Mortality, HIV transmission and growth in children exposed to HIV in rural Zimbabwe

BACKGROUND: Although prevention of mother-to-child transmission (PMTCT) interventions have substantially reduced vertical HIV infection in sub-Saharan Africa, mortality and growth among children who are HIV-exposed remain uncertain. METHODS: SHINE was a cluster-randomised trial of improved infant and young child feeding (IYCF) and/or water, sanitation and hygiene in two rural Zimbabwean districts with 15% antenatal HIV prevalence and >80% PMTCT coverage. Pregnant women enrolled between November 2012 and March 2015 underwent HIV testing. Children had longitudinal HIV testing and anthropometry. We compared mortality and growth between children who were HIV-exposed and HIV-unexposed through 18 months. Children receiving the IYCF intervention were excluded from growth analyses. FINDINGS: Among 4727 live births, 51/738 (7%) children who were HIV-exposed and 198/3989 (5%) children who were HIV-unexposed died (hazard ratio 1.41, 95%CI 1.02, 1.93). Among 738 children exposed to HIV, 25 (3%) tested HIV-positive, 596 (81%) were HIV-exposed uninfected (CHEU), and 117 (16%) had unknown HIV status by 18 months; overall transmission estimates were 4.3-7.7%. In CHEU compared to children unexposed to HIV, mean length-for-age Z-scores at 18 months were 0.38 (95%CI 0.24, 0.51) standard deviations lower, and stunting prevalence was 16 percentage points (95%CI 10,22) higher (51% versus 34%). Among 367 children exposed to HIV in non-IYCF arms, 147 (40%) were alive, HIV-free and non-stunted at 18 months, compared to 1169/1956 (60%) children unexposed to HIV (absolute difference 20%; 95%CI 15, 26). INTERPRETATION: In rural Zimbabwe, mortality remains 40% higher among children exposed to HIV, vertical transmission exceeds elimination targets, and half of CHEU are stunted. We propose the composite outcome of 'Alive, HIV-free and thriving' should be the long-term goal of PMTCT programmes.