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One of the most remarkable achievements of public health in Southern Africa over the last decade has been the reduction in the number of babies born with HIV. This goal has been achieved through the provision of antiretroviral therapy to pregnant and lactating women living with HIV. For example, the number of new HIV infections among children in South Africa increased from a high of 70,000 in 2003 to 13,000 in 2017.
Nevertheless, about 14.8 million children under the age of 15 were born around the world without being infected with HIV but exposed to their mother's HIV during pregnancy.
The largest number of children exposed to HIV but uninfected – 3.2 million – is in South Africa.
In South Africa, 30% of pregnant women are HIV-positive. Their children are exposed to HIV and antiretrovirals during pregnancy and badfeeding. Children exposed to HIV but not infected do not have HIV, so what's the problem?
This is a big problem because non-HIV-infected children born to HIV-infected mothers are prone to more serious infections, twice as likely to die before their first birthday, and are more likely to be born prematurely than children born to HIV-positive children. mothers without HIV.
In our recent study, we sought to quantify the contribution of deaths in uninfected and HIV-exposed infants to overall infant mortality rates in Botswana and South Africa.
We found that because children born to HIV-positive mothers constituted almost one in four children in Botswana and South Africa, they died more often than children born to uninfected mothers – even though they are not infected with HIV contributed to a higher infant mortality rate in both countries.
The risks
Even though they are not infected with HIV, children born to HIV-positive women experience a complex set of harmful exposures.
For example, infants exposed to HIV but not infected are still more often born premature or low birth weight. This increases their risk of complications and deaths very early in life.
They are also exposed to more infectious pathogens at home such as tuberculosis.
There are also other problems. Breastfeeding has tremendous nutritional and immunological benefits, but has often been avoided in infants born to women living with HIV. Maternal access to antiretrovirals has made it safer, but badfeeding is still low. A study in South Africa showed that, regardless of their HIV status, women stopped badfeeding their babies on average at the age of eight weeks.
In addition, infants exposed to HIV more often have sick or dead mothers. And HIV-affected households face difficult socio-economic conditions that can make children more vulnerable. These exposures during the first 1000 days of life can adversely affect early childhood development and have long-term consequences.
In addition, infants born to HIV-positive women are subject to factors during pregnancy that unexposed infants are not. These include exposure to HIV particles, which can make their immune systems grow differently. And these infants are exposed to at least three antiretroviral drugs given to the mother during pregnancy.
What research has found
To estimate the contribution of deaths of HIV-infected but uninfected infants to overall infant mortality rates, we used previously published research comparing the risk of mortality of uninfected HIV-exposed infants with the risk of mortality of unexposed infants, as well as United Nations estimates of infant mortality. mortality in Botswana and South Africa.
In Botswana, uninfected infants exposed to HIV accounted for 26% of the infant population but 42% of all infant deaths. Similarly, in South Africa, uninfected infants exposed to HIV accounted for 23% of the infant population but 38% of all infant deaths.
In real terms, this excess mortality among uninfected infants exposed to HIV has increased the overall rate of uninfected infant mortality in Botswana and South Africa, from about 30 deaths per 1,000 infants to 35 deaths per 100,000 live births. 1,000 in 2013.
Botswana and South Africa have adopted the World Health Organization's recommendation to provide life-long antiretrovirals to all pregnant and badfeeding women living with HIV. However, there is little research comparing the mortality of HIV-exposed children to unexposed infants under these new guidelines. Our calculations are therefore based on the year 2013, the most recent year preceding the policy changes in both countries. There is new evidence of a persistent increase in mortality among HIV-exposed infants, even with maternal antiretroviral therapy.
What then
With 1 in 4 children in Botswana and South Africa exposed to HIV and ARVs, robust systems need to be in place to monitor the long-term safety of these exposures during pregnancy. Countries need to invest in research to understand why children exposed to HIV are still at increased risk of dying. Countries must also ensure that routine child health interventions, such as immunization and the promotion of optimal badfeeding times, consistently affect children exposed to HIV.
More critically, countries such as South Africa and Botswana with high rates of HIV infection need to find responsible, transparent and accurate ways to share what is known and what is being done. the risks of HIV exposure among families affected by HIV and involve them in finding solutions.
Amy Slogrove, Senior Lecturer in Pediatrics and Child Health at the University of Stellenbosch; Kathleen M. Powis, Assistant Professor, Harvard School of Medicine; and Mary-Ann Davies, Associate Professor and Director, Center for Epidemiology and Infectious Disease Research, University of Cape Town.
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