Transmission of human immunodeficiency virus infection by breast-feeding

HIV transmission through breastfeeding: still possible in developed countries

We describe here the case of a 13-month-old boy who acquired HIV infection postnatally through breastfeeding in a developed country in 2012. His mother had regular pregnancy follow-up and was found to be seronegative for HIV on 2 consecutive screening tests (during pregnancy and just after delivery). However, 1 year later, diagnosis of HIV infection arose in both of them after a pediatric emergency department visit for bronchitis when unexplained hepatosplenomegaly and inflammatory syndrome were noted. The negative maternal viral load found just after delivery confirmed that the mother's seroconversion occurred postnatally, which allowed for active HIV transmission during lactation and lack of the efficient preventive measures that have implemented in Belgium for years. We discuss this uncommon but still existing mode of HIV transmission in industrialized countries and highlight the importance of implementing new targeted health education interventions in addition to constant clinicians' awareness.

Breastfeeding and HIV

Breastfeeding is a route of HIV transmission from an HIV-infected mother to her infant. However, breastfeeding is an important pillar of child survival and the ideal way of feeding an infant, as well as providing a unique biological and emotional basis for child development. This chapter will highlight the dilemma created by the risks and benefits of breastfeeding and will discuss factors which increase the risk of HIV transmission during breastfeeding, as well as strategies which could be employed to reduce these risks. The research agenda is very full as many questions still remain unanswered.

A history of pediatric immunology

Immunology has played a prominent role in the history of medicine. Pediatric immunologists have focused on immune aberrations in pediatric disorders, particularly those involving host defense mechanisms. These efforts have paid rich dividends in terms of fundamental knowledge of the immune system and major therapeutic advances, including 1) i.v. immunoglobulin therapy, 2) hematopoietic stem cell transplantation, and 3) gene therapy. Pediatric immunology as an organized discipline emerged in the early 1950s, when pediatricians and their basic scientist colleagues began to focus on clinical and basic research related to immunodeficiency. Since then, key organizations and infrastructure have been developed to support this research and the clinical care of immunodeficient patients. We review here the evolution of contemporary pediatric immunology, particularly in North America, from its roots in 19th-century Europe to its current expression as one of the fundamental scientific and clinical disciplines of pediatrics.

Human milk, breastfeeding, and transmission of human immunodeficiency virus type 1 in the United States. American Academy of Pediatrics Committee on Pediatric AIDS

Transmission of human immunodeficiency virus type 1 (HIV-1) through breastfeeding has been conclusively demonstrated. The risk of such transmission has been quantified, the timing has been clarified, and certain risk factors for breastfeeding transmission have been identified. In areas where infant formula is accessible, affordable, safe, and sustainable, avoidance of breastfeeding has represented one of the main components of mother-to-child HIV-1 transmission prevention efforts for many years. In areas where affordable and safe alternatives to breastfeeding may not be available, interventions to prevent breastfeeding transmission are being investigated. Complete avoidance of breastfeeding by HIV-1-infected women has been recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention and remains the only means by which prevention of breastfeeding transmission of HIV-1 can be absolutely ensured. This technical report summarizes the information available regarding breastfeeding transmission of HIV-1.

Breast milk transmission of viral disease

Breast milk transmission of maternal viral infection is well established for CMV and HIV-1. In the case of CMV, this usually does not pose a risk to the infant since serious disease is prevented by placentally transferred maternal antibody. However, in HIV infection, breast-feeding increases the risk of maternal-fetal transmission by about 25% with late breast-feeding (after six months of age) constituting a particular risk. In other maternal viral diseases, e.g., other herpes viruses, parvovirus, hepatitis A, B and C, and rubella, the virus is often demonstrated in the breast milk, but transmission is very rare. The highest risk is during an acute viral infection at the time of birth, since the breast milk has a high titer of virus, and a lack of antibody to neutralize the organism.

Is breast not best? Feeding babies born to HIV-positive mothers: bringing balance to a complex issue

Breastfeeding prevents millions of infant deaths each year throughout the world but causes at least one-third of all pediatric HIV infections. The first randomized trial of breastfeeding versus formula feeding, reported from Nairobi in March 2000, demonstrated an improved outcome for babies of highly selected HIV-positive mothers assigned to formula feed. However, several conditions must be in place and accepted before such replacement feeding can increase HIV-free survival. The proportion of sub-Saharan African women who have access to and will accept these conditions is small. In the short term, efforts to make breastfeeding safer will probably benefit a greater number of African babies.

The dilemma of postnatal mother-to-child transmission of HIV: to breastfeed or not?

The promotion of nearly universal breastfeeding has played an important role in improving child health by providing optimum nutrition and protection against common childhood infections, and by promoting child spacing. Unfortunately, it has become clear that breastfeeding is responsible also for much of the increasing burden of worldwide pediatric human immunodeficiency virus (HIV) infection, especially in the developing nations (12-14% additional risk of HIV infection transmitted by breastfeeding; 35% total proportion of all HIV-infected children in an area infected through breastfeeding). Several factors influence the transmission of HIV by breastfeeding, including whether a woman acquires her infection during breastfeeding (29% risk of transmission) or before pregnancy (7-10% risk of breastfeeding transmission),the degree of maternal plasma and breastmilk viral load, and the presence of mastitis. In areas of the world where adequate sanitary replacement feeding is not available, the decision to withhold breastfeeding so as to decrease HIV transmission may lead to increased rates of child morbidity and mortality from diarrheal and respiratory diseases, and malnutrition. This review summarizes current data on the pathophysiology of breastfeeding transmission of HIV infection, the risk factors for and incidence rates of transmission, and the feasibility of possible alternatives to exclusive breastfeeding in the setting of maternal HIV infection. Clearly, women must be fully informed about the risks of breastfeeding transmission of HIV, the risks of morbidity and mortality among nonbreastfed infants, and the expense and availability of procuring adequate replacement formula. If an uninterrupted access to a nutritionally adequate breastmilk substitute that can be safely prepared is ensured (as is possible in industrialized countries), HIV-infected women should be counseled not to breastfeed their infants.

Management of HIV-infected children in the home and institutional settings. Care of children and infections control in schools, day care, hospital settings, home, foster care, and adoption

The likelihood of high-risk pediatric exposure to HIV infection, other than perinatal exposure, has been shown to be low in most cases, and HIV PEP should be considered on a case-by-case basis. Generic considerations in the management of children who have become HIV infected emphasizes the principles of inclusion, maintaining confidentiality of a child's HIV status, and notifying those who need to know about the HIV status to care properly for the child or adolescent. Although appropriate infection-control precautions are applicable for all children and for many pathogens, children especially HIV-infected children, exposed to such pathogens, must be managed in a timely fashion. In many cases, recommendations that are applicable in one setting are applicable in others. Some exceptions apply, including infection-control precautions in hospitals versus other settings. A few additional considerations have been made for special settings and activities, including adoption, foster care, athletics, summer camp, and other recreational activities.

AIDS and reproductive health

Over 24 million adults worldwide have been infected with HIV. Primarily a sexually transmitted disease, AIDS is inexorably linked to reproductive health and care. Because HIV tends to infect those who are in their reproductive years, the impact of this disease on population growth and life expectancy is projected to be immense in some parts of the world, especially in sub-Saharan Africa. Not least is the challenge to individual families and infant care programs to care for AIDS babies. Estimates of the rate of vertical transmission of HIV range from < 10 to 46%. Transmission through sexual contact accounts for 75-85% of HIV infection worldwide, and today, nearly 20 years into the epidemic, the main tool to stall the spread is advocating change in sexual conduct. Numerous studies leave no doubt that the attributable risk of co-infection with other STDs--both ulcerative and non-ulcerative--in heterosexual transmission is substantial. The only known contraceptive method proven to reduce both infectiousness and susceptibility to HIV is barrier contraception. Spermicidal agents currently available have not been shown to reduce HIV concentrations in genital secretions, or to reduce transmission of the virus. The challenges that lie ahead are tremendous: we must continue to focus on development of affordable preventive measures; urge policy-makers to back further research in prevention to complement condom use; and advocate for continued support of basic research to learn more about fundamental mechanisms of HIV transmission.

Infant feeding and risk of mother-to-child transmission of HIV-1 in São Paulo State, Brazil. São Paulo Collaborative Study for Vertical Transmission of HIV-1

Although vertical transmission of HIV-1 can occur through breast-feeding, little is known about the effect of colostrum, duration of breast-feeding, mixing feeding, and nipple pathology. We used retrospective cohort data to examine the association between breast-feeding-related factors and transmission of HIV-1 from mother to child in São Paulo State, Brazil. Information on maternal and postnatal factors was collected by medical record review and interview. Infection status was determined for 434 children by anti-HIV-1 tests performed beyond 18 months of age or diagnosis of AIDS at any age. Among 168 breast-fed children, the risk of transmission of HIV-1 was 21%, compared with 13% (p = .01) among 264 children artificially fed. Breast-feeding was independently and significantly associated with mother-to-child transmission of HIV-1 after controlling for stage of maternal HIV-1 disease (odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.3-3.8). A trend was shown toward an increased risk of transmission with longer duration of breast-feeding, a history of bleeding nipples, and introduction of other liquid food before weaning, but these associations were not statistically significant. History of colostrum intake or cracked nipples without bleeding were not associated with transmission. Most of the women who breast-fed were unaware of their HIV-1 infection status at the time of delivery. Avoidance of mixed feeding and withholding of breast-feeding in the presence of bleeding nipples should be considered in further research as strategies to reduce postnatal transmission of HIV-1 in settings in which safe and sustainable alternatives for breast-feeding are not yet available.

Early spontaneous abortions and fetal thymic abnormalities in maternal-to-fetal HIV infection

The thymus is thought to play a major role in the immunopathogenesis of human immunodeficiency virus (HIV) infection, particularly in maternal-to-fetal HIV transmission. Characteristic lesions of the HIV-infected thymus include a prominent CD4+ CD8+ T lymphocyte depletion at the corticomedullary junction, the region of the thymus where immune selection occurs. At least threefold excess early spontaneous abortions were noted in a cohort of 124 HIV-infected pregnant women. In these 13 abortuses a very high rate (54%) of HIV vertical transmission was documented, with the thymus gland particularly affected. It is possible that the thymic insult in HIV-infected fetuses contributes to immune rejection of the fetus, possibly by an imbalance of maternal and fetal T1- and T2-type cytokines, known to be important in HIV disease progression. We propose, therefore, that the early spontaneous abortions occurring in HIV-infected pregnant women are due, at least in part, to abnormal immune forces created by HIV infection of the thymus.

Advances in mucosal immunology

HIV infection is likely to remain a significant medical and scientific problem well into the twenty-first century. During the first 15 years of the epidemic, much has been learned about the biology of HIV infection, but the majority of biomedical research has focused on the peripheral circulation. It is likely that the behavior of the virus within the unique immunologic environment of the intestinal mucosa differs from that which is observed in the periphery. Many clinical and epidemiologic features of HIV infection offer compelling reasons to encourage further examination of the mucosal immune system's role in AIDS pathogenesis. This article has touched on most of the significant observations concerning the mucosal immune system and HIV infection, and it is clear that much remains to be done. As mentioned earlier, the mucosal abnormalities observed in HIV infection are likely to have many causes. Careful evaluation of patients with early disease and fewer confounding variables may provide fresh insight into AIDS pathogenesis. Similarly, prospective evaluation of selected patient populations may be more informative in characterizing the progressive alterations in mucosal immune function than random cross-sectional studies of poorly defined groups. It is equally important for immunologic assessment to be correlated with nutritional and symptomatic evaluation. Finally, the success or failure of future antiretroviral therapies will be critically related to the impact of such agents on lymphoid reservoirs of HIV infection such as the gastrointestinal tract, which are at present refractory to treatment.

Maternal clinical factors influencing HIV-1 transmission

The complex puzzle of maternal factors involved in mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission is being put together. The risk of perinatal infection increases with mother's disease progression, but it remains stable in women seroconverting to HIV-1 during pregnancy and in consecutive pregnancies. Thus, transmission correlates with the HIV-1 progression rather than the duration of infection in the mother. Nutritional alterations such as vitamin A deficiency may also have a significant impact, whereas geographic origin and mode of maternal infection are of no influence. Placenta membrane inflammation and concurrent sexually transmitted diseases are other significant covariates. The rate of transmission appears directly correlated with maternal age and inversely with length of gestation. A protective effect of caesarean section has been reported in some observational studies but, being controversial, these results need to be corroborated by randomized trials.

Maternal HIV-1 viral load and vertical transmission of infection: the Ariel Project for the prevention of HIV transmission from mother to infant

Most HIV-1 infections of children result from mother-to-infant transmission, which may occur perinatally or postnatally, as a consequence of breast feeding. In this study, the influence of maternal viral load on transmission of infection to infants from non-breast-feeding mothers was examined using samples of plasma and peripheral blood mononuclear cells (PBMCs) collected at several time points during pregnancy and the 6-month period after delivery. These samples were analyzed by several quantitative methods, including virus cultures of PBMCs and polymerase chain reaction (PCR) assays for HIV-1 RNA in plasma and DNA in PBMCs. The risk of transmission increased slightly with a higher viral load, but transmission and nontransmission occurred over the entire range of values for each assay. No threshold value of virus load was identified which discriminated between transmitters and nontransmitters. We also noted a significant rise in viral load and a decline in CD4+ lymphocytes in the six months after delivery. These findings suggest that a high maternal viral load is insufficient to fully explain vertical transmission of HIV-1. Additional studies are needed to examine the post-partum increase in viremia.

Thermal inactivation of bovine immunodeficiency virus

Cell-associated bovine immunodeficiency virus (BIV) and cell-free BIV were subjected to increasing temperatures, including pasteurization conditions. To determine the effect of heat treatment on BIV viability, reverse transcriptase activity and infectivity of the heat-treated virus were assessed. BIV was inactivated by heating to 47 degrees C for 30 min and by low- and high-temperature pasteurization conditions.

Intrarectal transmission of simian immunodeficiency virus in rhesus macaques: selective amplification and host responses to transient or persistent viremia

Intrarectal simian immunodeficiency virus (SIV) infection in rhesus macaques is a model for sexual transmission of primate retroviruses. Phylogenetic studies on envelope gene sequences that were present in blood following intrarectal SIV inoculation provided evidence for selective amplification of a subset of viruses present in the inoculum and defined one amino acid sequence uniquely associated with intrarectal infection. Both persistent and transient viremia states were observed after intrarectal infection. Immune responses in persistently infected animals accounted for slower rates of disease progression despite the presence of highly pathogenic viruses that were documented by transfusion studies. Transient viremia elicited protective immunity against subsequent intrarectal virus challenge but did not protect against intravenous virus challenge. Transient viremia usually but not always led to self-limiting infection. In one animal, we documented a relapse to active viremia long after the initial transient viremia. SIV transmission across mucosal barriers affects pathogenesis in the short term by limiting the types of viruses established in the host and in the longer term by establishing host responses that slow disease progression despite the presence of highly pathogenic viruses in blood.

Pediatric human immunodeficiency virus infection

In the past decade, an increase in pediatric human immunodeficiency virus (HIV) infection has had a substantial impact on childhood morbidity and mortality worldwide. The vertical transmission of HIV from mother to infant accounts for the vast majority of these cases. Identification of HIV-infected pregnant women needs to be impoved so that appropriate therapy can be initiated for both mothers and infants. While recent data demonstrate a dramatic decrease in HIV transmission from a subset of women treated with zidovudine during pregnancy, further efforts at reducing transmission are desperately needed. This review focuses on vertically transmitted HIV infection in children, its epidemiology, diagnostic criteria, natural history, and clinical manifestations including infectious and noninfectious complications. An overview of the complex medical management of these children ensues, including the use of antiretroviral therapy. Opportunistic infection prophylaxis is reviewed, along with the important role of other supportive therapies.

Murine infection with lymphocytic choriomeningitis virus following gastric inoculation

Laboratory studies of arenaviruses have been limited to parenteral routes of infection; however, recent epidemiological studies implicate virus ingestion as a natural route of infection. Accordingly, we developed a model for oral and gastric infection with lymphocytic choriomeningitis virus to enable studies of mucosal transmission and vaccination by this additional route.

Transmission of HIV-1 in the breast-feeding process

Current laboratory techniques cannot distinguish the mode of vertical transmission (intrauterine, intrapartum, or postnatal) of human immunodeficiency virus type 1 (HIV-1) from mother to infant. The ability to transmit HIV-1 via breast feeding has been established in 24 case reports, primarily involving mothers who seroconvert after delivery. Whether breast-feeding adds a notable additional risk of HIV-1 infection to the risk from pregnancy is controversial. The importance of the duration and intensity of breast-feeding in modulating the outcome of HIV transmission via breast milk also remains unclear. Factors in breast milk may play important roles in an infant's susceptibility to infection with HIV and in the expression of the virus. Pasteurization and storage enhance the intrinsic, antiviral properties of human milk. Banked human milk is pasteurized to destroy the HIV-1 virus but retains properties that may be helpful to infants of HIV-1-positive mothers in developed countries where breast-feeding is not recommended. For infants in populations where the infant mortality rate is high, the risk of death associated with HIV infection acquired via breast milk is lower than the risk associated with not being breast-fed.

How valuable are IgA and IgM anti-HIV tests for the diagnosis of mother-child transmission of HIV in an African setting?

BACKGROUND

Babies born to HIV-infected mothers retain anti-HIV of maternal origin until 15-18 months of age. Because of this, HIV proviral DNA and p24 antigen measurements have become the methods of choice for timely diagnosis of HIV infection in infancy. They are, however, too expensive for widespread use in the developing world.

OBJECTIVE

To evaluate a simple, inexpensive serological method for diagnosing mother-child transmission of HIV, in an African population, which takes account of the effects of placental transfer of maternal antibody and continued exposure to HIV through breast-feeding.

STUDY DESIGN

Plasma specimens for a prospective study of mother-to-infant transmission of HIV in rural Zaire were collected at birth, 3, 6, 9, 12, 18 and 24 months from 21 infected infants (PP group), 21 uninfected infants (PN group) born to seropositive mothers and 21 control infants (NN group) born to uninfected mothers. The specimens were retrospectively tested for IgG, IgM and IgA anti-HIV by immunoglobulin class-specific capture EIAs, and by a commercial anti-HIV EIA.

RESULTS

In neonatal specimens, IgA and IgM anti-HIV were present, respectively, in 13 of 14 (97%) and 8 of 14 (57%) of the PP group and in 6 of 11 (55%) and 2 of 11 (18%) of the PN group. Later, at 3 months and older, IgA and IgM anti-HIV were only detected in the PP group. They peaked at 18 months (93%) and 24 months (67%) respectively. Of the 21 PP group children, 8 (38%) were transiently IgG anti-HIV-negative in the first year, indicating that infection had probably taken place after birth; four of the 8 had no detectable IgA anti-HIV during the first year. None of the specimens collected from the NN group babies were reactive for IgA, IgM or IgG anti-HIV.

CONCLUSIONS

IgA and IgM anti-HIV may be passively transferred across the placenta. Where breast-feeding is prevalent, about half of the transmissions may occur after birth, thus delaying the diagnosis of mother-child transmission. Nevertheless, this simple, cheap IgA anti-HIV, EIA identified 65% of transmissions by 9 months of age, and 93% at 18 months of age. It is a more useful marker than IgM anti-HIV, and gave a much more rapid answer than did tests for IgG anti-HIV seroreversion.

Mode of delivery and gestational age influence perinatal HIV-1 transmission. Italian Register for HIV Infection in Children

Some data suggest that cesarean section reduces mother-to-child HIV-1 transmission. To assess the influence of mode of delivery and other maternal and infant factors on the rate of transmission, we analyzed the data of 1,624 children prospectively followed from birth. Of these, at the last visit 1,033 were > 18 months of age or would have been had they not died of HIV-related illness. Among the 975 first singleton children, 180 [18.5%; 95% confidence limits (CL), 16.1-20.9] acquired infection, as did 8 of 56 (14.3%; 95% CL, 5.1-23.5) second-born children. Multivariate stepwise analysis showed that vaginal delivery and development of symptoms in the mother were significantly and independently associated with a higher transmission rate (vaginal delivery; odds ratio, 1.69; 95% CL, 1.14-2.5; symptoms: odds ratio, 1.61; 95% CL, 1.12-2.3). In contrast, a history of maternal drug use, birth weight, breast-feeding (only 37 infants were breast-fed), and child's sex did not have a significant impact on viral transmission. The percentage of infected children was highest (30.7%) among very premature infants (< or = 32 weeks of gestation); this significant trend subsequently decreased to 11.9% at the week 42 (p < 0.001), suggesting a parallel reduction in peripartum transmission. The reduced rate of infection observed in infants born by cesarean section underlines the urgent need for randomized controlled trials to evaluate the protective role of surgical delivery in preventing perinatal HIV-1 transmission.

The impact of recent advances in microbiology and immunology on perinatal and women's health care

Microbiology and immunology have offered important advances in the care of women and newborns. Understanding of the interplay between individuals and the microorganisms associated with them has provided the framework for important changes in practice. An excellent historical example of this idea, well known to nurses, involves puerperal fever. A recent example is knowledge of the relationship of breastfeeding and human immunodeficiency virus. Recent advances in microbiology and immunology that have improved women's health include improved diagnostic tests and a more complete understanding of the vaginal biofilm.

The reluctance of house staff to perform mouth-to-mouth resuscitation in the inpatient setting: what are the considerations?

OBJECTIVE

Medical house staff are required to perform cardiopulmonary resuscitation (CPR) as part of their job responsibilities. Previously it has been shown that house staff are reluctant to perform mouth-to-mouth resuscitation (MMR) in an out of hospital setting. Therefore, whether reluctance to perform MMR extends to the inpatient setting, and, if so, the reasons for this reluctance were investigated.

DESIGN

All 74 internal medicine house officers of a large metropolitan hospital responded to presentations of hypothetical inpatient cardiac arrest scenarios to assess their willingness to perform MMR.

SETTING

A 1200 bed university-affiliated teaching hospital in Los Angeles, California.

SUBJECTS

All categorical internal medicine house officers at this hospital.

INTERVENTIONS

This study is a survey which concerns whether the house officer would perform mouth-to-mouth resuscitation in different hypothetical cardiac arrest scenarios.

RESULTS

Forty-five percent would perform MMR on an unknown patient and 39% would perform MMR in the elderly patient scenario. Only 16% would do MMR on a patient with a small amount of blood on his lips and only 7% would perform MMR on a patient with presumed acquired immunodeficiency syndrome. Medical housestaff were much more reluctant to perform MMR on elderly, trauma, or presumed immunodeficient patients in an inpatient setting than in an outpatient setting. All house staff that indicated their unwillingness to perform MMR cited fear of human immunodeficiency virus infection as their reason.

CONCLUSION

Medical housestaff are quite reluctant to perform MMR in an inpatient setting. Thus, educating the medical house staff about the percent of patients that survive inpatient cardiac arrest and the actual risks of contracting infectious diseases, especially HIV infections, from MMR and preventative measures, such as effective barrier masks, should result in an increased willingness of physicians to perform MMR or mouth-to-mask ventilation on inpatients.

Immunologic benefits of breast milk in relation to human milk banking

A review of the immunologic benefits of human milk is presented, with emphasis on the antiviral properties of human milk. These properties are so important to infant health that the World Health Organization has restated its recommendation. "In all populations, irrespective of HIV infection rates, breast-feeding should continue to be protected, promoted, and supported." Infection control procedures are described for human milk banking, which should be supported as an immunologically beneficial feeding alternative for infants.

Progress in the understanding of HIV infection: an overview

The worldwide epidemic of human immunodeficiency virus (HIV) infection will likely be considered the most important public health event of the twentieth century. During the past 15 years, a wealth of information relating to the epidemiology, diagnosis, natural history, and treatment of HIV infection has accumulated. This article details the recent progress in each of these areas.

HIV disease and pregnancy. Part 3. Postpartum care of the HIV-positive woman and her newborn

For women with HIV infection, physical and psychosocial adaptation during the postpartum period is fraught with ambivalence. On the one hand, there is the joy of parenthood, but on the other, the burden of a chronic, terminal illness and the possibility of having an infected newborn. The nursing care of the HIV-positive woman and her newborn is discussed. Guidelines for hospital discharge teaching are included.

Clinical manifestations, management and therapy of HIV infection in children

Perinatal infection accounts for the majority of cases of HIV infection in children both in developed and developing countries. Transmission may occur in utero, intrapartum or postpartum as a result of breast-feeding. The actual risk of transmission through breast-feeding is unknown. The majority of infants reported to be infected through breast milk have been infected as a result of a recently acquired HIV infection in the mother. Infants with HIV infection frequently present with clinical symptoms early in life. There is a broad spectrum of clinical findings in paediatric HIV infection, with opportunistic infections and multiorgan system involvement being common. The management of infants born to seropositive mothers includes routine paediatric care as well as careful clinical and laboratory monitoring for evidence of HIV infection. Infants who are seronegative with normal clinical and immunological findings at 18 months of age are considered uninfected. The prognosis and outcome of infants with HIV infection have improved considerably with earlier diagnosis and the availability of specific antiviral therapy. Modalities of therapy include frequent medical evaluation, aggressive diagnosis and treatment of infection, prophylaxis for Pneumocystis carinii infection, the use of intravenous gamma-globulin and specific antiviral therapy, such as zidovudine, didanosine or other drugs in development through clinical trials. HIV infection in children is a chronic illness and requires a comprehensive, family-oriented approach to care. With longer survival, children require support systems and an atmosphere of care and understanding to give them a good quality of life as well as prolonged survival.