A gendered epidemic: addressing the intersection of HIV, women, and child health

Women are particularly vulnerable to HIV infection and transmission. Too many women in South Africa and around the world have little say in their own sexual health, with implications not only for themselves but also their children. In the wake of World AIDS Day on 1 December and at the conclusion of the 16 Days of Activism against women and child abuse we shine a light on the relationship between the HIV pandemic and gender. 

In South Africa we have the largest HIV epidemic in the world, with women and girls accounting for the majority of all new HIV infections in the last year. Every week about 4,900 young women become infected, and girls aged 15 to 24 are twice as likely to be living with HIV than men in the same age group.  
 

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Pregnant women are particularly at risk of HIV acquistion and vertical transmission to their infants. Women who are pregnant and postpartum face heightened vulnerability to HIV acquisition because of biological and behavioural changes, along with the elevated risk of transmission to their infants. Over one million children are born to mothers living with HIV each year, and in some countries, including South Africa, more than 20% of children are exposed to HIV in utero. 
 

Supporting women’s adherence to treatment 

While lifelong ART is now standard of care for all people living with HIV in South Africa, many people cycle in and out of treatment over time. This disengagement poses large risks in the case of pregnant and post-partum women and their children, as ART non-adherence is a major contributor to HIV transmission from mothers to babies. 

This study by Dr Tamsin Phillips, researcher in the School of Public Health, investigated ART interruptions in almost 7000 pregnant women living with HIV in Khayelitsha in Cape Town. They found that most women on ART remained compliant to their treatment after delivery, but women who had disengaged from treatment in the past, or had only restarted treatment during the most recent pregnancy were at high risk for future ART disengagement. 

This paper highlights the ongoing challenge of disengagement from HIV care after delivery and identifies pregnancy as a key point of re-entry into HIV care. People with a history of treatment interruptions and those newly starting ART may require additional support to remain in HIV care after delivery. 

Read the research here 
 

Preventing HIV transmission to pregnant mothers 

Oral pre-exposure prophylaxis (PrEP) is an effective tool to prevent maternal HIV infection in pregnant women without HIV. But a recent study by Dr Joseph Davey and colleagues found that while PrEP initiation rates are high among pregnant women, fewer than 20% continue to use it through 12 months postpartum. 

The study found that a number of social and HIV-related risk factors, such as maternal age, intimate partner violence and postpartum versus pregnancy status, impact PrEP continuation. 

Policy recommendations included access to supportive interventions for pregnant and postpartum women, integrating PrEP into antenatal and postpartum care and enhancing PrEP delivery options Read the research here. 

Understanding the challenges in HIV-exposed infants 

South Africa still has a high prevalence of HIV among pregnant women.  Thanks to effective medications such as PrEP and ART, vertical HIV transmission can now be prevented. However, many studies are now showing that HIV-exposed but uninfected infants are not unaffected even if they do not contract the virus. 

These findings can inform monitoring and intervention strategies to improve outcomes for these children. 

HIV exposure and brain development in-utero 

Children exposed to HIV in pregnancy show differences in brain structure compared to children not exposed to HIV, according to a study by Dr Catherine Wedderburn, neurodevelopment researcher at the Neuroscience Institute and Department of Paediatrics and Child Health, and colleagues.  

This study forms part of the Drakenstein Child Health Study, and used magnetic resonance imaging (MRI) to examine the components of brain structure in children with HIV exposure in utero.  

They found that, on average, the brain cortex in children who were HIV-exposed but uninfected was thicker than in children without HIV exposure. Secondly, children with HIV exposure had poorer language scores compared to HIV-unexposed children, and the brain differences were linked to the lower language scores. Overall, the study found that thicker cortex in specific brain regions may partly explain the connection between HIV exposure and poor language outcomes in this population.   

Further related work from the Drakenstein Child Health Study has shown that better antenatal maternal HIV care may improve child brain outcomes, supporting the work promoting ART adherence.  

Read more about the research. 
 

Higher infection risk for HIV-exposed but uninfected infants 

Infants exposed to HIV in the womb had less variety in their T cell receptors (TCRs), which are the very tools their immune systems use to recognise and fight off different pathogens. This means HIV-exposed infants are less able to fight off infections compared to infants never exposed to the virus. This was the recent finding by Dr Sonwabile Dzanibe, junior research fellow at the Institute of Infectious Disease and Molecular Medicine (IDM) at UCT and colleagues. This research in the immune systems of HIV-exposed infants is crucial in the design of vaccines for newborns. 

Read more about the research. 
 

Although the challenges of HIV treatment and prevention affect men and women, women and girls are disproportionately affected and often have limited autonomy. While we celebrate the incredible progress made in prevention of vertical HIV transmission, we continue to learn about the long-term impact of HIV and ART exposure and interventions to support exposed and uninfected children. UCT researchers are making important strides to identifying these inequalities to inform national and global policy and practice. 

 

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