Large numbers of HIV-infected pregnant women have now received antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT) of the virus. Some studies have suggested that HIV-exposed uninfected (HEU) children face higher mortality rates than HIV-unexposed children, however, many of these studies were carried out in the pre-ART era where breastfeeding was of limited duration and there was considerable maternal mortality. The authors were interested in whether the combination of maternal ART and prolonged breastfeeding under cover of ART may improve survival. They gathered data on 19,219 HEU children from 21 PMTCT trials/cohorts undertaken 1995-2015 in Africa and Asia. They found that the cumulative incidence of death was 5.5% by age 24 months. Low birth weight (LBW, <2500g) led to an adjusted hazard ratio (aHR) of 2.9, no breastfeeding of 2.5 and maternal death of 11.1. Maternal ART (aHR 0.5) was significantly associated with lower mortality. At a population level, LBW accounted for 16.2% of child deaths by 24 months, never breastfeeding for 10.8%, mother not receiving ART for 45.6% and maternal death for 4.3%. Therefore, these factors combined explained 63.6% of infant deaths by age 24 months. Therefore the survival of HEU children could be substantially improved if public health strategies provided all HIV-infected mothers with ART, supported optimal infant feeding and care for LBW neonates.
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