Growth Trajectories of HIV Exposed and HIV Unexposed Infants. A Prospective Study in Gweru, Zimbabwe

Antiretroviral-Induced Toxicity in Umbilical Cord Blood-Derived Haematopoietic Stem/Progenitor Cells

Improvements in administration and efficacy of antiretroviral therapy (ART) have reduced rates of mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV) to < 2%. However, in utero exposure to antiretrovirals (ARVs) leads to abnormalities in HIV-exposed uninfected (HEU) infants. We determined the effect of five ARVs on human umbilical cord blood (UCB)-derived haematopoietic stem/progenitor cells (HSPC) with the aim of exploring a potential causal relationship with haematological abnormalities. Efavirenz (EFV) was cytotoxic to HSPCs alone and in combination with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). Dolutegravir (DTG) had a biphasic effect on HSPC expansion. Immunophenotypic analysis showed increased erythroid and granulocyte precursors after 7-day culture with these drugs. Finally, using colony forming unit (CFU) assays, we observed impairment in the formation of CFU-GEMM and CFU/Burst forming unit (BFU) erythroid (E) in the presence of DTG, lamivudine (3TC) and TDF, both visually and immunophenotypically. We conclude that multiple potential HSPC toxicities exist with ARVs commonly used in pregnancy, prompting the need for further research to confirm the safety of these drugs in this vulnerable group.

Understanding HIV-Exposed Uninfected Children: A Narrative Review

The widespread implementation of antiretroviral therapy has significantly reduced HIV-related mortality and mother-to-child transmission. Despite being HIV-uninfected, HIV-exposed children (HEU) seem to face heightened risks of immune dysfunction, cardiometabolic diseases, growth delays, reduction in bone mineral density, and neurocognitive impairments compared to HIV-unexposed uninfected peers. These vulnerabilities can be attributed to maternal immune dysregulation during pregnancy, antiretroviral (ART) toxicity, HIV exposure, and adverse socioeconomic and nutritional environments. Emerging evidence highlights the impact of antiviral therapy exposure, particularly tenofovir disoproxil fumarate, on HEU mitochondrial dysfunction, bone resorption, neurocognitive delays, and zidovudine on cardiac abnormalities. This narrative review explores the multisystem effects of ART exposure in HEU children, focusing on immune function, neurodevelopment, cardiovascular health, growth, and bone metabolism. By synthesizing findings from diverse studies, the review aims to provide a comprehensive understanding of the potential risks associated with ART regimens and identify future research priorities to improve outcomes for HEU children.

Maternal Phenotype, Infant Size and Breast Milk Composition in Women Living With HIV

The impact of maternal factors on the size of HIV-exposed-uninfected (HEU) infants and breast milk composition is poorly understood. Anthropometry, bio-electrical impedance, haemoglobin and HIV viral load data of women living with HIV (WLWH) and without HIV (WLWOH) were compared and related to their infants' anthropometric Z-scores and breast milk macronutrients 6 weeks and 6 months postnatally. At both time points, WLWH (6-week: n = 83; 6-month: n = 63) had lower reactance (measure of body cell mass) (6-week: p = 0.016; 6-month: p < 0.001), phase angle (PhA) (measure of cell health) (6-week: p = 0.001; 6-month: p = 0.002) and haemoglobin (6-week: p = 0.002; 6-month: p = 0.004) than WLWOH (6-week: n = 90; 6-month: n = 73). HEU infants had lower weight-for-age Z-scores (WAZ) (6-week: p = 0.010; 6-month: p = 0.005). Breast milk composition did not differ between groups. At 6 weeks, HEU infants had lower head circumference-for-age Z-scores (HCAZ) (p = 0.014). Bivariate regression demonstrated maternal HIV predicted lower infant WAZ (ß = -0.442; p = 0.011) and HCAZ (ß = -0.445; p = 0.014). Maternal body mass index (BMI) and mid-upper arm circumference were positively associated with breast milk protein content (ß = 0.018; p = 0.014 and ß = 0.025; p = 0.002, respectively). At 6 months (bivariate regression) maternal HIV predicted lower infant WAZ (ß = -0.609; p = 0.005) and length-for-age Z-scores (ß = -0.741; p = 0.018). Higher maternal BMI and PhA were associated with higher infant WAZ (ß = 0.622; p = 0.015 and ß = 0.055; p = 0.017, respectively). On multivariable analysis, maternal HIV remained a predictor of lower WAZ (ß = -0.568; p = 0.024). In conclusion, maternal HIV infection and phenotype predict the size of infants and breast milk composition up to 6 months postnatally.

Effects of HIV exposure on anemia and vitamin D nutritional status in children aged 6-24 months: a hospital-based cross-sectional study

There is little research on anemia and vitamin D deficiency in HIV-exposed uninfected (HEU) children. This study was aimed to describe and compare the prevalence of anemia and vitamin D inadequacy in HEU children and HIV-unexposed uninfected (HUU) children, and to examine the associations of HIV exposure with anemia and vitamin D inadequacy. This was a hospital-based descriptive cross-sectional study nested within the Prevention of Mother-to-Child Transmission (PMTCT) of HIV program in Hunan Province during July and September 2022. The HEU children aged 6 to 24 months were recruited from the PMTCT outpatient clinics located in five Municipal Maternal and Child Health Care Hospitals. The HUU children were recruited from routine child health examination clinics in the same five Hospitals. Questionnaires about children's characteristics and maternal gestational conditions were collected from children's caregivers, and blood samples were collected from all children. Descriptive statistics, Chi-square test, non-parametric rank sum test, and logistic regression were used for analysis. The study population included 336 HEU children and 334 HUU children. The overall prevalence of anemia in the HEU and HUU children was 10.4% and 8.1%, respectively. The median hemoglobin concentrations were 120 (115-126) g/L in the HEU children and 122 (116-129) g/L in the HUU children. Neither prevalence of anemia nor hemoglobin concentration was significantly different between the two groups (P > 0.05). The prevalence of vitamin D inadequacy in the HEU children (19.6% for deficiency and 25.0% for insufficiency) was significantly higher than that of the HUU children (11.4% for deficiency and 16.2% for insufficiency) (P < 0.001). The median 25(OH)D concentration in the HEU children was significantly lower than that of the HUU children (23.80 (13.50-34.08) vs. 32.08 (18.60-39.32) ng/ml) (P < 0.001). HIV exposure in HEU children was significantly associated with an increased risk of vitamin D deficiency (adjusted OR (AOR) 1.72, 95% CI: 1.13-2.61) and vitamin D insufficiency (AOR 1.53, 95% CI: 1.01-2.34), but not with anemia (AOR 0.80, 95% CI: 0.32-2.01). The PMTCT program shall strengthen vitamin D supplementation in HEU children and caregivers shall appropriately extend the outdoor activity time of HEU children to reduce the occurrence of vitamin D inadequacy.

Impact of Maternal Viral Suppression on Growth Patterns for HIV-Exposed Uninfected Infants in Kenya

Background and Objective

Children born to mothers living with human immunodeficiency virus (HIV) are at risk for poor health outcomes but data characterizing these associations are limited. Our objective was to determine the impact of maternal viral suppression on growth patterns and malnutrition for infants who are HIV-exposed but uninfected (HEU).

Methods

We conducted a retrospective cohort analysis of clinical data for infants who were HEU and their mothers (September 2015 - March 2019) in Kenya. Infants were stratified based on maternal viral suppression status (≥ or <1000 copies/mL); t-tests were used to compare groups. Growth indicators were evaluated with Chi-square, Fisher's exact, and area under the curve. Moderate-to-severe underweight status, stunting, and wasting were defined by weight-for-age (WFA), height-for-age (HFA), and weight-for-height (WFH), z-scores ≤2, and were used to define malnutrition. Multivariate logistic regression analyses were performed to evaluate potential associations with malnutrition indicators between WFH and HFA.

Results

Among 674 infants who were HEU, 48.7% were male and 85.0% had mothers who were virally suppressed. The median age at first and last clinic visits was 1.5 and 16.4 months, respectively. WFA and HFA z-scores over time differed by sex, and WFA and HFA differed based on maternal viral suppression (P < 0.05). Male infants had higher adjusted odds for stunted status, and as children aged, they had slightly increased odds of becoming underweight or stunted. Maternal viral suppression and timing of maternal antiretroviral therapy initiation in relation to the prevention of vertical transmission (PVT) enrollment did not significantly affect malnutrition indicators.

Conclusion and Global Health Implications

Maternal viral suppression status was not associated with increased odds of more severe malnutrition indicators in children who were HEU. However, overall growth patterns over time, measured by z-scores of growth indicators, did differ based on maternal viral suppression status, and to a lesser degree, by gender.

A comparison of weight gain between HIV exposed uninfected and HIV unexposed uninfected infants who received KMC at Chris Hani Baragwanath Academic Hospital

INTRODUCTION

Kangaroo Mother Care (KMC) has been associated with improved growth in low birthweight infants and reduction in hypothermia, hypoglycaemia, apnoeas, sepsis, hospital stay, and mortality. The growth of HIV-infected children is poorer than those who are HIV-uninfected. There is paucity of data on weight gain in the HIV-exposed uninfected (HEU) infants compared to HIV-unexposed uninfected (HUU) infants receiving KMC.

AIM

This study compared the weight gain of HEU and infants HUU from admission to the KMC ward until 12 months corrected age (CA) follow-up visit.

METHODS

Retrospective record review of the neonates admitted in KMC at Chris Hani Baragwanath Hospital over a 2-year period (2012-2013). The weight gain was assessed via weight velocity using the formula; weight/kg/day from admission to KMC to discharge, and g/ week at term, 3, 6 and 9- and 12-months (CA). The demographics were collected and analyzed using Statistica.

RESULTS

Seventy-seven (129/166) percent of the mothers were HIV negative. HIV negative mothers were younger (25.9 vs. 31.6 years; p = 0.000) and had fewer pregnancies (p = 0.02). There was no difference between the gestational age (30.3 ± 2.53 vs. 30.8 ± 2.88 weeks; p = 0.35) and birthweight (1,345 g ± 234 vs. 1,314 g ± 209; p = 0.47) between HEU and HUU. There were no differences in the weight gain (23.83 g ± 12.2 vs. 23.22 g ± 15.2; p = 0.83) in KMC. There was no differences in weight gain at the different follow-up time points between the two groups.

CONCLUSION

Both HEU and HUU groups of infants showed reasonable weight gain despite maternal HIV status.

Strategies to Reduce Mortality Among Children Living With HIV and Children Exposed to HIV but Are Uninfected, Admitted With Severe Acute Malnutrition at Mulago Hospital, Uganda (REDMOTHIV): A Mixed Methods Study

BACKGROUND

Children living with HIV (CLHIV) and children who are exposed to HIV but uninfected (CHEU) are at increased risk of developing malnutrition. Severely malnourished children have high mortality rates, but mortality is higher in CLHIV/CHEU. This study aims to investigate whether empiric use of an antibiotic with greater antimicrobial sensitivity (ceftriaxone) than standard-of-care (ampicillin plus gentamicin) will reduce mortality among CLHIV/CHEU admitted with severe acute malnutrition.

METHODS

This is an open label randomized controlled trial involving 300 children; 76 CLHIV and 224 CHEU. The participants are being randomized to receive 1 week of ceftriaxone (n = 150) or standard-of-care (ampicillin/gentamicin) (n = 150), in addition to other routine care. The trial's primary outcome is in-hospital mortality. Secondary outcomes are: length of hospitalization; weight-for-height, weight-for-age and height-for-age z-scores; and pattern/antimicrobial sensitivity of pathogens. In addition, 280 severely malnourished children of unknown serostatus will be tested for HIV at admission to determine the prevalence and factors associated with HIV-infection. Furthermore, all the CLHIV on LPV/r will each provide sparse pharmacokinetic (PK) samples to evaluate the PK of LPV/r among malnourished children. In this PK sub-study, geometric means of steady-state LPV PK parameters [Area Under the Curve (AUC) _0-12h , maximum concentration (C_max) and concentration at 12 h after dose (C_12h)] will be determined. They will then be put in pharmacokinetic-pharmacodynamic (PK-PD) models to determine optimal doses for the study population.

DISCUSSION

This study will ascertain whether antibiotics with higher sensitivity patterns to common organisms in Uganda and similar settings, will produce better treatment outcomes. The study will also provide insights into the current pattern of organisms isolated from blood cultures and their antimicrobial sensitivities, in this population. In addition, the study will ascertain whether there has been a significant change in the prevalence of HIV-infection among children presenting with severe malnutrition in the WHO recommended option B plus era, while determining the social/structural factors associated with HIV-infection. There will also be an opportunity to study PK parameters of antiretroviral drugs among severely malnourished children which is rarely done, and yet it is very important to understand the dosing requirements of this population.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05051163.