Risk factors for mother-to-child transmission of HIV-1.

Children born to women known to be infected with human immunodeficiency virus type 1 (HIV-1) before delivery were followed prospectively from birth in nineteen European centres. This analysis, encompassing the period end-December, 1984, to beginning-August, 1991, focuses on risk factors for mother-to-child transmission of HIV-1 infection. Rate of vertical transmission, based on 721 children born to 701 mothers more than 18 months before the time of analysis, was 14.4% (95% Cl 12.0-17.1%). Transmission was associated with maternal p24-antigenaemia and a CD4 count of less than 700/microliters. In a multivariate analysis, odds ratios of transmission were: 2.25 (95% Cl 0.97-5.23) in breastfed children vs never-breastfed children; 3.80 (1.62-8.91) in children born before 34 weeks' gestation; and 0.56 (0.30-1.04) in children delivered by caesarean section. Transmission was higher with vaginal deliveries in which episiotomy, scalp electrodes, forceps, or vacuum extractors were used, but only in centres where these procedures were not routine. On the basis of these results, HIV-infected women contemplating pregnancy should be counselled according to their immunological findings and, if they have p24-antigenaemia or a low CD4 count, warned of an increased risk of viral transmission. Caesarean deliveries may have a protective effect, although it is premature to recommend routine operative delivery. The mechanism for the higher infection rate in children born before 34 weeks' gestation is unclear, but could reflect inadequate passive or active immunity at that age, combined with substantial transmission during labour or delivery. The balance of evidence suggests that mothers with established infection can transmit HIV infection through breastmilk, although the relative importance of this route remains to be defined.