African Children Exposed to HIV, ART Perinatally Face Higher Risk of Stunting

By Scott Baltic

November 13, 2019

NEW YORK (Reuters Health) - Prolonged perinatal exposure to maternal HIV and antiretroviral therapy (ART) is associated with lower height and weight and more stunting in uninfected babies and toddlers, according to data from a study of breastfed children in Malawi and Uganda.

"Our findings are likely generalizable to other breastfeeding populations in sub-Saharan Africa with endemic child undernutrition and high infectious-disease burden," Dr. Jim Aizire of the Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland, and colleagues write in AIDS, online October 12.

Dr. Aizire added in an email to Reuters Health that some of the potential longer-term outcomes of stunting and lower weight include a higher risk of behavioral and school difficulties, poorer overall survival up to age 5, and obesity and related metabolic complications.

For their study, he and his colleagues compared two groups of children: 472 who were ART and maternal-HIV exposed but uninfected, and 462 age-and-sex-matched children unexposed to HIV.

Mother-child pairs were recruited through two sites, one in Malawi and one in Uganda. In addition to ingesting maternal antiretroviral drugs in breast milk, the exposed infants received oral nevirapine as prophylaxis during the first six weeks of life.

Exposed infants in both countries had significantly lower birth weights than did control infants. While common in both groups, breastfeeding was significantly more prevalent among control infants.

In Uganda, exposed children at 12 and 24 months of age had significantly lower mean length for age and weight for age than control children. In addition, exposed children had significantly lower mean head circumference for age at 24 months.

The prevalence of stunting, defined as length for age more than two standard deviations below the WHO reference median, was high overall. Among exposed children, 29.8% and 32.3% had stunted growth at 12 and 24 months of age, respectively, which was significantly more than the 13.3% and 18.2% rates among control children.

In Malawi, similar trends were seen among exposed versus unexposed children, but only the differences in stunting at 24 months were statistically significant.

The researchers say theirs is the first study to show growth deficits among exposed versus unexposed children through 24 months of age, in settings where restricted childhood growth is endemic.

They note that stunting and underweight are associated with increased childhood mortality, and that early growth faltering, "even with catch-up later in childhood, has been associated with noncommunicable diseases later in adulthood."

Dr. Stanzi le Roux of the School of Public Health and Family Medicine at the University of Cape Town, in South Africa, has studied growth trajectories of breastfed exposed and control children in South Africa. She told Reuters Health by email that the new findings "align with other recent reports from sub-Saharan Africa, demonstrating an excess risk of chronic malnutrition among exposed compared to otherwise similar control children despite maternal use of ART and breastfeeding."

In some African countries, she added, exposed children now comprise up to 20%-30% of births.

Dr. le Roux, who was not involved in the study, called stunting "a red flag for whole-body depletion of essential nutrients. . . In turn, this depletion affects multiple organs and systems; from a public health perspective, most critical is the lack of nutrients required for brain growth and development."

At an individual level, she continued, growth faltering is strongly associated with failure to reach developmental potential, and "at a population level, this results in loss of human capital and the perpetuation of inter-generational poverty."

Dr. le Roux emphasized that "stunting is a process," and its onset occurs before what she called the study’s "rather arbitrary cut-point" for length for age.

"As with most illnesses, earlier intervention is not only more effective, but also cheaper from a cost-benefit perspective," she concluded. "Both (exposed) and (control) children should be receiving regular growth monitoring, with interventions to address nutritional depletion, concurrent infections and household situation at the point of onset of growth faltering."


AIDS 2019.