With the rapid global expansion of effective strategies to prevent mother-to-child transmission of HIV (PMTCT), an increasing proportion of HIV-exposed children (born to HIV-infected mothers) are uninfected. Worldwide, more than one million HIV-exposed uninfected infants (HEU) are born annually, most of them in low-income countries. In regions with high HIV prevalence, HEU infants are a growing population, commonly overlooked by preventive interventions, programmatic efforts are often focused on preventing new HIV paediatric infections.
HIV exposure directly or indirectly in utero, intrapartum, and during breastfeeding has been shown to confer risks to infants, even in the absence of vertical HIV transmission from mother to child. Several studies have described HEU infants to have increased risk of mortality and poor health, growth and development outcomes compared with HIV-unexposed infants; however, these associations are not well understood. Low social and economic background associated with being born in an HIV-affected household, increased exposure to maternal antiretroviral therapy (ART) and infectious pathogens, and shortened duration of breastfeeding may play a role in mediating adverse health consequences in HEU children.
Additionally, these children may have an impaired immunity as a result of HIV exposure, leading to an increased susceptibility to infections. However, most evidence comes from studies conducted in developed countries or prior to the scale-up of ART (1). A better understanding of the impact of maternal HIV infection on the health outcomes for HEU infants is needed in low-income settings, where malnutrition and comorbidities are frequent, and health monitoring resources are limited.
Mozambique has one of the highest burdens of HIV worldwide, with almost 30% of pregnant women infected with HIV in some regions (2). After a decade of scaling-up access to ART, two prospective studies have shown that maternal HIV infection continues to have adverse and severe consequences on pregnancy outcomes and infant health, even if vertical transmission is prevented. Importantly, HEU children were more likely to be undernourished, be admitted to hospital and die within the first 18 months of life compared with HIV-unexposed children (3, 4).
The current recommended approach for PMTCT—that is, the initiation of lifelong ART for all HIV-infected pregnant and breastfeeding women—is expected to further reduce the incidence of new paediatric HIV infections and potentially eliminate vertical transmission from mother to child (5). As the proportion of HIV-infected children declines, more focus should be given to the health needs of HEU children to ensure that the post-2015 Sustainable Development Goals are met. New programs and interventions must take into consideration the long-term health needs of this vulnerable population and address transmission from mother to child, not only to prevent infant infections, but also to improve child survival.
1. Evans C, Jones CE, Prendergast AJ. HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination. The Lancet Infectious Diseases.16(6):e92-e107.
2. Gonzalez R, Augusto OJ, Munguambe K, Pierrat C, Pedro EN, Sacoor C, et al. HIV Incidence and Spatial Clustering in a Rural Area of Southern Mozambique. PloS one. 2015;10(7):e0132053.
3. Gonzalez R, Ruperez M, Sevene E, Vala A, Maculuve S, Bulo H, et al. Effects of HIV infection on maternal and neonatal health in southern Mozambique: A prospective cohort study after a decade of antiretroviral drugs roll out. PloS one. 2017;12(6):e0178134.
4. Ruperez M, Gonzalez R, Maculuve S, Quinto L, Lopez-Varela E, Augusto O, et al. Maternal HIV infection is an important health determinant in non-HIV-infected infants. AIDS (London, England). 2017;31(11):1545-53.
5. WHO. Consolidated guidelines on the use of antiretroviral drugs treating and preventing HIV infection: recommendations for a public health approach. Second edition.World Health Organization; 2016.