Addressing health inequities in HIV exposed uninfected children

Over the past few decades, we have witnessed remarkable progress in the global fight against human immunodeficiency virus (HIV). Since 1995, new cases of HIV infection have decreased by 60%, primarily due to better access to antiretroviral therapy (ART). One of the most notable successes in the fight against the HIV epidemic is the dramatic reduction in perinatal HIV transmission. Before the widespread use of ART, transmission rates ranged from 15% to 45%. Today, those rates have fallen to around 2% globally, with some cities in developed countries reporting nearly zero transmission. As ART coverage has expanded, the number of HIV-positive children has decreased, while the number of HIV-exposed uninfected (HEU) children— uninfected offspring of HIV-infected mothers has risen. This group now represents a rapidly growing population of HIV-affected but uninfected individuals, totaling 16 million, with an annual increase of 1.6 million.

Health disparities are present at every stage of the HIV care continuum, and ongoing efforts aim to reduce the disproportionate HIV burden among marginalized communities. While these initiatives are commendable, it is crucial to also consider the impact of HIV on those who are affected but not infected, such as HIV-exposed uninfected (HEU) children, and to develop equitable strategies to address their unique challenges. Although HEU children are typically healthy, numerous studies indicate they may be at higher risk for adverse health outcomes, including growth restriction, increased susceptibility to infections, and neurodevelopmental disorders. It is well-established that infants with growth restriction are at an elevated risk of developing chronic conditions, including cardiometabolic and neurological disorders, later in life, a risk that is further heightened by low socioeconomic status. Research shows that a significant number of HEU children come from low socioeconomic backgrounds, where they may have restricted access to healthcare, nutrition, and other essential resources. This lack of access can accentuate the potential health complications associated with perinatal exposure to HIV and/or ART in these children.

The Bronx, a borough of New York City with a high poverty rate, exemplifies the intersection of poverty, limited healthcare access, and housing instability, all of which contribute to delayed HIV diagnoses and linkage to care. In 2021, over 80% of new HIV diagnoses in the Bronx occurred among socioeconomically disadvantaged Black and Hispanic communities. If not addressed, children born to HIV-infected mothers in marginalized areas may also experience significant health disparities and restricted access to care. A recent retrospective cohort study presented at the 2024 Association for Diagnostics & Laboratory Medicine (ADLM) conference examined the prevalence of neurodevelopmental disorders and dyslipidemia in HEU children in the Bronx. Using retrospective medical records, the study compared 127 HEU children with 157 HIV-unexposed uninfected (HUU) controls aged 0 to 15 years. The findings from the study revealed a higher prevalence of autism spectrum disorders, attention-deficit/hyperactivity disorder, and developmental delays among HEU children compared to controls. Additionally, metabolic issues were prevalent, with 33% of HEU children exhibiting elevated cholesterol levels (compared to the U.S. national average of 7%) and 54.5% having high triglyceride levels, significantly higher than the U.S. national average of 10.2%. This study underscores the significant health inequities faced by HEU children in the Bronx, highlighting an urgent need for targeted interventions.

Addressing health inequities in these unique patient populations requires more than access to care; it calls for a comprehensive approach encompassing a thorough understanding of their health challenges, enhanced surveillance, and tailored interventions. Given the growing population of HEU children, even small increases in adverse health outcomes could pose substantial public health challenges. To help these children reach their full potential, it is crucial to encourage further research to better understand their unique needs. Additionally, policies must be implemented to promote the equitable distribution of resources, ensuring timely screening and intervention for children in underserved communities.