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The United States has reduced new human immunodeficiency virus (HIV) infections and improved linkage to and retention in care for people living with HIV. New HIV infections have stabilized at approximately 45 000 per year from 130 000 new infections annually in the mid-1990s.1,2 In 2014, 74% of people were linked to care within a month of HIV diagnosis. In 2012, 55% of people living with HIV were retained in care.3 One of the most notable successes in battling the HIV epidemic in the United States to date has been the significant reduction in perinatal transmission, with elimination of mother-to-child transmission now a realistic goal. With the release in 1994 of the seminal AIDA Clinical Trials Group 076 study results demonstrating that a biomedical intervention of antiretroviral therapy could significantly reduce perinatal HIV transmission, the United States moved quickly to leverage the public health infrastructure and gain early successes.4,5 Illustrating the continued progress with preventing perinatal HIV transmission in the United States, in this issue of JAMA Pediatrics, Taylor et al6 report that the perinatal infection rate decreased from 5.37 per 100 000 live births in 2002 to 1.75 per 100000 live births in 2013. Although the United States has made significant progress in reducing new HIV infections overall, as well as perinatal infections, making further reductions with existing tools and resources will be difficult. Key to reducing new HIV infections— including perinatal infections—is ensuring that people living with HIV achieve viral suppression that reduces both sexual and perinatal transmission to negligible levels.7 Among clients receiving medical care services through the Ryan White HIV/AIDS Program (RWHAP), a federally funded program that supports HIV care and treatment to more than half of all people diagnosed with HIV in the United States, 83.4% had viral suppression in 2015, showing marked improvement from 69% in 2010.8 The findings of Taylor et al6 support the belief that improvements are needed in working with young women to ensure linkage and engagement in care, as well as viral suppression. In the RWHAP, only 67% of young women aged 13 to 24 years were virally suppressed in 2015.8 African American/ black young women in HIV care have some of the lowest rates (64%) of viral suppression. To improve perinatal transmission outcomes, the United States must improve outcomes among young women already engaged in care before, during, and after pregnancy as well as identify the undiagnosed individuals; however, there are few evidence-informed interventions documenting the best ways to reach, engage, and retain this population. This gap is noted in the article by Taylor et al6 finding that many women had missed at least 1 prevention opportunity, with only 25.4% of HIV-infected mother-infant pairs receiving antiretroviral therapy during pregnancy, delivery, and postnatal periods. Significant improvements can be achieved with a broad public health approach that focuses on the systems-level interventions to leverage existing points of care rather than relying on specific, narrowly provided programs. For example, opt-out testing at prenatal visits is one highly effective systematic approach that uses the existing health care infrastructure to identify and bring women infected with HIV into care. Repeating HIV testing in the third trimester to identify acute infections in areas with high rates of HIV or in the presence of risk factors also needs to become routine to drive improvements. However, focusing on medical interventions is necessary but not sufficient, since HIV infection is rarely the only major challenge faced by pregnant women living with HIV. These women are often profoundly affected by other social determinants of health that will need to be addressed to make further progress in reducing perinatal infections. The RWHAP is a resource that can be used to address and lower these barriers. The RWHAP improves access to care for medically underserved populations living with HIV by closing gaps in coverage and supporting comprehensive care and support services that help address competing challenges, including poverty, behavioral health conditions, homelessness, and other social factors. Studies have shown that people living with HIV, particularly those living in poverty, who are supported by a system of care that includes health care coverage and RWHAP care, treatment, and supportive services, have better HIV-related outcomes, including viral suppression, compared with those who do not access RWHAP services.9 Further highlighting the need for a systems-level approach to reducing perinatal transmission, Taylor et al6 found that, from 2010 to 2013, of the 370 perinatal HIV transmissions, 72% of those transmissions occurred in only 11 states, and 49% were concentrated in just 5 states. Nearly half of the 69 infants born with HIV infection in 2013 came from 3 states (Florida, Texas, and California). These data call upon 2 needed strategies—one that evaluates each transmission case and a second targeted population approach that addresses the regional and socioeconomic challenges at a systems level. To eradicate mother-to-child transmission of HIV, every case of perinatal transmission in these high-density areas should be reviewed as a sentinel health event where the multiple systems errors leading to the transmission can be idenRelated article Opinion