Understanding the Timing of HIV Transmission From Mother to Infant

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Abstract
Mother-to-infant transmission of human immunodeficiency virus (HIV) occurs, without any intervention, at rates of 14% to 42% in various settings.1,2 Determining the timing of such transmission is of great clinical relevance for implementing cost-effective prophylaxis.3,4 Based on virologic detection of HIV during the infant's first 2 days of life, it is generally accepted that about one third of transmissions in nonbreastfeeding women occur during gestation and the remaining two thirds during delivery.5-9 Further support for the notion that most HIV transmission occurs intrapartum includes the association of transmission with prolonged duration of membrane rupture,10-12 the protective effect of elective cesarean delivery,13-16 and a virologic and immunologic pattern of acute primary HIV infection in a majority of affected infants.17 However, these findings could be explained by transmission either very late in gestation or during labor.