIV-infected pregnant women who gave birth; (b) demographic, behavioral, and clinical information on those women, by race/ethnicity; and (c) clinical information on infants born to HIV-infected women. EPS methods are described in the Technical Notes.

The purpose of this report is to describe the population of HIV-infected women who gave birth during 2000 through 2003. These data provide information for further focusing perinatal prevention efforts in the United States and the dependent areas. The data are presented by child’s birth year so that readers can understand the characteristics of this population in a particular year.

HIGHLIGHTS

• The majority of HIV-infected pregnant women reported to EPS were black, not Hispanic (66%); 19% were Hispanic; 11% were white, not Hispanic; and 1% were Asian/Pacific Islander (Table 1).
• Thirty-two percent (32%) of the HIV-infected pregnant women were exposed to HIV through heterosexual contact, 11% were exposed through injection drug use, and exposure was unknown for 28% (Table 1).
• Most (88%) of the HIV-infected pregnant women received some prenatal care, eight percent (8%) did not receive prenatal care, and receipt of prenatal care was unknown for 4%. Of those HIV-infected pregnant women who received some prenatal care, 66% had 3 or more prenatal care visits (Table 2).
• HIV status was known before the pregnancy for 60% of HIV-infected pregnant women; 34% of women were diagnosed with HIV during labor and delivery; 2% were not tested for HIV before giving birth (Table 3).
• Eighty-one percent (81%) of HIV-infected pregnant women received ART during the prenatal period and 81% received ART intrapartum. Of the infants born to HIV-infected women, 93% received ART during the neonatal period (Table 4).
• More than one third (36%) of the HIV-infected pregnant women had an elective cesarean section; 44% had a vaginal birth (Table 5).
• One fifth (20%) of the HIV-infected pregnant women had used illicit drugs during pregnancy (Table 6).
• By race/ethnicity, the following proportion of HIV-infected pregnant women received prenatal care: 90% of white, not Hispanic women; 91% of Hispanic women; 89% of Asian/Pacific Islander women; and 88% of black, not Hispanic women (Table 9).
• The proportion of HIV-infected pregnant women who were tested before pregnancy varied by race/ethnicity: 68% of white, not Hispanic women; 61% of Hispanic women; 59% of black, not Hispanic women; and 41% of Asian/Pacific Islander women (Table 10).
• The proportion of HIV-infected women who were tested during labor varied by race/ethnicity: 43% of Asian/Pacific Islander women; 32% of black, not Hispanic women; 30% of Hispanic women; and 22% of white, not Hispanic women (Table 10).
• ART during the prenatal period was received by 86% of white, not Hispanic women; 84% of Hispanic women; 84% of Asian/Pacific Islander women; and 80% of black, not Hispanic women (Table 11).
• ART during the intrapartum period was received by 85% of white, not Hispanic women; 84% of Hispanic women; 84% of Asian/Pacific Islander women; and 80% of black, not Hispanic women (Table 11).
• Similar proportions of infants, categorized by mother's race/ethnicity, received ART during the neonatal period: 94% of infants born to white, not Hispanic women; 94% of those born to Hispanic women; 94% of those born to Asian/Pacific Islander women; and 93% of those born to black, not Hispanic women (Table 11).
• The proportion of HIV-infected women, by race/ethnicity, who had an elective cesarean section were: 40% of white, not Hispanic women; 40% of Hispanic women; 35% of black, not Hispanic women; and 32% of Asian/Pacific Islander women (Table 12).
• Similar proportions of HIV-infected women, by race/ethnicity, had a vaginal delivery: 46% of black, not Hispanic women; 46% of Asian/Pacific Islander women; 41% of white, not Hispanic women; and 41% of Hispanic women (Table 12).
• The proportion of HIV-infected women who reported illicit drug use during pregnancy varied by race/ethnicity: 25% of white, not Hispanic women; 21% of black, not Hispanic women; 16% of Hispanic women; and 8% of Asian/Pacific Islander women (Table 13)
• Of the 7,228 infants born to HIV-infected women, 274 (4%) were perinatally infected with HIV, 4,742 (66%) were not infected, and 2,212 (31%) remain in the indeterminate category; 2,780 cases were excluded due to missing HIV status (Table 16).
• By race/ethnicity, the following proportion of HIV-infected pregnant women delivered preterm: 34% of black, not Hispanic women; 33% of white, not Hispanic women; 31% of Hispanic women; and 22% of Asian/Pacific Islander women (Table 18).
• Similar proportions of HIV-infected women, by race/ethnicity, had children who were identified to have a birth defect within their first year of life: 4% of black, not Hispanic women; 3% of white, not Hispanic women; 3% of Asian/Pacific Islander women; and 2% of Hispanic women (Table 19).
• The majority of HIV-infected pregnant women (92%) received reimbursement for their medical treatment (Table 20).

REFERENCES

1. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994;331:1173–80.
2. CDC. Recommendations of the U.S. Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR 1994;43(RR-11):1–20.
3. Public Health Service Task Force. Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States.
4. CDC. U.S. Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR 1995;44(RR-7):1–15.
5. CDC. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR 2006;55(RR-14):1–17.
6. CDC. CDC report regarding selected public health topics affecting women's health. MMWR 2001;50(RR-6):17–28.
7. Institute of Medicine, National Research Council. Reducing the Odds: Preventing Perinatal Transmission of HIV in the United States. Washington, DC: National Academy Press;1999.

SUGGESTED READINGS

• CDC. Guidelines for national HIV case surveillance, including monitoring for HIV infection and AIDS. MMWR 1999;48(RR-13):1–28.
• CDC. 1999 Revised surveillance case definition for HIV infection. MMWR 1999; 48(RR-13);29–31.
• CDC. Achievements in public health: reduction in perinatal transmission of HIV infection—United States, 1985–2005. MMWR 2006;55(21);592–597.
• Harris NS, Fowler MG, Samson SL, et al. Use of enhanced perinatal human immunodeficiency virus surveillance methods to assess antiretroviral use and perinatal human immunodeficiency virus transmission in the United States, 1999–2001. AJOG 2007;197;S33–41.