In the 35 years since the first World AIDS Day (WAD) commemoration, the global scientific community has made enormous strides in developing safe and highly effective strategies to prevent and treat HIV. Yet there remains much to do, including efforts to apply these powerful tools globally and to reduce stigma and other barriers to care. Although NICHD is one of several NIH institutes that support and conduct HIV/AIDS research, it has a unique focus on infants, children, adolescents, and women, including those who are pregnant.
The theme for WAD2023—Remember and Commit—invites reflection on some of NICHD’s recent progress in advancing HIV research and the institute’s ongoing efforts to ensure healthy and optimal lives for those affected by HIV/AIDS.
Optimizing Outcomes for Infants and Children
Since the mid-1990s, NICHD research has led to the implementation of HIV testing and prevention measures that have helped lower the rate of perinatal HIV transmission in the United States to less than 1%. Encouraging pregnant people with HIV to take antiretroviral therapy (ART) throughout pregnancy is extremely successful at reducing the number of children born with HIV, but the potential effects of antiretroviral drugs on the child’s neurodevelopment remain less clear. Recent NICHD-funded research found that the risk for developmental delay by age 5 years was lower among HIV-negative children whose mothers began ART before pregnancy, compared to those whose mothers began treatment during pregnancy. The findings underscore the importance of starting ART early to help protect the health of the fetus.
Optimizing outcomes for children with perinatal exposure to HIV and ART is the theme of a recently published special issue of the Journal of the International AIDS Society. The supplement includes a commentary from NIH scientists highlighting ways to address research gaps to prevent and treat negative health outcomes for these children as they grow into adolescence and young adulthood.
A Time of Transition: Tailoring Care for Adolescents and Young Adults
Young people ages 13 to 24 years account for one in five new HIV diagnoses in the United States. The latest estimates from the Centers for Disease Control and Prevention indicate that HIV rates are declining in this age group, suggesting that efforts to improve the reach of HIV testing, treatment, and prevention strategies are paying off.
Yet youth remain the least likely of any U.S. age group to know their HIV status. Early diagnosis of HIV enables early treatment, which both improves the health of the person living with the virus and prevents transmission to others. NICHD funded the development and evaluation of a digital tool that may increase HIV testing among youth visiting hospital emergency departments. Such a tool could offer a convenient way for hospitals to promote HIV testing and allow health care providers to collect more accurate data on risk behaviors, including substance use before or during sex.
Youth also are less likely than adults to use pre-exposure prophylaxis (PrEP), medicine taken to prevent getting HIV. The recent availability of generic versions of a daily PrEP pill has decreased costs substantially, compared to branded drug prices. NICHD-supported research predicted that, compared to annual HIV screening alone, generic PrEP with HIV screening every three months would result in fewer HIV acquisitions, longer life expectancy, and fewer HIV-associated costs among U.S. young men who have sex with men.
Getting into care and staying in care can be challenging for young adults in general, but particularly for people whose HIV is acquired or diagnosed during young adulthood. NICHD recently announced a new program to prevent and treat HIV among adolescents and young adults in low- and middle-income countries. Researchers will evaluate HIV prevention, treatment, and care interventions suited to local health care infrastructure in eight African countries. The effort will focus on locations with limited research capacity and with populations underrepresented in HIV research, such as sexual and gender minorities, commercial sex workers, and people who use drugs.
The transition from pediatric to adult HIV care programs is another obstacle to improving health outcomes among youth with HIV. A recent NICHD-supported study highlighted the importance of social support just prior to this transition. Young adults born with HIV who reported average or high levels of social support were more likely to maintain viral suppression—when ART reduces the amount of HIV in the blood to an undetectable level—than peers with low social support.
Linking HIV and Reproductive Health
Worldwide, most new HIV acquisitions occur through sex. Many women are simultaneously at risk for unintended pregnancy and sexually transmitted infections (STIs), including HIV. NICHD supports the development and testing of multipurpose prevention technologies—contraceptive products that also protect against STIs. For example, researchers at Boston University and their collaborators are developing a vaginal film that can deliver an anti-sperm antibody, as well as antibodies against HIV and herpes simplex virus 2. Another NICHD-supported project is evaluating the potential of a contraceptive vaginal ring that also prevents HIV acquisition.
NICHD also supports work to optimize contraceptives for people with HIV. Some antiretroviral drugs interact with hormonal birth control, meaning that a woman taking ART may be more likely to become pregnant despite using contraception. For example, NICHD-supported research revealed that women with a contraceptive implant who were taking efavirenz-containing ART had substantially lower levels of contraceptive hormones than women not taking ART. Better understanding these drug-drug interactions is essential to advancing contraceptive options for women with HIV.
Supporting Pregnancy and Parenthood
Knowing one’s HIV status also is critical to planning for a healthy pregnancy. Taking ART throughout pregnancy not only reduces the risk of perinatal transmission but also benefits the health of the pregnant person. An NICHD-funded study found that those with low C4+ cell counts—an indication that HIV has weakened the immune system—in early pregnancy and those who began ART later in pregnancy were at greatest risk for new-onset hypertensive disorders of pregnancy. Another study found that those with higher viral loads during pregnancy had a higher ratio of omega-6 to omega-3 fatty acids, indicating an inflammatory response and possibly a less healthy environment for the developing fetus. Findings from these studies underscore the importance of receiving comprehensive HIV treatment throughout pregnancy.
Other NICHD-supported research focuses on the experiences of mothers living with HIV. A recent study showed that widowed mothers and those who were recently diagnosed with HIV had more negative feelings or thoughts about their HIV status—known as internalized stigma. A related analysis found that women with higher levels of internalized stigma were less likely to disclose their HIV status to their children. Better understanding of internalized stigma and its impacts may aid efforts to reduce stigma more broadly and support mothers living with HIV.
These study summaries provide just a glimpse into the some of the recent progress NICHD has made in preventing and treating HIV among its populations of interest. The following resources provide additional information: