The role of obstetric interventions in the prevention of pediatric human immunodeficiency virus infection

By the end of the decade 10 million children will be infected with human immunodeficiency virus. Several potential means of preventing vertical transmission of human immunodeficiency virus are under study. Although the perinatal use of antiretroviral agents can prevent some of these infections, those agents are neither uniformly effective nor universally available. A significant portion of vertical transmission may be an intrapartum phenomenon, potentially amenable to obstetric interventions, such as cesarean section or vaginal virucides. The utility of these obstetric interventions will be determined in large part by the timing of vertical transmission. This work reviews the evidence that human immunodeficiency virus can be transmitted during the intrapartum period and critically reviews the data supporting a role for obstetric interventions. Finally, we outline the necessary elements for the conduct of a conclusive efficacy trial and delineate a mechanism to arrive at a definitive standard of care in the absence or anticipation of a trial.