Intended for healthcare professionals

CCBYNC Open access
Analysis Vertical Transmission of HIV

Unmasking the vulnerabilities of uninfected children exposed to HIV

BMJ 2019; 366 doi: (Published 05 August 2019) Cite this as: BMJ 2019;366:l4479
  1. Vundli Ramokolo, researcher1,
  2. Ameena E Goga, researcher1 2 3,
  3. Amy L Slogrove, researcher4,
  4. Kathleen M Powis, assistant professor5 6 7
  1. 1Health Systems Research Unit, South African Medical Research Council, South Africa
  2. 2Department of Paediatrics, University of Pretoria, South Africa
  3. 3HIV Prevention Research Unit, South African Medical Research Council, South Africa
  4. 4Department of Paediatrics and Child Health and Ukwanda Centre for Rural Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Worcester, South Africa
  5. 5Massachusetts General Hospital, Departments of Medicine and Pediatrics, USA
  6. 6Harvard T H Chan School of Public Health, Department of Immunology and Infectious Diseases, USA
  7. 7Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
  1. Correspondence to: V Ramokolo vundli.ramokolo{at}

Although programmes to reduce vertical transmission of HIV mean fewer children are acquiring HIV, more needs to be done to understand the longer term outcomes of exposure, say Vundli Ramokolo and colleagues

The number of children exposed to HIV who remain uninfected has been rising over the past two decades. In 2017, there were an estimated 14.8 million (uncertainty bounds 10.7-19.2 million) exposed but uninfected children, of whom 90% lived in sub-Saharan Africa.1 The number of uninfected children exposed to HIV in South Africa grew from one million in 2002 to more than three million in 2017 (fig 1). The increase is largely due to the success of public health programmes to prevent perinatal and postnatal vertical transmission of HIV. However, World Health Organization policy to provide lifelong antiretroviral treatment to all pregnant women with HIV2 has meant growing numbers of infected women conceive while taking antiretrovirals, leading to fetal exposure to antiretroviral drugs during the critical period of organogenesis in the first 10 weeks of a pregnancy.

Fig 1

UNAIDS estimates of the number of uninfected children exposed to HIV in South Africa.1 Solid line represents the point estimate with the uncertainty bounds in the shaded area

Beyond preventing infants from acquiring HIV, it is important to ensure that exposed children also thrive. Research shows that uninfected children exposed to HIV are not only more likely to be have been born premature and small for their gestational age but also tend to have poorer growth and developmental outcomes than their unexposed counterparts.3 Thus, this vulnerable population needs close monitoring to quantify the short and long term effects of in-utero exposure to HIV and antiretrovirals so that effective interventions can be implemented to reduce any health or developmental disparities. Failure to invest in protecting the health of these …

View Full Text