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Pediatr Infect Dis J. 2018 Sep 18. doi: 10.1097/INF.0000000000002193. [Epub ahead of print]

HIV Viremia During Pregnancy and Neurodevelopment of HIV-Exposed Uninfected Children in the Context of Universal Antiretroviral Therapy and Breastfeeding: A Prospective Study.

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Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, South Africa.
Department of Paediatrics & Child Health, University of Cape Town, South Africa.
Division of Developmental Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town South Africa.
Neonatal service, Mowbray Maternity Hospital, Cape Town South Africa.
Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health & Family Medicine, University of Cape Town, South Africa.
ICAP at Columbia, Mailman School of Public Health, Columbia University. New York, NY.
College of Physicians & Surgeons, Columbia University, New York, NY.



Elevated HIV viral load (HIV-VL) in pregnancy has been linked to increased risk of mortality, immunological abnormalities, infectious morbidity and restricted growth among HIV-exposed uninfected (HEU) children, but little is known about effects on child development.


HIV-infected women initiating lifelong ART (tenofovir+emtricitabine+efavirenz) antenatally were followed from first antenatal visit through delivery and with their breastfed infants postpartum. Cognitive, motor and expressive language development (Bayley Scales of Infant and Toddler Development, BSID-III; delay defined as score <85) were assessed on a subset of HEU infants. HIV-VL was measured at ART initiation, in third trimester and around delivery. Cumulative viraemia in pregnancy was expressed as log10 VL copies x year/mL (viraemia copy-years, VCY). Relationships between VCY and development were examined after adjusting for socio-economic, behavioural and psychosocial confounders.


Women (median pre-ART log10 VL 4.1, CD4 349 cells/mm) commonly reported adverse social circumstances (44% informal housing, 63% unemployed, 29% risky drinking). Among 214 infants (median age 13 months; 53% male; 13% born <37 weeks' gestation), viraemia predicted lower motor and expressive language, but not cognitive, scores in crude and adjusted analysis [per log10 VCY increase, aβ (95%CI): motor, -2.94 (-5.77; -0.11); language, -3.71 (-6.73; -0.69) and cognitive-2.19 (-5.02; 0.65)]. Increasing VCY also predicted higher relative odds of motor delay [adjusted odds ratio, aOR 3.32 (95% CI 1.36; 8.14)] and expressive language delay [aOR 2.79 (95% CI 1.57; 4.94), but not cognitive delay [aOR 1.68 (0.84; 3.34)].


Cumulative maternal HIV viraemia in pregnancy may have adverse implications for HEU child development.

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