In Mozambique, a national survey in 2015 found that a third of HIV-infected children age 6-23 months had HIV-negative mothers. In a national survey in eSwatini in 2006-7, 22% of tested mothers of HIV-positive children age 2-12 years were HIV-negative.
With evidence like that, why does UNAIDS say that 100% of HIV-positive children age 0-14 years got HIV from their mothers? Why do health experts from US and African estimate that 97% of HIV-positive children aged 10-14 years in five countries in southern Africa got HIV from their mothers?
Ignoring unexplained infections — not finding and stopping risks – allows risks to continue and to infect others. Too many foreign and national experts have been doing just that – ignoring unexplained infections.
How do children with HIV-negative mothers get HIV? The answer to that question depends on the time and place. Answers come with on-site investigations to find and stop specific risks. Where people have looked – in countries outside sub-Sahara Africa – investigations have found hundreds to thousands infected from health care procedures. Investigations found and stopped risks – and, most importantly, protected others (see “outbreaks and unexpected infections” in the menu on the right).
Here’s a letter recently rejected by Clinical Infectious Diseases (below).Because UNAIDS, health experts, and journal editors are not warning Africans to find and stop blood-borne HIV risks, it’s up to people at risk to begin informal investigations and to push their governments to join. Africans at risk have been waiting decades for health experts to discover their hearts and to do the right thing.
REJECTED LETTER: Unexplained HIV infections in children and adolescents in Africa
TO THE EDITOR – In a recent paper, Low and colleagues use data from national surveys in five countries during 2015-17 (eSwatini, Lesotho, Malawi, Zambia, and Zimbabwe) to examine HIV in adolescents aged 10-19 years. Survey data are sufficient to describe short-comings in finding and treating cases: among 707 identified HIV-positive adolescents, 39.1% had not been diagnosed before the survey, and only 47.1% had suppressed viral loads.
On the other hand, survey data are insufficient to determine sources of infections. For example, setting aside 22 adolescents with recent infections, Low and colleagues estimate 71% (485) of the remaining 685 got HIV from their mothers even though only 35% (= 242/685) of their mothers tested HIV-positive. The only other risk identified from the survey was having had sex, which was reported for 22% (= 150/707) of infected adolescents (without attention to partners’ HIV status). Unspecified behavioral risk was reported for 10% (= 72/707) of infections; surveys did not ask about skin-piercing health care or cosmetic services.
Focusing on children, Low and colleagues’ estimate 97% of infections in children aged 10-14 years came from mothers. Similarly, UNAIDS assumed all infections in children aged 0-14 years came from mothers. On the other hand, Ng’eno and colleagues, with data from a 2012 national survey in Kenya, identified no risk for 4 of 9 HIV-positive children aged 10-14 years.
Table 1: Attributed risks for HIV infections in Africans aged 0-14 years
Source of estimate
% of infections attributed to mother-to-child transmission
Low et al
eSwatini, Lesotho, Malawi, Zambia, Zimbabwe
Low and colleagues’ and UNAIDS’ low estimates of the percentages non-vertical HIV infections in children disregard relevant evidence. For example: in a 2006-7 national survey in eSwatini, 22% of mothers of HIV-positive children aged 2-12 years tested HIV-negative (among tested mothers only); and in a 2015 national survey in Mozambique, 33% of mothers of HIV-positive children aged 6-23 months tested HIV-negative. Moreover, many mothers surveyed in eSwatini and Mozambique likely got HIV from infected children (in two studies with relevant data, breastfeeding children infected from health care infected 40% to 60% of their mothers). If Low and colleagues had looked for HIV in children aged 0-9 years in the five surveys they used to study HIV in adolescents, would they have found similar percentages of unexplained infections?
Disputes about estimates are, of course, matters of judgment. But Low and colleagues’ and UNAIDS’ low estimates of non-vertical (unexplained) HIV infections in children arguably support government decisions not to investigate unexplained infections, which is a matter of fact not judgment: governments in sub-Saharan Africa have not investigated unexplained infections. Unexplained infections challenge governments to investigate to find and fix dangerous skin-piercing procedures to protect public health (see, e.g., recent investigations in Pakistan and Cambodia).
Avoidable infections from undiscovered risks are not the only consequences when public health experts overlook unexplained HIV infections. Low and colleagues decry stigma as an obstacle to finding and treating HIV-positive adolescents. Unfortunately, their estimates contribute to stigma: attributing almost all infections to mothers or sex stigmatizes parents of infected children and/or infected adolescents, whether or not sexually active.
1. Low A, Teasdale C, Brown K, et al. Human Immunodeficiency Virus Infection in Adolescents and Mode of Transmission in Southern Africa: A Multinational Analysis of Population-Based Survey Data. Clin Infect Dis 2021, 73: 594-604. doi: 10.1093/cid/ciab031. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366830/ (accessed 14 September 2021).
2. Mahy M, Penazzato M, Ciaranello A, et al. Improving estimates of children living with HIV from the Spectrum AIDS Impact Model. AIDS 2017; 31:13–22. Available at: https://pubmed.ncbi.nlm.nih.gov/28301337/ (accessed 24 October 2021),
5. Mozambique: Survey of Indicators on Immunization, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015, Supplemental Report Incorporating Antiretroviral Biomarker Results. Maputo: Ministério da Saúde (MISAU) Instituto Nacional de Estatística (INE), 2019. Available at: https://www.dhsprogram.com/pubs/pdf/AIS12/AIS12_SE.pdf (accessed 15 October 2021).
6. Little KM, Kilmarx PH, Taylor AW, et al. A review of evidence for transmission of HIV from children to breastfeeding women and implications for prevention. Pediatr Infect Dis J 2012; 31: 938-942. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4565150/ (accessed 15 October 2021).
8. Rouet F, Nouhin J, Zheng D-P, et al. Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015. Clin Infect Dis 2018; 66: 1733-1741. Available at: https://pubmed.ncbi.nlm.nih.gov/29211835/ (accessed 24 February 2021).