Early childhood development among HIV exposed uninfected children Nigel Rollins Department of Maternal, Newborn, Child and Adolescent Health World Health Organization Geneva, Switzerland IAS, 22 July 2018

Magnitude of the challenge and opportunity Data Source: UNAIDS 2018

Early childhood development in children living with HIV Delayed development among infected children has long been reported. Microcephaly and impaired growth commonly noted Issues are complex and more monitoring and research needed to inform and improve management Cognitive delay frequently reported among HIV infected children Complex social and health contexts Need greater monitoring and research to understand the problem and to improve management

Development in HIV exposed uninfected children Increasing awareness and reports of developmental delay in HIV exposed, uninfected children Delays reported compared to the general population but ….. Development can be normal

Why HIV exposed, uninfected children are vulnerable to sub-optimal development Potential mechanisms … HIV exposure itself (but data not indicative of a stand-alone risk) ART exposure in utero Postnatal ARVs as prophylaxis Maternal well-being and care practices Non-breastfeeding: to prevent HIV transmission Increased risk of exposure to opportunistic infections Poverty, stress and undernutrition HIV exposed children are vulnerable to developmental delay irrespective of their HIV status due to combined effect of risk factors like poverty, prenatal drug exposure, stress and chronic illness in family and malnutrition But reports of these outcomes span 15+ years when different ARVs were implemented to improve the health of mothers and prevent transmission and breastfeeding was commonly avoided. Data needed in the context of maternal ART for life and breastfeeding

HIV exposed, uninfected children are also susceptible to the same risk factors for impaired child development as the general population Low birth weight Stunting Undernutrition Poverty Sub-optimal care practice Responsive caregiving Early learning opportunities All that is provided through ……. Nurturing care

Where to now? Health services have a major opportunity to contribute to early child development of a large and vulnerable population in SSA (historically, ECD has been seen as an education sector issue) Maternal and child health services plus other sectors should orient around the nurturing care framework Identify vulnerable children: LBW, stunted, HIV-infected, HIV exposed Offer integrated care according to the mother and child’s vulnerability HIV-specific or non-HIV vulnerabilities HIV-specific care and non-HIV specific care Research to understand HIV-specific risk factors in the context of ART for all. We have talked about integration for the past decade. ECD for HEU is a prime example of where this is an absolute necessity

New paradigm, new target, ….. ?new metric HIV prevention HIV free survival HIV free survival and development