Racial/Ethnic Disparities Among Children with Diagnoses of Perinatal HIV Infection --- 34 States, 2004--2007

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Early in the epidemic of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in the United States, racial/ethnic disparities were observed in the diagnoses of AIDS among adults and children (1). Since the early 1990s, the annual number of diagnoses of perinatally acquired AIDS and HIV infection has declined by approximately 90% in the United States as a result of routine HIV screening of pregnant women and the availability of effective interventions to prevent transmission (2,3). To characterize the most recent trends in diagnoses of perinatal HIV infection by race/ethnicity, CDC analyzed national HIV surveillance data for the period 2004--2007 from 34 states. This report summarizes the results of those analyses, which indicated that, during 2004--2007, 85% of diagnoses of perinatal HIV infection were in blacks or African Americans (69%) or Hispanics or Latinos (16%). The average annual rate of diagnoses of perinatal HIV infection during 2004--2007 was 12.3 per 100,000 among blacks, 2.1 per 100,000 among Hispanics, and 0.5 per 100,000 among whites. However, from 2004 to 2007, the racial/ethnic disparity narrowed, as the annual rate of diagnoses of perinatal HIV infection for black children decreased from 14.8 to 10.2 per 100,000, and the rate for Hispanic children decreased from 2.9 to 1.7 per 100,000. To further reduce perinatal HIV transmission and racial/ethnic disparities, HIV-infected pregnant women, and particularly black and Hispanic women, should receive timely prenatal care, early antiretroviral treatment, and other recommended interventions.

HIV infection and AIDS are notifiable in all 50 states, the District of Columbia, and five U.S. territories. States have implemented HIV infection reporting over time, and national HIV surveillance with uniform reporting was not implemented fully until 2008.* CDC regards data from states with confidential, name-based HIV surveillance systems to be adequate for monitoring trends only if they have been reported for at least 4 years (2). For this analysis, HIV and AIDS diagnosis data for the period 2004--2007 (the latest data available) were obtained from the 34 states† that have had name-based reporting since at least December 2003. A diagnosis of perinatal HIV infection (definitive or presumptive) was defined in a child who 1) was born to a woman with HIV infection, 2) was aged <13 years, and 3) had met CDC's 2008 revised surveillance case definition for HIV infection in children (4). The number and percentage of diagnoses of perinatal HIV infection during 2004--2007 were calculated by year of diagnosis and stratified by race/ethnicity. To calculate rates of HIV diagnoses per 100,000 infants aged ≤1 year in each racial/ethnic group, yearly population estimates were obtained for the 34 states from the U.S. Census Bureau. Population data for infants were used as a proxy for live births because race/ethnicity data were not available for live births in the 34 states in the same manner that race and ethnicity are reported in HIV surveillance. Trends in the annual rates of diagnosis of perinatal HIV infection were analyzed by the two-sided Cochran-Armitage test, with statistical significance at p<0.05. Rate ratios were calculated to compare rates for blacks, Hispanics, and children of other or multiple races with rates for whites.

During 2004--2007, the average annual overall rate of diagnoses of perinatal HIV infection was 2.7 per 100,000 infants aged ≤1 year in the 34 states (Table). The highest rates were among children who were black (12.3 per 100,000), followed by children who were Hispanic (2.0), of other or multiple races (1.6), and white (0.5). Using the rate among white children as the referent, the rate ratios for black and Hispanic children and children of other or multiple races were 23.1, 3.8, and 3.1, respectively. From 2004 to 2007, the annual rate of diagnoses of perinatal HIV infection for black children decreased from 14.8 to 10.2 per 100,000 (p = 0.003), and the rate for Hispanic children decreased from 2.9 to 1.7 per 100,000 (p = 0.04). The rates for white children and for children of other or multiple races did not change significantly (Figure 1).

During 2004--2007, among all children with diagnoses of perinatal HIV infection in the 34 states, 69% were black, 16% were Hispanic, 11% were white, and 4% were of other or multiple races. In contrast, 15% of infants in the 34 states aged ≤1 year were black, 22% were Hispanic, 56% were white, and 7% were of other or multiple races. The percentages of black and Hispanic females aged ≥13 years with HIV infection were similar to those for children with diagnoses of perinatal HIV infection; 67% were black, and 14% were Hispanic (Figure 2).

Reported by

MA Lampe, MPH, S Nesheim, MD, RL Shouse, MD, CB Borkowf, PhD, V Minasandram, K Little, PH Kilmarx, MD, S Whitmore, DrPh, A Taylor, MD, L Valleroy, PhD, Div of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC.

Editorial Note

Racial/ethnic disparities in the incidence of HIV/AIDS among children have been documented since 1981--1986, when 78% of children with AIDS were black or Hispanic (1). These racial/ethnic disparities have been reflected in rates of perinatal HIV infection. Although the total number of annual perinatal HIV infections in the United States has decreased approximately 90% since 1991 (3) and the findings in this report indicate a continued decrease during 2004--2007, racial/ethnic disparities persist. Of all reported diagnoses of perinatal HIV infection during 2004--2007, 85% were in children who were black or Hispanic, and rates were several-fold higher among black and Hispanic children than among white children. To eliminate perinatal transmission and racial/ethnic disparities, continued measures are needed, including primary HIV prevention for women, reproductive health and family planning for women with HIV infection, and prenatal care and early treatment with antiretroviral medications for pregnant women and their infants.

These disparities are directly related to the racial/ethnic distribution of women diagnosed with HIV infection (Figure 2). High-risk heterosexual transmission remains the principal source of exposure for HIV-infected women of all races/ethnicities, accounting for 80% of new infections among women (5). Recent studies also have suggested that the higher rates of HIV infection among blacks in the United States are related to a number of social factors, such as tight social networks, assortative mixing, and poverty (6). In addition, in a study of women enrolled in Medicaid during 1995--1997, black (71%) and Hispanic women (74%) were significantly less likely than non-Hispanic white women (81%) to initiate prenatal care in the first trimester and less likely (62% and 69% versus 72%, respectively) to make an adequate number of prenatal care visits (7), indicating that black women would have less opportunity for timely HIV testing and early initiation of antiretroviral prophylaxis to prevent perinatal transmission.

In the Pediatric Spectrum of Disease Study, black HIV-infected mothers of HIV-exposed infants were twice as likely as white HIV-infected mothers not to engage in prenatal care (odds ratio = 2.1 [95% confidence interval = 1.0--4.5]) (7). In a large clinical trial conducted during 1997--2000 to study methods to reduce perinatal HIV transmission, black (44%) and Hispanic (47%) women were less likely than white women (49%) (p = 0.02) to have antiretroviral therapy before pregnancy, and black (12%) and Hispanic (15%) women were more likely than white women (10%) (p = 0.007) to have entered the study with lower CD4 cell counts. In addition, white women were more likely to have viral suppression (<1,000 copies/mL) at delivery, the primary factor associated with prevention of perinatal HIV transmission (9). In that study, white race was predictive of successful viral suppression at delivery in a multivariate model incorporating type of antiretroviral regimen, time of antiretroviral initiation and therapy, and time of prenatal care initiation (9).

The findings in this report are subject to at least two limitations. First, the data were reported only from the 34 states with confidential, name-based HIV surveillance systems, and these states might not be representative of all persons in the United States who receive a diagnosis of perinatal HIV infection. Diagnoses of HIV infection from areas with high AIDS morbidity (e.g., California, Illinois, and the District of Columbia) that did not conduct confidential, name-based surveillance during 2004--2007 were not included. However, the racial/ethnic disparities described in this report are consistent with disparities observed among persons with AIDS from all 50 states (2). Second, because diagnoses of HIV infection are assigned to the year of diagnosis, they might not represent new infections, except among those aged ≤1 year with diagnoses of perinatal HIV infection.

Further reductions in perinatal HIV transmission are achievable, toward an elimination goal of <1% among infants born to HIV-infected women (10) and <1 transmission per 100,000 live births. Primary HIV prevention in women is the best way to prevent HIV infection in children. All women with HIV infection should have reliable access to comprehensive HIV treatment and primary women's health care to optimize their health before pregnancy and receive effective contraception to avoid unintended pregnancy. To eliminate perinatal HIV transmission, all HIV-infected pregnant women must 1) receive a diagnosis of HIV infection before or early in pregnancy, 2) receive prenatal care, 3) adhere to an antiretroviral medication regimen during pregnancy, 4) have a scheduled cesarean delivery at 38 weeks' gestation if viral suppression has not been achieved, and 5) receive antiretroviral medication during labor and delivery.§ Antiretroviral medication also should be provided to HIV-exposed newborns within the first hours after birth and for the first 6 weeks of life.

References

1. CDC. Acquired immune deficiency syndrome (AIDS) among blacks and Hispanics---United States. MMWR 1986;35:655--66.
2. CDC. Cases of HIV infection and AIDS in the United States, 2007. HIV/AIDS surveillance report, 2007. Vol. 19. Atlanta,GA: US Department of Health and Human Services, CDC; 2009. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports. Accessed February 3, 2010.
3. Lindegren ML, Byers RH, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA 1999;282:531--8.
4. CDC. Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years---United States, 2008. MMWR 2008;57(No. RR-10).
5. CDC. Subpopulation estimates from the HIV incidence surveillance system---United States, 2006. MMWR 2008;57:985--9.
6. Aral SO, Adimora AA, Fenton KA. Understanding and responding to HIV and other sexually transmitted infections in African Americans. Lancet 2008;372:337--40.
7. Gavin NI, Adams EK, Hartmann KE, Benedict MB, Chireau M. Racial and ethnic disparities in the use of pregnancy-related health care among Medicaid pregnant women. Matern Child Health J 2004;8:113--26.
8. Peters V, Liu KL, Dominguez K, et al. Missed opportunities for perinatal HIV prevention among HIV-exposed infants born 1996--2000, pediatric spectrum of HIV disease cohort. Pediatrics 2003;111:1186--91.
9. Cunningham CK, Balasubramanian R, Delke I, et al. The impact of race/ethnicity on mother-to-child HIV transmission in the United States in Pediatric AIDS Clinical Trials Group Protocol 316. J Acquir Immune Defic Syndr 2004;36:800--7.
10. European Collaborative Study. Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. Clin Infect Dis 2005;40:458--65.

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