The HIV epidemic in resource-limited settings: exploring the health disparities between HIV-negative infants born to HIV-negative mothers and those born to HIV positive mothers
Consestein, Caleb Madden
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The HIV/AIDS epidemic has had a devastating impact on families and communities all across the world since it began. Nowhere is this more true than in low- and middle-income countries, especially in sub-Saharan Africa (SSA). While infections can be counted and number of deaths estimated, the burden the virus has had on societies as a whole are far more difficult to quantify and, indeed, may never be fully realized. A truly unfortunate phenomenon within the epidemic is the vertical infection of hundreds of thousands of newborn children every year born to HIV-positive mothers. Infection may occur while the infant is developing in the womb, during delivery, and after birth through breastfeeding-a feeding practice that is necessary to ensure survival in the face of the poverty and limited resources in SSA. Thankfully, in the past 5-10 years, the immense benefits of antiretroviral therapy have begun to be extended to low- and middle-income countries around the world, many of them in SSA. The medications that helped halt the spread of the disease in the developed world over the last couple of decades are now starting to be provided to the regions of the world that need them more than any other. Substantial progress has been made, especially in the reduction of vertical transmission from mother to child. With antiretroviral treatment transmission rates from mother-to-child can be as low as 1% however in the absence of treatment transmission rates can be as high as 40%. Indeed, antiretroviral(ARV)-based prevention of mother-to-child transmission has been considered by many to be one of the greatest public health initiatives in recent history. As the scale-up in treatment continues many challenges remain that include proper programmatic design to ensure judicious allocation of resources. Additionally, a mysterious set of observations that are raising concerns involve the health outcomes of those infants, born to HIV-positive mothers, who are exposed to the virus, but remain uninfected themselves. As this population of HIV-exposed, but uninfected children has begun to grow ever larger as transmission rates continue to decrease in the presence of ARV treatment, it has become increasingly clear that although these children do far better than their HIV-infected counterparts, they do not perform as well as HIV-negative children born to HIV-negative mothers. The enormous size of this growing patient population has led to an increased urgency among health experts to determine the causal factors for these observed disparities. The goal of this paper is to evaluate the current literature on HIV-exposed infant experiences in utero, during delivery, and after birth. Specifically, the literature demonstrates an enormous variety of factors that not only determine whether or not an infant becomes infected, but may also contribute to its health beyond the neonatal period. With this basis, the observed health disparities among HIV-exposed, uninfected (EU) infants reported in the literature will then be discussed along with the biological phenomena researchers propose as causes for these findings. Findings in health disparities between EU infants and infants that have never been exposed to HIV (NE infants) vary in type and magnitude. There have been statistically significant differences found in rates of mortality, infection, growth, and malnutrition as well as meaningful trends in other areas. Proposed causes for the findings are even more varied and range from decreased maternal health and ability to care for the child, to toxic effects of the ARV medications the infant is exposed to in the womb and after birth through breastfeeding. This review finds that a predominant cause still remains to be found and it is likely that multiple factors, both biological and social, likely contribute, and more research is needed in many areas to address this. As the postnatal period is the time over which healthcare practitioners and mothers have the most control, this review highlights several more questions to be answered about nature of exposure during this time period. Specifically, differences in breast milk between infected and uninfected mothers needs to be more fully elucidated.
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