HIV-exposed infants: rethinking care for a lifelong condition
Sugandhi, Nanditaa; Rodrigues, Jessicab,c; Kim, Mariad; Ahmed, Saeedd; Amzel, Anouke; Tolle, Miked; Dziuban, Eric J.f; Kellerman, Scott E.g; Rivadeneira, Emiliaf; The Child Survival Working Group of the Interagency Task Team on the Prevention and Treatment of HIV infection in Pregnant Women, Mothers and Children
aClinton Health Access Initiative, New York, New York
bUNICEF New York, New York
cIATT Secretariat New York, New York
dBaylor College of Medicine Texas Childrens Hospital, Houston, Texas
eUSAID, Washington DC
fDivision of Global HIV/AIDS, Centers for Disease Control and Prevention Atlanta, Georgia
gManagement Sciences for Health, Arlington, Virginia.
Correspondence to Nandita Sugandhi, Clinical Advisor, Clinton Health Access Initiative, 383 Dorchester Suite 400, Boston, MA 02127, USA. E-mail: firstname.lastname@example.org
Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210 000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother–infant pairs.
Currently, over 1 million HIV-exposed (HIV-E) infants are born to HIV-infected women worldwide every year though the majority of these infants will not become infected. Most are born in resource-limited settings and therefore exposed to increased mortality and morbidity common for children in such regions. In addition, a limited but growing body of evidence suggests that HIV exposure itself may contribute to poor health outcomes as well as a host of unique psychosocial and economic challenges that can have a profound effect on overall well being and ultimate outcomes. Access to healthcare, education, and social services may also be affected due to family and social circumstances. Even when the risk of HIV infection has passed, HIV-exposed uninfected (HIV-EU) infants will continue to be affected by the social, economic and health impacts of HIV on their families, to possible long-term adverse effects of antiretroviral drugs, and to a higher risk for acquisition of HIV-related infections through ongoing exposure during childhood.
The scale-up of prevention of mother-to-child transmission (PMTCT) programs has significantly reduced perinatal HIV-infection rates . Programs which have been successful include the implementation of effective provider-initiated testing and counseling (PITC) services, increased availability to antiretroviral prophylaxis and antiretroviral therapy (ART) for pregnant women and their infants, improved delivery practices for HIV-infected women, and an enhanced understanding of how to minimize risk of transmission during the breastfeeding period . Despite increasing access to HIV-related services for women during pregnancy, delivery and breastfeeding, most will now need long-term service provision to ensure optimal outcomes. Interestingly, implementing an agreed upon ‘package of services’ for these women and their infants has been challenging and more efforts are needed to help countries define and implement what these services should be and where and how these services should be offered.
Although the numbers of new pediatric HIV infections will continue to decline as the number of pregnant women and mothers having access to effective PMTCT interventions increase, improving the delivery of services to HIV-exposed infants continues to be a priority for both PMTCT and Pediatric HIV programs in most resource-limited settings. Furthermore, as more adults benefit from ART and have healthier and longer lives the population of HIV-E infants is likely to increase, highlighting the importance and need for countries to strengthen the capacity to provide quality long-term services for this population. These efforts should ideally be complementary to national and international efforts to improve overall child survival as HIV-EU children are still at risk from preventable childhood diseases such as measles, malnutrition, and tuberculosis (TB).
Long-term impact of HIV exposure on infant and childhood health outcomes
The prenatal period and the first few years of a child's life set the stage for long-term physical and mental health. Although better understanding of the long-term impact that HIV has on HIV-EU in resource-limited settings is needed, there is evidence that early exposure to HIV has health effects lasting beyond the transmission period . The effects of exposure to HIV itself must be considered as well as the impact of environmental factors related to birth into an HIV-affected household including orphanhood, stigma, discrimination, and extreme poverty. A brief review of these concerns is helpful as we rethink the types and duration of services, interventions and surveillance needed to ensure optimal outcomes for these children.
Evidence of increased morbidity and mortality
Initial evaluation of increased morbidity and mortality in HIV-E infants in Africa arose from early trials to evaluate PMTCT regimens. A pooled analysis of seven such trails found that risk factors for death among HIV-E infants included maternal death, lower maternal CD4 cell counts , and early weaning  (See Infant Feeding article in this series). Though maternal ART adherence is effective in reducing under-5 mortality , further studies continue to link increased risk of child mortality with poor maternal health and HIV exposure and there is a need to better understand what drives this increased risk of death to develop effective prevention strategies [7,8].
The reasons for increased morbidity and mortality are likely multifactorial, but there is some evidence that HIV exposure in utero or during the postnatal period affects development of the infant's immune and other organ systems. Moreover, HIV exposure and maternal placental responses to the virus have resulted in modifications or interference with the immune response of HIV-EU infants, resulting in immunological abnormalities and increased susceptibility to childhood diseases [7,9].
The immune system is underdeveloped at birth and as a result infants and young children may be thought of as immune-compromised regardless of previous HIV-exposure . HIV-infected women or HIV-infected family members are at high risk for co-infection with opportunistic pathogens and are more likely to transmit horizontally to children, resulting in an increased risk of primary acquisition of HIV-related infections in children [11,12]. In addition, HIV-E infants are at risk to congenital or acquired infections such as TB, herpes, syphilis and cytomegalorvirus than their unexposed peers. Globally, CMV is the most commonly transmitted infection from mother to child, occurring in 0.2%–2.2 of live-born infants in the United States with similar transmission rates likely in resource limited settings. The prevalence of CMV infection among HIV-infected pregnant women is higher than in the general population, with approximately 90% of HIV-infected pregnant women being co-infected with CMV .
Cotrimoxazole prophylactic treatment (CPT) is currently recommended for all HIV-E infants and while the benefits are clear for HIV-infected children, the evidence of benefit for uninfected infants is less so [14,15]. The Breastfeeding, Antiretrovirals, and Nutrition (BAN) study demonstrated that the use of prophylactic cotrimoxazole was associated with reduced rates of morbidity and mortality in HIV-EU infants. However, other than temporary protection from malaria, CPT offered no protection against anemia, malnutrition or severe illness and death than for HIV negative children [16,17]. Given limited data that CPT may increase risk of diarrheal illness in HIV uninfected infants there is a need to define the optimal duration of cotrimoxazole prophylaxis and possibly re-examine current guidelines .
Growth and neurodevelopment
Growth stunting is associated with preterm or low birth weight infants both of which occur more commonly in infants born to HIV-infected mothers [19,20]. Additionally, growth stunting is associated with discontinuation or reduction in breastfeeding, which significantly affects a child's health and cognitive development [20,21]. Differences in growth between HIV-EU and unexposed children typically present in the first months of life and some studies on postnatal growth show minimal difference in early growth of HIV-EU children compared with unexposed controls .
With the rollout of Option B+ (provision of lifelong triple drug therapy for HIV-infected pregnant women not dependent on CD4 cell count), the impact of exposure to triple therapy on a child's growth and development needs to be closely examined. Recent evidence from the Mashi and MmaBana trials in Botswana revealed that both weight for age and length for age were significantly lower in HIV-E infants exposed to ART in utero compared with those only exposed to maternal single drug prophylaxis with Azidothymidine (AZT) . It remains unclear whether these differences have a short-term impact or whether they predispose the child for subsequent poorer health, obesity, chronic disease or cognitive dysfunction .
The impact of prenatal antiretroviral (ARV) exposure on neurocognitive development given the association of nucleoside reverse transcriptase inhibitors (NRTI's) with mitochondrial toxicity is also of concern [25,26]. Early reports of birth defects and mitochondrial toxicity from exposure to ARVs remains equivocal and while a French study reported 0.5% of ARV exposed children had mitochondrial dysfunction  more recent evidence evaluating outcomes in HIV-EU children found no association between in-utero exposure to any ARV and neurodevelopmental outcomes when assessed using a standardized measure of infant development [28,29]. Similarly evidence suggests that most detectable developmental delays among HIV-EU children are a result of environment factors and not a consequence of in-utero or postnatal HIV exposure and that with improved attention to a child's early developmental and psychosocial needs such delays may be prevented or reversed [27–30].
Potential for short and long-term antiretroviral -related toxicity
At present the benefits of ART reducing vertical transmission and improving maternal health greatly outweigh the potential adverse effects of ARV exposure to children. However as PMTCT coverage increases the number of uninfected infants exposed to ART in utero or through breastfeeding will likewise increase making it critical to continue to monitor for adverse effects. Considerable data link protease inhibitors to preterm delivery and low birth-weight [31–33]. Hematologic abnormalities may also be associated with exposure to ARV's; both short and long-term effects on several hematologic parameters have been noted in infants exposed in utero and postnatally to different ARV's . Firm conclusions about the potential long-term physiologic effects of exposure to ARVs in utero are lacking as significant heterogeneity often exists between studies, however the benefits of antenatal exposure to ARV's must be weighed against an understanding of any risk. Of greatest importance is ensuring the most effective and acceptable regimens are available, as the risks of virologic nonsuppression are substantial for both the mother and the child.
As more pregnant women living with HIV initiate ART during pregnancy, many women are likely to become pregnant again while taking the preferred first-line regimen containing both tenofovir (TDF) and efavirenz (EFV). There has been concern about the use of EFV in pregnancy due to the association with heterogeneous central nervous system defects in animal studies. However, a recent meta-analysis reported only one neural tube defect in infants born to women on EFV-based as compared to non-EFV-based regimens; a lower rate than what is reported for the general population . Therefore, while it appears that the potential risks to the infant with EFV exposure is very low, definitive studies and birth defect surveillance with larger sample sizes are needed and current data indicates there is no reason to limit use of EFV in pregnant women [36,37].
TDF is known to affect bone mineral density and renal function in adults, although the clinical significance of these effects is still not clear [38–40]. Infants exposed to TDF in-utero had no growth parameter (e.g., birth weight and length) differences when compared with infants exposed to non-TDF containing regimens . The US Pediatric HIV/AIDS Cohort Study compared infants exposed to combination drug regimens in-utero with and without TDF and found no differences at birth between the two groups (e.g., birth weight, length, or head circumference). However, at 1 year of age, those infants who were exposed to TDF in-utero were found to have a small but statistically significant difference in length-for-age and head circumference-for-age compared with TDF-unexposed infants . Although current literature does not show any serious risks associated with TDF exposure in utero, the evidence is limited and more research is warranted. The US Antiretroviral Pregnancy Register has seen a rate of all birth defects in infants exposed to TDF in the first trimester of 2.3%, equivalent to the 2.7% prevalence seen in the overall US population .
Impact of living in households affected by HIV
A growing body of evidence indicates that an adverse intra-uterine environment and maternal stressors during early infancy significantly affects a child's long-term development . In addition, HIV-affected households may experience various economic and psychosocial stressors that in turn can increase a child's vulnerability.
Limited data exists examining the psychosocial development and experiences of HIV-EU children making it difficult to isolate the stressors and risk factors associated with HIV exposure. Some studies have demonstrated that maternal stressors associated with the onset of HIV symptoms can affect a child's psychosocial adjustment [45,46] while other studies indicated that it is a mother's illness or physical well being, not maternal HIV status that affects a child's behavior (See Psychosocial article in this series) . Of particular interest, is the relationship between a parent's disclosure of their illness or HIV status and an HIV-E infant's access to healthcare services, psychosocial adjustment and resilience [46,47]. Nondisclosure of a parent's HIV status is also associated with increased levels of depression and anxiety among HIV-affected children [48,49].
By virtue of living in an HIV-affected household, HIV-E children are often exposed to death, illness and family disruptions at an early age. If there are other children or adults living with HIV in the household the needs of HIV-EU children may not be prioritized, as food and healthcare may be rationed to care for ill family members . Illness within the family can result in income loss, decreased food availability, frequent relocation and lower rates of school attendance . A study conducted in South Africa to identify the reasons for loss to follow-up among HIV-E children underscored the role that poverty and socioeconomic conditions played on members of an HIV-affected household's long-term access to healthcare . Due to changes in family composition and orphan hood, HIV-E children may also have multiple caregivers or live outside their home of origin and may be treated differently from non-HIV-affected relatives .
In 2011, an estimated 15.2 million children in sub-Saharan Africa were orphaned due to AIDS and it is likely that a significant proportion of these orphans were also HIV-E [1,52]. While more nuanced data on orphan hood and HIV exposure is needed, findings from the literature on the impact of orphan hood on the psychosocial development of children may provide additional clues regarding the stressors experienced by HIV-exposed children. Two studies on the relationship between stigma and psychosocial well being in South Africa and China showed that AIDS orphans reported higher levels of stigma, which was associated with poorer psychological outcomes [53,54]. In South Africa, AIDS orphans engaged in less positive activities and were more likely to experience higher rates of depression, posttraumatic stress, delinquency and difficulties with peer relationships compared with children orphaned by other causes . Similarly, children orphaned by AIDS are less likely to receive social or economic support and therefore do not reap the psychological benefits of such assistance; namely lower rates of depression, anxiety, bullying, and behavioral problems .
Resiliency in HIV-affected children
Resiliency, or the ability to overcome stressors in a psychologically healthy way, amongst AIDS orphans is attributed to caregiver quality, contact with immediate and extended family and school attendance; while risk factors for poor outcomes include bereavement, frequent changes in caregivers, caregiver illness, discrimination as a result of living in another household and exposure to abuse or violence . Studies have shown that male involvement and a mother's status as a member of an association of people living with HIV (PLHIV) can have a positive influence on an infant's health outcomes . These findings highlight the importance of ensuring that HIV-E infants and their families are appropriately evaluated and referred to programs in the community, including those that are aimed at providing support for Orphans and Vulnerable Children (OVC).
Programmatic challenges and opportunities
Guidance for the care of HIV-E infants has largely centered on recommendations to minimize the risk of transmission through delivery of appropriate antenatal care (ANC) services, encouragement of safe delivery practices, use of ARV prophylaxis and adherence to breastfeeding guidance (Table 1). The greatest challenge with providing services for these children is addressing some of the issues that affect retention in care through the end of the exposure period. However longer follow-up should be encouraged to address the health impacts of exposure and provide needed support to alleviate or prevent negative outcomes that may manifest after the risk of HIV transmission has passed.
Factors that affect retention of these infants in care are multiple and include those stemming from the healthcare system itself particularly staffing and infrastructure, as well as social and individual or family factors. There has been limited success in conducting routine and systematic monitoring of HIV-E infants towards the end of breastfeeding. This is illustrated by the lack of data available on the proportion of HIV-E infants with confirmed HIV status at 18 months of age . Quality of early infant diagnosis services and long turnaround times for results may also affect levels of trust in the healthcare system and influence adherence to follow-up care and the use of prophylactic medications .
An additional programmatic challenge has been the lack of standardized, easy to use tools for mother–infant pair tracking and site-level and program data collection. Most services for HIV-E and infected infants currently take place within PMTCT program settings, though increasingly the introduction of lifelong treatment for HIV-infected pregnant women and the emphasis on decentralization of care means that more mothers and families could be receiving care in routine health care settings.
Full integration of HIV services for women and their infants into health centers would require modification of registers used during pregnancy, in delivery units and in postnatal care sites to link women to their infants from the time of ANC diagnosis through 24 months of age or beyond. In addition, the lack of simple medical records for HIV-E infants presents additional challenges to healthcare providers and programs. Some countries have added information related to maternal HIV and HIV-E infant interventions to the hand-held cards that women carry during pregnancy and in under-5 childhood health cards in order to facilitate the identification of exposed infants each time they access the healthcare system. This allows healthcare providers to tailor services to address specific needs for mother–infant pairs at each health encounter.
Maternal health is critical to child survival and long-term development, yet care is often provided to mother–infants pairs separately. Currently, there is vague guidance on the best service delivery model for HIV-E infants. PMTCT programs general focus on maternal interventions and pediatric care and treatment programs are designed to care for HIV-infected children. Although provision of early infant diagnosis in MCH platforms is effective in some settings, longer term care to improve retention and HIV-free survival will require a shift in the organization of programs which have historically been vertically implemented in most countries .
Providing specialized follow-up care for at risk children, separate from well child clinics may contribute to stigma and discourage mothers from accessing services. Fear of disclosure may also inhibit caregivers from getting children tested, or even initiating treatment, making identification and follow-up of HIV-E and HIV-infected children more challenging . Treatment initiation, as with most child health issues is a family decision; limited male involvement may also be a barrier to providing more comprehensive care to HIV-E infants in order to prevent transmission, ensure HIV-free survival and provide care for optimal development beyond the confirmation of final HIV status.
As many countries are shifting their PMTCT programs towards the use of ART throughout the duration of pregnancy and breastfeeding, if not for life, there is a need to adapt service delivery models to ensure the long-term retention of women on treatment. This need offers a great opportunity for improving how programs follow and offer services to the infants born to HIV-infected women. Ideally, services and interventions for mother–infant pairs should be provided at the same time and preferably in the same setting. Some of these interventions include screening for TB in the child and family members, supporting cotrimoxazole adherence, ensuring all childhood vaccines are provided, and assessing family support needs and establishing linkages with OVC programs to minimize negative psychosocial, developmental and financial effects.
As PMTCT programming becomes more refined and effective, the number of HIV-EU infants will continue to grow. Gaining a deeper and more nuanced understanding of the impact HIV and ARV exposure in-utero and in infancy has on children's physical and psychological development is crucial to providing better care. Surveillance for adverse events in pregnant and breastfeeding women and their infants as well as more robust systems to capture pregnancy outcomes and follow long-term cohorts of HIV-EU children are a priority to more fully understand the effects of ARVs on this population. This is particularly critical in resource-limited settings where malnutrition and comorbidities are more common and in which monitoring capacity is limited. Linked to toxicity monitoring is the potential/need to further investigate the efficacy, safety and viability of alternative ARVs for prophylaxis, particularly as resistance to nevirapine and potentially zidovudine are concerns for children who become infected. Further investigation is needed to understand the immune-response of HIV-EU infants to determine whether HIV or ARV exposure compromises the ability to ward off future infections and if the benefits of cotrimoxazole prophylaxis outweigh the risks for HIV-EU infants.
Emerging evidence demonstrates that early stress and shocks in utero and for the first 2 years of life have significant impact on a child's development into adulthood though very few studies have begun to isolate the medium and long-term psychosocial impacts of HIV exposure compared with HIV-infected and nonaffected children. Research to explore the interplay between neurological insults and cognitive and psychosocial development is an area that deserves more attention.
Operations research to evaluate the effectiveness of specific programmatic interventions such as integrated follow-up of HIV-E infants with growth monitoring, immunization and other well child services should be considered as postpartum follow-up of mother–infant pairs is weak in most programs. Although there is some evidence that these programming shifts have increased rates of EID testing and treatment initiation among infants and young children, determining which interventions individually and in combination have the greatest impact on improving HEI identification and follow-up is an area for further research . Considering that postpartum and postnatal care is weak in many programs, identifying the determinants of postnatal care uptake – both structural and sociocultural may provide key insights into the barriers that impede mothers from accessing postpartum care, which in turn, may point to potential solutions for reducing loss to follow-up among HEI.
Until recently, the long-term effects of HIV and ARV exposure on uninfected infants and children has received limited attention. Yet, the number of HIV-EU children will expand in the coming years assuming that MTCT rates continue to decline. Although pediatric HIV can be considered a neglected disease, the care of HIV-E and HIV-EU infants and children is even more overlooked. Retention and provision of follow-up care to mother–infant pairs through the end of exposure to minimize risks of HIV transmission is critical, as is reinforcing provider initiated testing and counseling at all entry points and training health staff on specific needs of HIV-E during and beyond the transmission period.
The evidence suggests that the effects of HIV and ARV exposure extend through childhood and beyond. Providing comprehensive care for HIV-E, HIV-infected and HIV-EU children requires a paradigm shift and significant changes to programmatic approaches. Community outreach to highly vulnerable children for active case finding and referral to support services, such as food assistance, cash transfers, and social welfare should be integral to all programs. Strengthening linkages with community-based testing and support services and OVC programs is imperative to increase identification of HIV-exposed and infected children and to provide longer term care and support through home visits to all children who are ill.
Essentially, these recommendations call for a shift away from individual disease specific care to family-friendly services that address the spectrum of health needs along different time points, promote safe disclosure and adherence support. Strengthening family and community involvement from ANC, throughout pregnancy and infancy may reduce stigma and discrimination and help to overcome persistent barriers to identifying and caring for these infants.
Conflicts of interest
There is no conflict of interest.
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the World Health Organization or the U.S. government including the U.S. Centers for Disease Control and Prevention and Agency for Toxic Substances Disease Registry and the United States Agency for International Development. The authors acknowledge the support of UNICEF and the Canadian International Development Agency (CIDA) whose financial assistance made this series possible and the U.S. President's Emergency Plan for AIDS Relief for support of contributing staff time.
3. Shapiro R, Lockman S. Mortality among HIV-exposed infants: the first and final frontier
. Clin Infect Dis
4. Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F, et al. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis
5. Kuhn l, Sinkala M, Semrau K, Kankasa C, Kasonde P, Mwiya M, et al. Elevations in mortality associated with weaning persists into the second year of life among uninfected children born to HIV-infected mothers
. Clin Infect Dis
6. Ndirangu J, Newell M, Thorne C, Bland R. Treating HIV-infected mothers reduces under 5 years of age mortality rates to levels seen in children of HIV-uninfected mothers in rural South Africa
. Antiviral Therapy
7. Kuhn L, Kasonde P, Sinkala M, Kankasa C, Semrau K, Scott N, et al. Does severity of HIV disease in HIV-infected mothers affect mortality and morbidity among their uninfected infants?
. Clin Infect Dis
8. Clerici M, Saresella M, Colombo F, Fossati S, Sala N, Bricalli D, et al. T-lymphocyte maturation abnormalities in uninfected newborns and children with vertical exposure to HIV
9. Filteau S. The HIV-exposed, uninfected African child
. Trop Med Int Health
10. Futata E, Fusaro A, De Brito C, Sato M. The neonatal immune system: immunomodulation of infections in early life
. Rev Anti-Infect Therapy Mar
11. Mofenson LM, Oleske J, Serchuck L, Van Dyke R, Wilfert C. Treating opportunistic infections among HIV-exposed and infected children: recommendations from CDC, the National Institutes of Health, and the Infectious Diseases Society of America
. Clin Infect Dis
2005; 40 (Suppl 1):S1–S84.
12. Bates M, Monze M, Bima H, Kapambwe M, Kasolo FC, Gompels UA. CIGNIS study groupHigh human cytomegalovirus loads and diverse linked variable genotypes in both HIV-1 infected and exposed, but uninfected, children in Africa
13. Marin G, Fernandez I, Tome MI, Saavedra L, Barajas-Sanchez V, Rojo C, Ramos A. Congenital cytomegalovirus infection in the infants of HIV-infected mothers
. AnPediatr (Barc)
15. Chintu C, Bhat GJ, Walker AS, Mulenga V, Sinyinza F, Lishimpi K, et al. CHAP trial teamCo-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomised placebo-controlled trial
16. Kourtis AP, Wiener J, Kayira D, Chasela C, Ellington SR, Hyde L, et al. Health outcomes of HIV-exposed uninfected African infants
17. Dow A, Kayira D, Hudgens M, Van Rie A, King C, Ellington S, et al. Effects of cotrimoxazole prophylactic treatment of adverse health outcomes among HIV-exposed uninfected infants
. Pediatr Infect Dis J
18. Coutsoudis A, Coovadia H, Kindra G. Time for new recommendations on cotrimoxazole prophylaxis for HIV-exposed infants in developing countries?
. Bull World Health Organ
19. Coley JL, Msamanga GI, Fawzi MCS, Kaaya S, Hertzmark E, Kapiga S, et al. The association between maternal HIV-1 infection and pregnancy outcomes in Dar Es Salaam
. Tanzania BJOG
20. World Health Organization, Horta BL, Bahl R, Martines JC, Victora CG. Evidence on the long-term effects of breastfeeding
21. Kuhn L, Sinkala M, Semrau K, Kasonde P, Mwiya M, Hu CC, et al. Elevations in mortality associated with weaning persist into the second year of life among uninfected children born to HIV-infected mothers
. Clin Infect Dis
22. Isanaka S, Duggan C, Fawzi WW. Patterns of postnatal growth in HIV-infected and HIV-exposed children
. Nutr Rev
23. Powis K, Smeateon L, Fawzi W, Ogwu A, Machakaire E, Souda S, et al.In utero HAART exposure associated with decreased growth among HIV-exposed uninfected breast fed infants in Botswana
. In: 5th International Workshop on, HIV., Pediatrics, 2013 June 28–29, Kuala Lumpur Malaysia: Reviews in Antiviral Therapy, Infectious Diseases, 2013_7., Abstract, 011
24. Gillman MW. The first months of life: a critical period for development of obesity
. Am J Clin Nutr
25. Foster C, Lyall H. HIV and mitochondrial toxicity in children
. J Antimicrobial Chemother
26. Blanche S, Tardieu M, Rustin P, Slama A, Barret B, Firtion G, et al. Persistent mitochondrial dysfunction and perinatal exposure to antiretroviral nucleoside analogues
27. Msellati P, Lepage P, Hitimana D, Van Goethem C, Van de Perre P, Dabis F. Neurodevelopmental testing of children born to human immunodeficiency virus type 1 seropositive and seronegative mothers: a prospective cohort study in Kigali, Rwanda
28. Sirois P, Huo Y, Williams P, Malee K, Garvie P, Kammerer B, et al. Safety of perinatal exposure to antiretroviral medications: developmental outcomes in infants
. Pediatr Infect Dis J
29. Williams P, Marino M, Malee K, Brogly S, Hughes M, Mofenson L. Neurodevelopment and in utero antiretroviral exposure of HIV-exposed uninfected infants
30. Van Rie A, Mupuala A, Dow A. Impact of the HIV/AIDS epidemic on the neurodevelopment of preschool-aged children in Kinshasa, Democratic Republic of the Congo
31. European Collaorative StudyExposure to antiretroviral therapy in utero or early life: the health of uninfected children born to HIV-infected women
32. Cotter AM, Garcia AG, Duthely ML, Luke B, O'Sullivan MJ. Is antiretroviral therapy during pregnancy associated with an increased risk of preterm delivery, low birth weight, or stillbirth?
. J Infect Dis
33. Patel K, Shapiro D, Brogly S, Livingston E, Stek A. P1025 team of the international maternal pediatric adolescent AIDS clinical trials groupPrenatal protease inhibitor use and risk of preterm birth among HIV-infected women initiating antiretroviral drugs during pregnancy
. J Infect Dis
34. Pacheco SE, McIntosh K, Lu M, Mofenson LM, Diaz C, Foca M, et al. Effect of perinatal antiretroviral drug exposure on hematologic values in HIV-uninfected children: An analysis of the women and infants transmission study
. J Infect Dis
35. Ford N, Calmy A, Mofenson L. Safety of efavirenz in the first trimester of pregnancy: an updated systematic review and meta-analysis
36. Myer L, Carter RJ, Katyal M, Toro P, El-Sadr WM, Abrams EJ, et al. Impact of antiretroviral therapy on incidence of pregnancy among HIV-infected women in Sub-Saharan Africa: a cohort study
. PLoS Med
38. Laprise C, Baril JG, Dufresne S, Trottier H. Association between tenofovir exposure and reduced kidney function in a cohort of HIV-positive patients: results from 10 years of follow-up
. Clin Infect Dis
39. Cooper RD, Wiebe N, Smith N, Keiser P, Naicker S, Tonelli M. Systematic review and meta-analysis: renal safety of tenofovir disoproxilfumarate in HIV-infected patients
. Clin Infect Dis
40. Stellbrink HJ, Orkin C, Arribas JR, Compston J, Gerstoft J, Van Wijngaerden E, et al. Comparison of changes in bone density and turnover with abacavir-lamivudine versus tenofovir-emtricitabine in HIV-infected adults: 48-week results from the ASSERT study
. Clin Infect Dis
41. Vigano A, Mora S, Giacomet V, Stucchi S, Manfredini V, Gabiano C, et al. In utero exposure to tenofovir disoproxilfumarate does not impair growth and bone health in HIV-uninfected children born to HIV-infected mothers
. Antiviral Therapy
42. Siberry GK, Williams PL, Mendez H, Seage GR 3rd, Jacobson DL, Hazra R, et al. Pediatric HIV/AIDS Cohort Study (PHACS)Safety of tenofovir use during pregnancy: early growth outcomes in HIV-exposed uninfected infants
43. Antiretroviral Pregnancy Registry Steering Committee. Antiretroviral pregnancy registry international interim report for 1 Jan 1989–31 January 2012. Wilmington, NC: Registry Coordinating Center; 2012. Available at http://www.APRegistry.com
44. Lye S. Tracing health to it's roots: linking early child development to healthy adulthood. Fraser Mustard Institute for Human Development, University of Toronto, Presentation at CCABA Road to Melboure Meeting, New York, NY. May 2013.
45. Hough ES, Brumitt G, Templin T, Hough ES, Brumitt G, Templin T. A model of mother-child coping and adjustment to HIV
. Soc Sci Med
46. Sipsma H, Eloff I, Makin J. Behavior and psychological functioning of young children of HIV-positive mothers in South Africa
. AIDS Care
47. Hankin CD, Newell ML, Tookey P. Long-term follow-up of uninfected children born to HIV-infected women and exposed to antiretroviral therapy: survey of parents’ and health professionals’ views
. AIDS Care
48. McNally L, Hadingham J, Archary D, et al. HIV-exposed but uninfected children: why are they vulnerable?
. Vulnerable Children Youth Stud
49. Kmita G, Baranska M, Niemiec T. Psychosocial intervention in the process of empowering families with children living with HIV/AIDS: a descriptive study
. AIDS Care
50. Richter L. Pharoach R. The Impact of HIV/AIDS on the development of children
. Institute of Security Studies, A generation at risk? HIV/AIDS, vulnerable children and security in Southern Africa
. Cape Town:2004.
51. Jones SA, Sherman GG, Varga CA. Exploring socio-economic conditions and poor follow-up rates of HIV-exposed infants in Johannesburg, South Africa
. AIDS Care
53. Zhao G, Li X, Zhao J, Zhang L, Stanton B. Relative importance of various measures of HIV-related stigma in predicting psychological outcomes among children affected by HIV
. Commun Mental Health J
54. Boyes M, Cluver L. Relationships among HIV/AIDS orphanhood, stigma, and symptoms of anxiety and depression in South African Youth. A longitudinal investigation using a Path Analysis Framework
. Clin Psychol Sci
55. Cluver L, Gardner F, Operario D. Effects of stigma on the mental health of adolescents orphaned by AIDS
. J Adolesc Health
56. Cluver L, Gardner F. Risk and protective factors for psychological well being of children orphaned by AIDS in Cape Town: a qualitative study of children and caregivers’ perspectives
. AIDS Care
57. Aluisio A, Richardson BA, Bosire R, John-Stewart G, Mbori-Ngacha D, Farquhar C, et al. Male antenatal attendance and HIV testing are associated with decreased infant HIV infection and increased HIV-free survival
. J Acquir Immune Defic Syndr
58. Chatterjee A, Tripathi S, Gass R, Hamunime N, Panha S, Kiyaga C, et al. Implementing services for Early Infant Diagnosis (EID) of HIV: a comparative descriptive analysis of national programs in four countries
. BMC Public Health
59. Ong’ech JO, Hoffman HJ, Kose J, Audo M, Matu L, Savosnick P, Guay L. Provision of services and care for HIV-exposed infants: a comparison of maternal and child health clinic and HIV comprehensive care clinic models
. J Acquir Immune Defic Syndr
60. Boender S, Sigaloff KC, Kayiwa J, Musiime V, Calis JC, Hamers RL, et al. Barriers to initiation of pediatric HIV treatment in Uganda: a mixed-method study
. AIDS Res Treat
61. McCollum ED, Johnson DC, Chasela CS, Siwande LD, Kazembe PN, Olson D, et al. Superior uptake and outcomes of early infant diagnosis of HIV services at an immunization clinic versus an ‘under-five’ general pediatric clinic in Malawi
. J Acquir Immune Defic Syndr
HIV-exposed infant; HIV-exposed uninfected; mother–infant pair
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