Mortality Remains High Among Children Exposed to HIV in Utero in Zimbabwe

Newly introduced interventions to prevent of mother-to-child transmission of HIV have reduced vertical transmission in sub-Saharan Africa. However, health outcomes among children who are exposed to HIV remain underexamined.

The investigators of a new study published in Clinical Infectious Diseases have provided evidence that more needs to be done to meet the needs of children in rural Zimbabwe who are exposed to HIV. Mortality in this population remains higher than that of the general population. Additionally, vertical transmission rates still exceed elimination targets and half of children who are exposed to HIV but not infected with the virus have stunted physical growth.

To gather more information investigators from Queen Mary University of London and Zimbabwe conducted the SHINE (Support, Healthcare, INtervention, Education) trial. The SHINE study was a cluster-randomized trial that evaluated the results of interventions which improved water, sanitation, and hygiene and/or improved infant and young child feeding in 2 rural Zimbabwean districts.

The 2 rural Zimbabwean districts had 15% antenatal HIV prevalence and > 80% coverage by prevention of mother-to-child transmission programs.

Between November 2012 and March 2015, 5280 pregnant women were enrolled and underwent HIV testing. Their children received longitudinal HIV testing and anthropometry. The investigators then compared growth and mortality between children who were exposed to HIV in utero with children who were not exposed to HIV for 18 months.

Of 5280 pregnant women, there were 738 live births to 726 mothers who were living with HIV. Among the 3937 HIV-negative women, there were 3989 live births. Mothers living with HIV tended to be an average of 4 years older, had less education, came from smaller households, and were in lower household wealth quintiles.

Among 4727 live births ultimately studied, 51 of 738 (7%) children who were exposed to HIV and 198 of 3989 (5%) children who were not exposed to HIV died. Of the 51 children exposed to HIV who died, 29 (57%) of the deaths occurred before 28 days of age. Mortality was lower in children whose mothers received antiretroviral therapy.

Of the 738 children exposed to HIV in utero, 25 (3%) tested positive for HIV transmission. In contrast, 596 (81%) were exposed to the virus but did not test positive for HIV. The remaining 117 children (16%) had an unknown HIV status by 18 months.

Overall estimates of transmission ranged from 4.3-7.7%.

Children who were exposed to HIV but did not become infected had mean length-for-age Z-scores at 18 months which were 0.38 standard deviations lower compared with children unexposed to HIV. Growth stunting prevalence among children who were exposed to HIV but not infected was 16% higher than among unexposed children, at 51% and 34%, respectively.

Of the 367 children exposed to HIV who were not excluded from analysis due to involvement in improved infant feeding programs, 147 (40%) were alive, HIV-free, and had not experienced growth stunting at 18 months compared with 1169 of 1956 (60%) of the children who were not exposed to HIV.

While increased coverage by prevention of mother-to-child transmission programs has significantly reduced the number of children living with HIV in communities similar to the ones studied in rural Zimbabwe, there is substantial room for improvement.

“These findings from a rural setting with high antenatal HIV prevalence, similar ART coverage to global estimates and high exclusive and prolonged breastfeeding rates, highlight the urgent action that is needed to ensure that children born to HIV-positive mothers survive and thrive,” study authors wrote.