Neurodevelopment in Children Born to HIV-Infected

Mothers by Infection and Treatment Status

abstract
BACKGROUND: We reviewed the impact of HIV, HIV exposure, and
antiretroviral therapy/prophylaxis on neurodevelopmental outcomes
of HIV-infected and HIV-exposed-uninfected infants and children.
METHODS: A literature search of Medline, Embase, PsychINFO, Web of
Science, PubMed, and conference Web sites (1990March 2011) using
the search terms, infant, child, HIV, neurodevelopment, cognition, language, and antiretroviral therapy, identied 31 studies of HIV/
antiretroviral exposure using standardized tools to evaluate infant/
child development as the main outcome. Articles were included if
results were reported in children ,16 years of age who were
exposed to HIV and antiretrovirals in fetal/early life, and excluded if
children did not acquire HIV from their mothers or were not exposed
to antiretrovirals in fetal/early life.
RESULTS: Infants who acquired HIV during fetal and early life tended to
display poorer mean developmental scores than HIV-unexposed
children. Mean motor and cognitive scores were consistently 1 to 2
SDs below the population mean. Mean scores improved if the infant
received treatment before 12 weeks and/or a more complex
antiretroviral regimen. Older HIV-infected children treated with
highly active antiretroviral therapy demonstrated near normal
global mean neurocognitive scores; subtle differences in language,
memory, and behavior remained. HIV-exposed-uninfected children
treated with antiretrovirals demonstrated subtle speech and
language delay, although not universally.
CONCLUSIONS: In comparison with resource-rich settings, HIV-infected
and HIV-exposed-uninfected infants/children in resource-poor settings
demonstrated greater neurodevelopmental delay compared with HIVunexposed infants. The effects on neurodevelopment in older HIVinfected children commenced on antiretroviral therapy from an
early age and HIV-exposed-uninfected children particularly in
resource-poor settings remain unclear. Pediatrics 2012;130:e1326
e1344

e1326

AUTHORS: Kirsty Le Doar, BA(Hons), MBBS, MRCPCH,a,b

Ruth Bland, BSc, MB ChB, DCH, FRPCH, MD,c,d and MarieLouise Newell, MB, MSc, PhDc,e
aCentre for International Health and Development, and eMRC
Centre of Epidemiology for Child Health, University College
London, Institute of Child Health, London, United Kingdom;
bCroydon University Hospital, London, United Kingdom; cAfrica
Centre for Health and Population Studies, University of KwaZuluNatal, Mtubatuba, South Africa; and dGlasgow University Medical
Faculty, Glasgow, United Kingdom

KEY WORDS
neurodevelopment, HIV, childhood development, antiretroviral
therapy, HAART
ABBREVIATIONS
ARVantiretroviral drug
HAARThighly active antiretroviral therapy
Dr Le Doar prepared and undertook the literature review and
was responsible for writing the rst draft of this article.
Professor Newell and Dr Bland reviewed the data and provided
comments during writing, and substantially contributed to, and
approved, the nal manuscript.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0405
doi:10.1542/peds.2012-0405
Accepted for publication Jun 26, 2012
Address correspondence to: Kirsty Le Doar, MBBS, MRCPCH, c/o
Paediatric Department, Croydon University Hospital, London
Road, Croydon CR7 7YE, UK. E-mail: kirstyledoare@gmail.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
FUNDING: The Africa Centre for Health and Population Studies is
funded by a core grant from the Wellcome Trust (grant number
082384/Z/07/Z).

LE DOAR et al

Downloaded from by guest on March 6, 2016

REVIEW ARTICLE

Mother-to-child transmission during

pregnancy, delivery, or breastfeeding is
the dominant mode of acquisition of
HIV infection in children.1 Without prophylaxis, 15% to 30% of babies born
to HIV-infected women will acquire HIV
in utero or during delivery and a further
5% to 20% through breastfeeding.24
Maternal HIV has been associated with
an increased risk of low birth weight
(,2500 g)57 and small-for-gestationalage infants,6,8,9 both of which are
independently associated with an increased risk of mortality and of developmental delay.1012
HIV-1 is thought to enter the central
nervous system days to weeks after
primary infection,1315 causing neuronal damage and cell death.16,17 This
infective process manifests in childhood as a progressive encephalopathy,
and previously affected 8% to 50% of
children diagnosed with HIV infection
in the United States and Europe.1821
Symptoms can vary greatly, with motor
manifestations predominating.19,22 Microcephaly can be seen as a result of
brain atrophy22,23 and radiologic studies demonstrate periventricular and
basal ganglia calcications and cerebral matter attenuation.24,25
Studies of cerebrospinal uid from
children with progressive encephalopathy found active and persistent brain
infection, highlighting the need for
antiretroviral drugs (ARVs) that cross
the blood-brain barrier. This information has recently been developed
into a ranking system to aid clinicians
ARV prescribing.26 Highly active antiretroviral therapy (HAART), containing
ARVs that cross the blood-brain barrier, has been found to reduce the incidence of progressive encephalopathy
by 50% compared with non-HAART
regimens.27 With the routine use of
ARVs in childhood in the United States
and Europe, cumulative incidence of
progressive encephalopathy in HIVinfected children aged 6 months to 16

years has fallen from more than 30%

to less than 2%.2830 Prevention of
mother-to-child transmission through
maternal ARV prophylaxis and treatment has successfully reduced transmission rates since the 1990s,31,32 and
in countries offering a combination of
ARV prophylaxis, elective cesarean delivery, and avoidance of breastfeeding,
transmission rates of ,2% have been
reported.33
HAART has been associated with severe
prematurity (twofold increased risk of
being born at ,32 weeks gestation)34,35
in Europe and the United States. Similar reports from Africa, where most
women with HIV infection live, indicated
that women on a HAART regimen containing a protease inhibitor were twice
as likely to deliver prematurely (before
37 weeks) than those on a regimen not
containing a protease inhibitor,36,37 and
were 50% more likely to deliver extremely premature infants (before 28
weeks).37 An increased risk has also
been reported in regimen containing
efavirenz and nevirapine.38,39 Severe
prematurity increases the risk of cerebral events, such as hypoxic brain
injury and cerebral hemorrhage, which
will affect future neurodevelopmental
potential.11,12
Interventions to improve development
in the rst 3 years of life, including nutritional supplementation, developmental stimulation, dedicated
health and community-based development centers, have demonstrated
sustained improvement in later cognition and schooling in developing
countries40,41 but this has not been
specically investigated in children affected by HIV.
Assessing neurodevelopmental outcomes is a difcult task owing to potential confounders, such as maternal
health, mood, infant-mother bonding
and attachment, early years stimulation, maternal substance misuse, poverty, illiteracy, malnutrition, and

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

disease.41 The past 10 years have seen

a large investment in prevention of
mother-to-child transmission programs and the treatment of HIVinfected children at an earlier disease
stage with more aggressive therapy.42
With earlier detection and improved
treatment, HIV has become a chronic
disease rather than a fatal illness.
Therefore, improving the quality of life
for infants and children affected by HIV,
including interventions to improve
neurodevelopmental outcomes and
maximize school achievement are vital.
This review aims to summarize what
has been learned about neurodevelopmental outcomes in HIV-infected and
HIV-exposed-uninfected infants and
children and discusses the effects of
different antiretroviral regimens on
neurodevelopmental outcomes. We discuss the implications of these ndings
to improve the care of children infected
and affected by HIV.

METHODS
We searched the online databases
Medline, Embase, PsychINFO, Web of
Science, and PubMed for studies published in English between 1990 and
March 1, 2011, with the following search
terms: infant, child, HIV, neurodevelopment, cognitive impairment,
motor impairment, language impairment, antiretroviral therapy. The
search identied 210 studies in Medline; subsequent searches identied
additional studies: 16 in Embase, 7 in
PsychINFO, and 12 in PubMed. The
results of this review have been
reported using the checklist described
for writing systematic reviews by Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA).43
The current focus of HIV programs
globally is on prevention of mother-tochild transmission and early detection
of childhood infection with immediate
treatment. Therefore, to determine the
effect on neurodevelopment of maternal

e1327

HIV and possible ARV exposure in utero

or early life, and of childhood exposure
to ARVs, studies were included if they
met the following criteria:
1. The study concerned HIV-infected
and HIV-exposed-uninfected infants
and children ,16 years of age who
were exposed to ARVs in fetal and/
or early life
2. The study used a standardized tool
to evaluate infant/child development
3. A developmental variable was the
main outcome
4. English language articles/abstracts
Studies of special groups, such as
patients with hemophilia, orphans, or
HIV-infected children who had not acquired HIV infection via mother-to-child
transmission, were excluded, as these
groups would either not have been
exposed to HIV/ARVs in utero or have
other potential confounders that are
known to affect development, independent of child health status.15
In addition, a manual search of the references from selected articles and
recent conferences of interest (international AIDS conferences, Conference
on Retroviruses and Opportunistic
Infections from 20022010) was carried out to ensure all relevant articles
were identied. This yielded an additional 8 studies that met the inclusion
criteria; 31 studies fullled the inclusion criteria and were reviewed
(Fig 1).

CHARACTERISTICS OF STUDIES
Three-quarters of the studies reviewed
(75%) emanated from the United States
or Canada (n = 18)4461 and Europe
(n = 5),6266 whereas studies from
resource-poor settings accounted for
25%: Africa (n = 6),6772 South/Central
America and the Caribbean (n = 1),73
and Asia (n = 1).74 The characteristics
of the studies included in this review
are outlined in Tables 1, 2, and 3.

e1328

FIGURE 1

Flowchart of study selection process (based on PRISMA owchart).

The prevalence of infants born before

37 weeks gestation ranged from 6%
to 29%50,52,55 in HIV-infected children
and 2.8% to 17.3% in HIV-exposeduninfected children.48,53,54 The prevalence of low birth weight (,2500 g)
among HIV-infected children ranged
from 13% to 33%50,55 and 12% to 16% in
HIV-exposed-uninfected children.53,54
Only 1 study commented on mean duration of ARVs in pregnancy (17.7
weeks).54
Additional exposure to maternal alcohol and drug abuse, including cocaine,
cannabis, and heroine was reported in
31 studies with a prevalence of between
9% and 67%.44,45,48,5055,57,6061 All these

LE DOAR et al

Downloaded from by guest on March 6, 2016

studies were from the United States or

Europe.

HIV-INFECTED INFANTS AND

CHILDREN EXPOSED TO ARVS IN
RESOURCE-RICH SETTINGS
HIV-Infected Infants
HIV-infected infants examined using the
Bayley Scales of Infant Development
(I and II, Psychomotor Developmental
Index, and Mental Developmental Index,
mean score of 100, SD 15)75 displayed
mean neurodevelopmental scores
more than 1 SD below the population
mean. Compared with HIV-exposeduninfected infants, HIV-infected infants

1996

1999

1999

Culnane (48)

Raskino (49)

1995

Chase (46)

Pollack (44)

1994

Year

Nozyce (45)

First Author
(Reference
No.)

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

US

US and
France

US

US

US

Location

Cohort

Cohort

Cohort

Cohort

Cohort

Study
Type

831

332

91

51

274

All HIV-infected

HIV-exposeduninfected

HIV-unexposed = 27

HIV-infected = 22
HIV-exposeduninfected = 42

HIV-infected = 24
HIV-exposeduninfected = 27

All HIV-infected

Groups
Studied

Mean age 3.8 y

2 mo18 y

03 y

0-2 y

470 mo

324 mo

Age at
Entry

TABLE 1 Infants Exposed to HIV/ARVS In Utero and Early Life in Resource-Rich Settings

BSID, MSCA,
WIT

BSID
MSCA

BSID

BSID

BSID

Development
Scale

Not stated if antenatally.

Infants randomized
to receive zidovudine
or didanosine
monotherapy or
combination
zidovudine and
didanosine therapy

Not stated if antenatally.

Infants received
zidovudine

Not stated if antenatally.

11/18 zidovudine
postnatally at mean
age of 4.5 mo.

Yes, not stated when.

ARVS not stated.

Not antenatally.
On therapy depending
on disease stage.
ARVs not stated.

Exposure to ARVs

No SDs in groups for

BSID or MSCA.
Developmental results
improved with
combination
zidovudine and
didanosine.

Yes- not stated

how many

Low birth weight

Growth, immunologic
parameters, birth
weight and gestation

Growth failure
Mean MDI and PDI
predictive of
scores comparable
neurocognitive
at birth but declined
scores.
versus controls by 12
mo if HIV-infected
(83.5 vs 112 vs 116,
P = .01). HIV-infected
10.5 times more
likely to have mean
MDI score .1 SD
lower and 4.4 times
more likely PDI mean
score ,85 (,1 SD)
below population
mean.
Not stated

Yes not stated

Not stated

Additional
Outcome
Measures

Not stated
Early motor delay and
mental decline if HIVinfected versus HIVexposed-uninfected.
Mean scores
decelerate over time.
Variable outcomes,
even if HIV-infected.

Those with worse

disease stage at
higher risk of lower
neurodevelopmental
scores than the
population mean.

Yes not stated

Not stated

Developmental
Outcomes

Additional In
Utero Exposure
to Drugs (Cocaine,
Heroin, Other)

REVIEW ARTICLE

e1329

e1330

LE DOAR et al

Downloaded from by guest on March 6, 2016

Smith (50)

Chase (47)

First Author
(Reference
No.)

2000

2000

Year

TABLE 1 Continued

US

US

Location

Cohort

Cohort

Study
Type

114

595

All HIV-infected

HIV-infected = 114
HIV-exposeduninfected = 481

Groups
Studied

03 y

036 mo

Age at
Entry

BSID

BSID

Development
Scale

Not stated if antenatally.

All infants treated
with zidovudine.

ARVS not stated.

Yes, not stated when.

Exposure to ARVs

Yes 48%

Yes 38.7% to 55.8%

in all mothers

Additional In
Utero Exposure
to Drugs (Cocaine,
Heroin, Other)

Additional
Outcome
Measures

Prematurity,
At 4 mo no signicant
birth weighta
difference except in
mean scores. Mean
score ,1 SD from
the population mean
by 24 mo for both MDI
and PDI, P = .05. Early
HIV-1 infection was
associated with
a decline in
estimated mean
motor scores of 1
standard score point
per mo compared
with 0.28 point in the
late infected group (P
, .02). Estimated
mean mental scores
of the early-infected
group declined 0.72
point/mo, whereas
the average decline
of the late-infected
group was 0.30
point/mo (P , .13).

HIV-infected RR of .1 SD Prematurity, maternal

education assoc. with
below population
lower mean
mean for
neurocognitive
neurodevelopment:
scores
1.5 CI (1.032.18) P =
.034; RR .2 SDs
below population
mean for
neurodevelopment:
2.40; 95% CI: 1.27
4.56; P = .007. RR of
PDI .1 SD below
population mean:
1.66, CI (1.12-2.45) P =
.011; RR .2 SDs
below population
mean: 3.81; 95% CI:
1.937.54; P = .0001.

Developmental
Outcomes

2003

2006

Foster (64)

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

UK

US

Canada

Blanchette (51) 2001

Llorente (52)

Location

Year

First Author
(Reference
No.)

TABLE 1 Continued

Cohort

Cohort

Crosssectional

Study
Type

62

157

50

HIV-infected

All HIV infected

HIV-infected = 25
HIV-exposeduninfected = 25

Groups
Studied

733 mo

036 mo

637 mo

Age at
Entry

BSID, GMDI

BSID

BSID

Development
Scale

Additional In
Utero Exposure
to Drugs (Cocaine,
Heroin, Other)

Not stated if antenatally.

Category C disease: all
received ARVs; 12/31
mono/dual therapy
before HAART,
median number of
drugs =5 (range 3
12).
Category A/B disease:
23/31 HAART, 9
received mono/dual
therapy before
HAART. Median
number of drugs = 4
(range 211).

Not stated if antenatally.

Either zidovudine
monotherapy, dual
therapy without
protease inhibitor or
HAART.

Not stated

38% to 63%

Not stated when.

Yes 20% in
3 had therapy including
HIV-infected mothers
a protease inhibitor
and reverse
transcriptase
inhibitors.
Others had combination
therapy with
nucleoside analogs
only.

Exposure to ARVs

Additional
Outcome
Measures

Lower scores if low

birth weight or
premature and
increased risk of
mortality

Disease stage,
Lower verbal scores
worse stage = lower
than population
scores
mean. Children with
worse disease stage
have scores .2 SDs
below the population
mean, not improved
by HAART.

Children with worse

disease had scores
.2 SDs below the
population mean.
Increased risk of
mortality per 10point decrement in
initial MDI and PDI
scores versus
population mean,
even after adjusted
for treatment. 1.32
(CI 1.071.63).

Mean MDI lower in HIV- CT abnormalities

scores worse in HIVinfected group (P ,
infected if also had
.001 [71.4 CI 62.4
CT abnormalities.
80.4]) versus 92.3 [CI
84.599.9]). Mean PDI
lower in HIV-infected
group (61.9 [CI 55.3
68.6] vs 90.9 [CI 80.1
98.1] P , .001); HIVexposed-uninfected
normal scores in all
domains.

Developmental
Outcomes

REVIEW ARTICLE

e1331

e1332

LE DOAR et al

Downloaded from by guest on March 6, 2016

2010

Williams (53)

US

Italy

US

US

Location

Cohort

Crosssectional

Cohort

Crosssectional

Study
Type

HIV-exposeduninfected = 39
HIV-unexposed = 24

Groups
Studied

HIV-infected = 15
HIV-exposeduninfected = 14

1840 All HIV-exposeduninfected

29

1211 HIV-infected = 152

HIV-exposeduninfected = 1059

63

02 y

2 wk36 mo

02 y

1836 mo

Age at
Entry

BSID

DDST

BSID

BSID

Development
Scale

Excluded

Yes -17%

Yes 1694 exposed to

any ARVS antenatally.

11% to 25%

HIV-exposeduninfected
versus 12% HIVunexposed

Yes 51%

Additional In
Utero Exposure
to Drugs (Cocaine,
Heroin, Other)

Yes, not stated when.

ARVS not stated.

79% antenatally. Infants

on HAART 6 protease
inhibitor

All HAART exposed: at

least 3 ARVs for at
least 1 wk during
pregnancy and
zidovudine at delivery
and postnatal period
(mean 17.7 wk of
exposure).

Exposure to ARVs

Prematurity, low
birth weight

Additional
Outcome
Measures

Not stated

MDI 94.8 vs 92.2, PDI 93.9 Infants with low

= near normal.
birth weight had
Improved MDI scores
better scores if ARV
with increased
exposed.
duration of maternal
therapy (92 for 0 wk
versus 95.9 for .26
wk exposure). MDI
scores also improved
with maternal
zidovudine and
lamivudine therapy
in second and third
trimesters.

HIV-infected infants
62.5% abnormal
scores vs 14% if HIVexposed-uninfected.
Treatment before 12
wk of age improved
scores versus those
treated later.

Low birth weight,

In pre-protease
gestational age
inhibitor era, HIVinfected lower MDI
and PDI versus HIVexposed-uninfected
by 1 y of age and
remained lower at
age 2 y. Limited
improvement in MDI
and PDI with addition
of PI-based HAART.

Percentage MDI scores

.1 SD below the
population mean
54% vs 25% P = .025;
not signicant when
adjusted for
maternal substance
misuse.

Developmental
Outcomes

BSID, Bayley Scales of Infant Development; CI, condence interval; MDI, Mental Developmental Index; MSCA, McCarthy Scale of Childhood Abilities; PDI, Psychomotor Developmental Index; PI, protease inhibitor; RR, relative risk; WIT, Wechsler Intelligence Tests.
a Children followed until 5 y of age.

2008

2007

Lindsey (55)

Caplo (63)

2006

Year

Alimenti (54)

First Author
(Reference
No.)

TABLE 1 Continued

2000

2001

Blanchette (61)

2000

Bisiacchi (62)

Fishkin (57)

1992

Year

Levenson (56)

First Author
(Reference No.)

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

Canada

US

Italy

US

Location

80

42

49

Cross- sectional 25

Cross-sectional

Cross-sectional

Cross-sectional

Study Type

Groups Studied

HIV-infected = 14
HIV-exposeduninfected = 11

HIV-infected = 40
HIV-unexposed = 40

HIV-infected = 29
HIV-exposeduninfected = 13

HIV-infected = 41
HIV-exposeduninfected = 8

TABLE 2 Children Exposed to ARVS in Resource-Rich Settings

512 y
Mean 9.4 y

35 y

615 y

School-age

Age at Entry

WIT

WIT

Own tests

MSCA

Development Scale

Developmental
Outcomes

Additional Outcome
Measures

Not stated

Not stated
Executive function
scores lower in
HIV-infected than
HIV-exposeduninfected;
language and
memory scores
only poorer with
worse disease.
HIV-exposed
scores normal
for age.
Yes, not stated how All neurocognitive
many
scores lower in
HIV-infected
group but not
signicant, only
signicant
difference
executive
function: block
design 6.08 vs
7.53 P = .002

Not stated

Yes, not stated how 44% scored .2 SDs Not stated

many
below the
population mean.
Poor verbal and
memory scores if
HIV-infected and
symptomatic.

Additional In Utero
Exposure to Drugs
(Cocaine, Heroin,
Other)

CT changes
Not stated when.
Yes 20% in HIVNo differences in
4 children on ARVs +
associated with
infected mothers
cognition. Subtle
PI; 8 children
visuospatial and
ne and gross
ARVs without PI;
visuomotor
motor strength
Average no. of
difculties.
differences.
drugs = 2 (range
Signicant
04)
differences in
mean scores in
HIV-infected with
worse disease
stage.

Not stated when.

ARVs not stated

Not stated when.

ARVs not stated

Not stated when.

ARVS not stated

Exposure to ARVs

REVIEW ARTICLE

e1333

e1334

LE DOAR et al

Downloaded from by guest on March 6, 2016

Smith (60)

Jeremy (59)

First Author
(Reference No.)

TABLE 2 Continued

2006

2005

Year

US

US

Location

Cohort

Cohort

Study Type

Groups Studied

HIV-exposeduninfected = 422

539 HIV-infected = 117

489 All HIV-infected

MSCA

WIT

Mean age 6.8 y

37 y

BSID

Development Scale

24 mo 17 y

Age at Entry

Postnatally owing to
infection, not
stated if
antenatally.
Pre-1997:
zidovudine/
lamivudine (100),
stavudine
/ritonavir (97),
zidovudine/
lamivudine/
ritonavir (100).
Post-1997:
stavudine/
nevirapine/
ritonavir (41),
stavudine/
lamivudine/
nelnavir (63),
stavudine/
nevirapine/
nelnavir (44), or
the 4-drug (44)
Not stated if
antenatally.
Children treated
with:
35% monotherapy,
17% HAART, 10%
other multidrug
therapy but not
HAART.

Exposure to ARVs

Only children with Lower mean scores

associated with
the class C
viral load,
disease
primary
performed
language and
poorly. All other
maternal
scores
education.
comparable with
norms.

Yes 41%

Additional Outcome
Measures

Motor, memory, and Low birth weight,

prematurity
language scores
.1 SD below the
population mean
at baseline.
Small
improvement in
verbal score only
with introduction
of PI-based ARVs,
no difference
between the PIcontaining
regimen.

Developmental
Outcomes

Yes, not stated

Additional In Utero
Exposure to Drugs
(Cocaine, Heroin,
Other)

Location

Study Type

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

2010

Thomaidis (66)

Greece

US

Cross-sectional

Cross-sectional

All HIV-infected

Groups Studied

60

HIV-infected = 20
HIV-unexposed = 40

HIV-exposeduninfected = 134

325 HIV-infected = 206

22

318 y
Mean age
11.76 y

916 y

9.46 y

Median

617 y

Age at Entry

WIT
GMDI

PPVT;WRAT III

SON

Development Scale

All HIV-infected
treated with
HAART not stated
when treatment
started. Not
stated if
antenatal

Not stated if
antenatal
exposure.

84% of youths on
ARVS not stated
which.

18 postnatally
treated with
HAART.
Not stated
antenatally

Exposure to ARVs

Additional Outcome
Measures

33% HIV-infected
Youths on ARVS had
scored below
lower WRAT III
10th centile in
scores than those
both tests.
not taking
medication
PPVT:HIV-infected
mean score 83.9
vs 85.3;
HIV-exposeduninfected: mean
score 87.5
HIV-infected with CT Prematurity and low
birth weight
changes had
lower mean
general, practical
and IQ scores P ,
.001. HIV-infected
without CT
abnormalities had
normal cognitive
scores but
increased
emotional
symptoms and
hyperactivity P ,
.05.
Not stated

Global scores within Higher CD4% at

initiation of
the average range.
therapy and
Differences in
prolonged
executive function
therapy
noted with mean
associated with
scores .1 SD
better mean
below the
scores in pattern
population mean
recognition and
in: verbal scores,
baseline speed.
baseline speed,
pattern
recognition,
shifting set,
visuospatial
memory all P ,
.001.

Developmental
Outcomes

Not stated

Not stated

Additional In Utero
Exposure to Drugs
(Cocaine, Heroin,
Other)

BSID, Bayley Scales of Infant Development; CI, condence interval; CT, computed tomography; GMDI, Grifths Mental Developmental Index; MDI, Mental Developmental Index; MSCA, McCarthy Scale of Childhood Abilities; PI, protease inhibitor; PPVT, Peabody
Picture Vocabulary Test; SON, Snijers-Oomen Non-verbal WIT; Wechsler Intelligence Tests; WRAT, Wide-Ranging Ability Test.

2009

2008 Netherlands Cohort

Year

Brackis-Cott (58)

Koekkoek (65)

First Author
(Reference No.)

TABLE 2 Continued

REVIEW ARTICLE

e1335

e1336

LE DOAR et al

Downloaded from by guest on March 6, 2016

2008

2008

Leartvanangkui
(74)

2008

Smith (71)

Van Rie (72)

1995

Year

Gay (73)

Author

Thailand
2008

2008

Congo

South
Africa

Haiti

Location

Groups Studied

39

HIV-infected

126 HIV-infected = 28
HIV-exposeduninfected = 98

Cross304 HIV-infected = 25
sectional
HIV-exposeduninfected = 279

HIV-exposeduninfected = 35
HIV-unexposed=90

Cross160 HIV-infected = 35
sectional

Cohort

Cohort

Study Type

05 y

Mean age
43.7 mo

1872 mo

Mean age
60 mo

024 mo

Age at Entry

TABLE 3 Infants and Children Exposed to HIV/ARVS in Resource-Poor Settings

DDST

BSID, PPVT,
SON

GMDI

BSID

Development
Scale

Additional Outcome
Measures

Yes, not stated when

but part of PMTCT
program

No

Gross motor and language delay Stunting and

in HIV-infected children, ne
wasting
motor and language delay in
prevalent in the
HIV-exposed-uninfected.
HIV-infected
group

Motor and cognitive lower in HIV- Stunting and

wasting higher in
infected and HIV-exposedthe HIV-infected
uninfected children (60%
group.
cognitive delay in HIV-infected
versus 40% in HIV-exposeduninfected; 28.6% motor delay
HIV-infected versus 14.3% HIVexposed-uninfected. Delay in
language expression 84.6%,
comprehension 76.7% P ,
.01. HIV-infected children
aged 1829 mo performed
worse, 91% mental, 82%
motor delay, versus 46% and
4% in HIV-infected children
aged 3072 mo. Children
presenting before clinically
eligible for HAART had better
cognitive/ motor scores than
those presenting with
requirement for HAART.
No

Yes, not stated

when, recruited
from HIV
treatment and
care program so
most ,1 mo of
HAART at
recruitment.

Mean cognitive scores were less Weight-for-height

than the norm at baseline and
at 6 mo despite 6 mo of HAART NB: 86% Xhosa rst
language
(mean scores 6778 pre-and
post-HAART commencement);
33% to 81% subnormal
intelligence quotients, 33%
abnormal motor function.

No

Yes all started

HAART at
enrollment.
Stavudine,
lamivudine and
ritonavir or
efavirenz.

Mean MDI and PDI scores .1 SD Not stated

below the population mean if
HIV-infected at 3 mo.
Differences between groups
increased over time. 33%
normal cognitive scores, 50%
normal motor scores.

Developmental
Outcomes

No

Additional In Utero
Exposure to Drugs
(Cocaine, Heroin,
Other)

Not in utero, 13
infants treated
with zidovudine,
mean age at
initiation 14.6 mo

Exposure to ARVs

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

2011 Zimbabwe
2010

Kandawasvika
(68)

HIV-exposeduninfected = 35

HIV-infected = 51

Groups Studied

Cohort

Cohort

593 HIV-infected = 16
HIV-exposeduninfected = 577

122 All HIV-infected

Cross115 HIV-infected = 92
sectional
HIV-exposeduninfected = 28
HIV-unexposed = 34

Cross86
sectional

Study Type

GMDI

BSID

BINS

,2.5 y, mean age

18.5 mo

,12 mo

BSID

Development
Scale

1015 mo

133 mo

Age at Entry

Yes- single dose

nevirapine in
labor, not stated
if postnatally.

Not stated if
antenatally. 18
children
receiving HAART

Yes, not stated when

66.6% of children on
ARVs at
recruitment

39.2% antenatally.

Exposure to ARVs

No

No

No

No

Additional In Utero
Exposure to Drugs
(Cocaine, Heroin,
Other)

NB: Study in Xhosa

through
interpreter

Not stated

Additional Outcome
Measures

HIV-infected most at risk if

discovered HIV-infected
before 3 mo of age

Children on ARVs had lower

developmental scores than
the population mean.

Head
circumference
and low birth
weight
associated with
low BINS scores

Stunting and
wasting common
and associated
with poorer
developmental
scores.

Motor scores lower in HIVGeneral quotient

infected if treatment deferred
higher if treated
until clinically necessary,
with ARVs
versus those on treatment
from diagnosis.

Scores reported as
a percentages:
66.6% HIV-infected had motor
delay versus 5.7% for
controls.
Children exposed to ARVs in
utero had fewer scores .2
SDs below the population
mean than those unexposed
to ARVs in utero.

Developmental
Outcomes

BINS, Bayley Infant Developmental Screener; BSID, Bayley Scales of Infant Development; DDST, Denver Developmental Screening Tool; GMDI, Grifths Mental Developmental Index; MDI, Mental Developmental Index; PDI, Psychomotor Developmental Index; PI,
protease inhibitor; PPVT, Peabody Picture Vocabulary Test; SON, Snijers-Oomen Non-verbal.

2009 South
Africa
2001

Potterton (70)

South
Africa
2008

2009 South
Africa
2009

2009

Ferguson (67)

Location

Laughton (69)

Year

Author

TABLE 3 Continued

REVIEW ARTICLE

e1337

demonstrated a greater proportion of

oor scores (scores 3 SD below the
population mean or less; ie, scores of
,49).
Studies that investigated the effects of
other variables known to affect neurodevelopment independent of HIV status reported that prematurity,47,52 low
birth weight,52,55 low weight-for-height
scores,44 and low maternal education46,51 were all associated with poorer
mean neurodevelopmental scores in
HIV-infected infants by the age of 12
months compared with the population
mean. In general, even when adjusting
for these variables, HIV-infected infants
demonstrated mean scores .1 SD below the population mean by the age of 12
months. Those infants with worse disease stage and higher viral loads
appeared to be at greatest risk of neurodevelopmental delay with mean
scores .2 SD from the population
mean, indicating moderate to severe
neurodevelopmental impairment.45,51,64
The prevalence of HIV-infected infants
exposure to ARVs in utero ranged from
39.2% to 96.6%.50,55 In HIV-infected and
HIV-exposed-uninfected infants exposed
to ARVs in utero, mean mental scores
ranged from 85 to 96 and mean motor
scores from 75.0 to 96.5.50,55 Lindsey
et al55 noted that infants born to mothers treated with ARVs in pregnancy had
improved motor scores compared with
those born to mothers with no ARVs in
pregnancy. They also noted that in the
pre-protease inhibitor era, mean mental and motor scores in HIV-infected
infants ,1 year of age were signicantly lower than those among HIVexposed-uninfected
infants
and
remained lower up to 2 years of age and
that these mean scores remained signicantly lower than those of HIVexposed-uninfected infants even after
the introduction of a protease inhibitor.
Mean scores declined for both HIVexposed-uninfected infants and HIVinfected infants over time; however,
e1338

despite this, there was evidence of limited improvement in the HIV-infected

infants overall mean scores after
a protease inhibitorbased treatment
had been instigated.55
Despite the widespread use of ARVs in
pregnancy, infants with early infection
(positive result within 48 hours of life,
presumed in utero infection) had lower
mean mental and motor scores compared with children diagnosed as
infected after 48 hours (presumed
peripartum infection),50 and by 24
months, early HIV-infected infants performed signicantly less well in both
mental and motor mean scores than
those infants with later infection.50
There are several limitations to conclusions that can be drawn from this
study, namely that it was conducted at
a time when maternal HAART in pregnancy was not available and initiation
of infants on early treatment was not
indicated. Evidence is emerging that
infants initiated before the age of 12
weeks have improved locomotor
scores compared with those initiated
later.62 With the recently changed
guidelines recommending early diagnosis and initiation of antiretroviral
therapy in infants,42 the impact on the
long-term development of these children remains to be documented.

LONG-SURVIVING HIV-INFECTED
CHILDREN TREATED WITH ARVS IN
RESOURCE-RICH SETTINGS
Early studies of ARV-naive HIV-infected
children .30 months of age at study
enrollment demonstrated slower disease progression and better clinical
outcomes than infants who seemed to
have a more rapidly progressive disease and died early.20,76 These studies
did not collect data on maternal ARV
treatment in pregnancy and describe
characteristics of children who had
never been treated with ARVs.
In the earliest studies of children aged 3
to 18 years treated with dual therapy,

LE DOAR et al

Downloaded from by guest on March 6, 2016

mean global cognitive scores using the

Wechsler Intelligence Tests (mean
score 100, SD 15)77 and McCarthy
Scales of Childhood Abilities (mean
100, SD 15)78 vary from within the
normal range57,61,62 to the neurocognitive impairment range (.2 SDs
below the population mean).49,56 A
proportion of children with severe
disease56,57,62 and high viral loads56,61,62
and those who demonstrated changes,
such as cerebral atrophy on computed
tomography scan,49,61 displayed mean
neurocognitive scores ,70, indicating
moderate-severe neurocognitive impairment.
Differences between scores before and
after treatment instigation are reported by Raskino et al,49 who found that
the mean score improved by 11 to 13
points after 24 weeks of treatment with
combination zidovudine and didanosine therapy but remained in the range
of neurocognitive impairment.
Most early studies of older children
treated with any ARV indicated normal
global cognitive scores, although all
highlighted subtle signicant differences in executive function, memory,
and verbal skills. It is important to note
that there was a large attrition rate
because of disease progression, as
most of these studies include children
treated at a time when children were
commenced on ARVs only in advanced
disease, with low numbers of children
followed for prolonged periods, making
generalizability of the results to todays
situation when ARVs are commenced
early in infants and at an earlier stage
in children problematic.
Recent studies of children treated with
a HAART regimen containing a protease
inhibitor all indicated normal global
cognition mean scores.59,60,65,66 As with
earlier studies, subtle signicant differences were noted in executive
function,59,65 verbal skills,58,59,65 behavior,66 and memory.59,65 This is not universal, however, and a large study by

REVIEW ARTICLE

Smith et al60 reported no signicant

differences in cognitive scores between groups unless the child had
symptomatic disease.
In a small case-control study from the
Netherlands (2008), Koekkoek et al65
reported higher, but still below average, global neurocognitive scores
among those children with higher CD4
percentage on initiation of HAART and
longer duration of HAART compared
with children with lower CD4 percentage and shorter duration of treatment.
Language skills were the most widely
reported decit in children older than 3
years. Mean scores from 1 to 2 SD below
the population mean were reported
in overall language ability,56,58 word
recognition,58 receptive vocabulary,61
expressive language,58 and verbal uency.65 Although language skills continued to develop, this appeared to be
at a slower rate than in HIV-exposeduninfected children, even taking into
account the effect of home circumstances and caregiver arrangements
and irrespective of treatment.58
Jeremy et al59 reported no improvement in overall neurocognitive score
after commencement with protease
inhibitor-based HAART, but noted improvement in verbal scores compared
with pretreatment assessment. It is of
note that a large proportion of children
were tested in a language other than
their mother tongue (range 9% to
75%).58,59,65 The effects of being
assessed in a second language or via an
interpreter on language scores have
been reported in only 1 study.60

HIV-EXPOSED-UNINFECTED
CHILDREN IN RESOURCE-RICH
SETTINGS
Few studies have evaluated the effects
of perinatal exposure to HIVand ARVs on
the neurodevelopment of children
who are HIV-exposed-uninfected. Interpretation of these results was difcult because of the heterogeneity of the

study populations in terms of sample

size (range 441694 subjects), sociodemographics, and percentage of maternal substance misuse, together with
a lack of clarity surrounding length of
maternal antiretroviral therapy in
pregnancy. Most studies do not consider results compared with a matched
control group, but rather use normative data from the standardization of
the neurodevelopmental instrument as
a comparison. The scales used are not
normed to socioeconomically disadvantaged groups; hence, it is difcult to
interpret whether the results reported
are a result of social disadvantage, HIV
exposure, or ARV exposure.
Studies in early infancy and up to the
age of 2 years have not demonstrated
any global developmental delay in HIVexposed-uninfected children once variables such as maternal substance misuse were allowed for.44,4648,50,5355,60,61
However, it appears that subtle decits
in cognition, motor function, expressive and receptive language, and behavior may be present in older children
manifesting during the preschool
years (ages 35 years).58

DEVELOPMENTAL OUTCOMES IN
HIV-INFECTED CHILDREN IN
RESOURCE-POOR SETTINGS
The association between HIV infection
and neurodevelopmental impairment
in infants and children in resource-poor
settings is not well described. In contrast to resource-rich settings, where
prevention of mother-to-child- transmission programs are widespread and
infants are predominantly formula fed,
children in resource-poor settings are,
until very recently, less likely to have
been exposed to ARVs in utero and early
life and are still predominantly
breastfed. In ARV-naive children, neurodevelopmental decits were reported in 6% to 40% of HIV-infected children
in resource-poor settings, depending
on disease stage.79,80

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

A direct comparison of studies of children exposed to HIV/ARVs in utero and

early life was limited by the use of different methodological designs and the
variety of developmental screening and
diagnostic tools used: Denver Developmental Scale Test (percentage fail
scores)81; Cognitive Adaptive Test,
Clinical Linguistics and Auditory Milestones (percentage fail scores)82; Bayley Scales of Infant Development;
McCarthy Scales of Childhood Abilities;
and Grifths Mental Development
Scale83 (all mean 100 SD 15). In addition, comparisons were hampered by
adaptations of these tools, including
nonvalidated translation into local
language and substitution of items
with culturally appropriate alternatives.67,71 As in resource-rich settings, most studies report results
compared with normative data from
the standardization of the instrument
rather than a matched control group.
Further, the effect of ARVs on neurodevelopment is only just emerging, and
several studies had only abstracts
available, meaning an in-depth analysis
of factors that may contribute to neurodevelopmental scores could not be
fully assessed.
In comparison with resource-rich settings, a greater proportion of HIV-infected
infants in resource-poor settings had
scores ,2 SD below the mean (16% to
85% in Africa),70,72 even when adjusting for birth weight and gestational
age.73 Infants demonstrating the most
severe neurodevelopmental delay
were those diagnosed as HIV-infected
before the age of 3 months,68,72 those
with the most advanced disease,69,70
those children who were eligible for
HAART at the time of presentation,67,69,70
and those children with the lowest
weight-for-height scores.70,71
Only one study reported the effect of
prevention of mother-to-child transmission programs on neurodevelopmental outcomes. Kandawasvika et al68
e1339

indicated that maternal treatment with

single-dose nevirapine in labor did not
inuence neurodevelopmental outcomes
(adjusted odds ration of high risk of
neurodevelopmental impairment with
single-dose prophylactic nevirapine 0.9;
95% condence interval 0.991.0). The
authors report that background risk of
neurodevelopmental impairment was
9.4% in both HIV-infected and HIVexposed-uninfected infants, probably
owing to survival bias in the HIV-exposeduninfected groups, as the authors speculated that HIV-infected infants with
severe disease would not have survived
to the 12-month analysis.68
As in resource-rich settings, infants
presenting at an earlier disease stage
and those commenced on antiretroviral
therapy at an earlier age demonstrated
some improvement in cognitive and
motor developmental scores once
commenced on antiretroviral therapy
as compared with than those presenting laterand with worse clinical disease
at instigation of ARVs.72
There are few studies with long-term
follow-up of children born to HIVinfected mothers, and such studies
have been hampered by high mortality
rates in HIV-infected and HIV-exposeduninfected children.70,72,74 In resourcepoor settings where new HIV treatment
guidelines recommending early ARV
initiation have not been implemented,
older children who survive early
childhood would tend to have slowly
progressing disease. Young children
who developed encephalopathy, and
those with more advanced disease
generally, would be expected to have
a shorter life expectancy.84 This selective attrition was seen in some of the
earlier studies in resource-poor settings. So the population samples
available may be children who were
less at risk for central nervous system
effects of HIV disease and therefore
function at a higher cognitive level.
Additionally, these children would have
e1340

been diagnosed as HIV-infected at

a time when early treatment was not
yet available, hindering extrapolation
to the current situation with early initiation of antiretroviral therapy and
improved survival rates.85
Despite subsequent HAART treatment,
high levels of motor delay are noted
(66.7% to 85%)67,70 and mean motor
scores remained .2 SDs below the
population mean. In common with
resource-rich settings, language delay
was also noted in older HIV-infected
children with scores remaining below
the mean despite 6 months of antiretroviral therapy.71,74 These studies
were limited by their small sample
sizes.
Few studies in resource-poor settings
reportresultsfor HIV-exposed-uninfected
children. Contrary to studies from United
States and Europe, these HIV-exposeduninfected children in Africa demonstrated cognitive impairment (40%),
motor impairment (14.3%), and language
expression delay compared with HIVunexposed infants.72,74 Evidence from
Thailand indicated that HIV-exposeduninfected children assessed using the
Denver Developmental Screening Test
demonstrated language decits and ne
motor problems compared with their
HIV-unexposed peers.74 As with studies of
older HIV-infected children in this setting,
conclusions were difcult owing to the
small sample size and cross-sectional
nature of the study.

CONCLUSIONS
All studies identied HIV-infected
infants as having worse mean neurodevelopmental scores than the reference population in infancy with mean
scores consistently more than 1 SD
below the population mean, irrespective of whether they had been exposed to ARVs in utero or not. Infants
presenting with HIV infection before the
age of 3 months had the lowest scores.
Since the advent of prevention of

LE DOAR et al

Downloaded from by guest on March 6, 2016

mother-to-child-transmission
interventions, studies have indicated variable
improvement in mean developmental
scores in HIV-infected infants exposed
to a protease inhibitorbased HAART
regimen in utero. Infants commencing
treatment before the age of 12 weeks
demonstrated better, but still subnormal, mean locomotor scores, than
those with delayed treatment. No studies have yet examined the effect of early antiretroviral therapy on cognitive
scores.
Older HIV-infected children demonstrated near normal global neurocognitive scores, probably as a result of
slower disease progression in this
group. However, there is evidence that
subtle decits in higher cognitive
functioning (poorer memory, language
development) and behavior exist in
school-aged children with only limited
improvement after initiation of antiretroviral therapy. Evidence suggests
that the subtle differences detected in
older children in the pre-HAART era may
be improved with more effective HAART
and that language skills may be improved with a protease inhibitorbased
ARV regimen.
The evolution of more effective antiretroviral therapy, from single therapy
to HAART, appears to have had a positive
impact on mean neurodevelopmental
scores in infants and children in the
United States and Europe who are HIVinfected and HIV-exposed-uninfected.
Lately, results appear to highlight improved outcomes for children treated
with ARVs while they are still clinically
well. There is also an indication that
commencing HAARTat an earlier stage of
disease benets long-surviving children.
This highlights the importance of the
continuing effort to roll out the World
Health Organization recommendations42
in resource-poor settings for early and
more effective antiretroviral therapy to
all eligible pregnant women and their
infants.

REVIEW ARTICLE

The extent to which HIV-exposeduninfected children are affected by in

utero exposure to HIV and ARVs remains
unclear. This group has only recently
become the focus of attention. Although preliminary studies of neurodevelopment from the United States
and Europe are reassuring, these
studies have yet to be replicated in
Africa, where most these children live.
Results of the few small studies from
sub-Saharan Africa and Asia indicate
that in contrast to normal developmental scores seen in populations
from the United States, a larger proportion of HIV-exposed-uninfected
infants and children displayed global
developmental scores 1 to 2 SDs below
the population mean, and children
appeared to show decits in language
and behavior by the age of 5 years. There
are a number of factors that should be
considered when reviewing these
results. First, access to ARVs in
resource-poor settings in pregnancy
has only recently become widespread.
Although prevention of mother-to-childtransmission programs began to be
established in sub-Saharan Africa from
the early 2000s, UNAIDS estimated that
only 9% of eligible HIV-infected pregnant
women in resource-poor settings received ARVs in pregnancy in 2004, increasing to 33% in 2007.86 In addition,
in low- and middle-income countries,
47% of eligible adults now have access

to ARVs.1 So most children in studies

from resource-poor settings included
in this review will have been born to
mothers who are unwell themselves,
with higher viral loads and increased
number of associated conditions, such
as poor nutrition and concurrent illnesses. This will have had a direct effect on transmission of HIV and ability
to care for and stimulate their infants,
but also possible longer-term effects
including impaired attachment between mother and child, which affects
developmental potential, even if the
child is HIV-exposed-uninfected. Added
factors, such as poverty and early infant malnutrition and growth, also
combine to give a more complicated
picture of developmental challenges in
this environment.

tools used, lack of matched control

groups, and the need for modication
and translation into local languages
hinders synthesis and summary of data.
Robust studies that use validated neurodevelopmental assessment tools are
uncommon, and a large number of
studies were excluded from our review
because such tools were lacking. What
is needed is an internationally validated
tool that is easy to adapt culturally and
can be administered quickly by laytrained staff in everyday practice to
screen and identify developmental delay early.

Measures of cognitive, neurologic and

behavioral function serve as an indirect
means of assessing central nervous
system function, along with the more
direct measures, such as computed
tomography/magnetic resonance imaging. The variety of developmental

Interventions to reduce the rate of

mother-to-child transmission have
been successful in resource-rich settings, and the recent scale up of prevention of mother-to-child transmission
programs in resource-poor settings
looks set to do the same. Issues remain
in unraveling the long-term effect of
exposure to HIV and ARVs on HIVexposed-uninfected children and investigating speech, language, and
memory decits in older children who
now have earlier access to therapies
that cross the blood-brain barrier. Only
a concerted, multidisciplinary approach
to diagnosing and treating developmental delay, including antiretroviral
therapy, physiotherapy, and early psychological/behavioral therapy will enable these children to reach their full
potential.

4. Newell ML, Dunn DT, Peckham CS, Semprini

AE, Pardi G. Vertical transmission of HIV-1:
maternal immune status and obstetric
factors. The European Collaborative Study.
AIDS. 1996;10(14):16751681
5. Brocklehurst P, French R. The association
between maternal HIV infection and perinatal outcome: a systematic review of the
literature and meta-analysis. Br J Obstet
Gynaecol. 1998;105(8):836848
6. Habib NA, Daltveit AK, Bergsj P, Shao J, Oneko
O, Lie RT. Maternal HIV status and pregnancy

outcomes in northeastern Tanzania: a registry-based study. BJOG. 2008;115(5):616624

7. Rollins NC, Coovadia HM, Bland RM, et al.
Pregnancy outcomes in HIV-infected and
uninfected women in rural and urban
South Africa. J Acquir Immune Dec Syndr.
2007;44(3):321328
8. Bulterys M, Chao A, Munyemana S, et al.
Maternal human immunodeciency virus 1
infection and intrauterine growth: a prospective cohort study in Butare, Rwanda.
Pediatr Infect Dis J. 1994;13(2):94100

Studies have already indicated the

benecial effects of maternal antiretroviral therapy on child survival87,88
and it is probable that in addition to
improving child survival, improving
maternal health with HAART would
benet developmental outcomes in HIVexposed-uninfected children.

REFERENCES
1. Report G. UNAIDS Report on the Global AIDS
Epidemic 2010. WHO Geneva Library
Cataloguing-in-Publication Data; 2010
2. De Cock KM, Fowler MG, Mercier E, et al.
Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice.
JAMA. 2000;283(9):11751182
3. Wiktor SZ, Ekpini E, Nduati RW.
Prevention of mother-to-child transmission
of HIV-1 in Africa. AIDS. 1997;(11 suppl B):
S7987

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

e1341

9. Taha TE, Dallabetta GA, Canner JK, et al. The

effect of human immunodeciency virus
infection on birthweight, and infant and
child mortality in urban Malawi. Int J Epidemiol. 1995;24(5):10221029
10. Woythaler MA, McCormick MC, Smith VC.
Late preterm infants have worse 24-month
neurodevelopmental outcomes than term
infants. Pediatrics. 2011;127(3). Available at:
www.pediatrics.org/cgi/content/full/127/3/
e622
11. Schendel DE, Stockbauer JW, Hoffman HJ,
Herman AA, Berg CJ, Schramm WF. Relation
between very low birth weight and developmental delay among preschool children without disabilities. Am J Epidemiol.
1997;146(9):740749
12. Karimi M, Fallah R, Dehghanpoor A, Mirzaei
M. Developmental status of 5-year-old
moderate low birth weight children. Brain
Dev. 2011;33(8):651655
13. Sharer LR. Pathology of HIV-1 infection of
the central nervous system. A review. J
Neuropathol Exp Neurol. 1992;51(1):311
14. Persidsky Y, Zheng J, Miller D, Gendelman
HE. Mononuclear phagocytes mediate
blood-brain barrier compromise and
neuronal injury during HIV-1-associated
dementia. J Leukoc Biol. 2000;68(3):413
422
15. Armstrong FD. Neurodevelopment and
chronic illness: Mechanisms of disease and
treatment. Ment Retard Dev Disabil Res
Rev. 2006;12(3):168173
16. Kaul M, Lipton SA. Signaling pathways to
neuronal damage and apoptosis in human
immunodeciency virus type 1-associated
dementia: chemokine receptors, excitotoxicity, and beyond. J Neurovirol. 2004;10
(suppl 1):97101
17. Epstein LG, Gelbard HA. HIV-1-induced neuronal injury in the developing brain. J
Leukoc Biol. 1999;65(4):453457
18. Tardieu M. Update on the neurological
consequences of HIV-1 infection (2006) [in
French]. Rev Neurol (Paris). 2006;162(1):
1921
19. Lobato MN, Caldwell MB, Ng P, Oxtoby MJ;
Pediatric Spectrum of Disease Clinical
Consortium. Encephalopathy in children
with perinatally acquired human immunodeciency virus infection. J Pediatr. 1995;
126(5 pt 1):710715
20. Englund JA, Baker CJ, Raskino C, et al.
Clinical and laboratory characteristics of
a large cohort of symptomatic, human
immunodeciency virus-infected infants
and children. AIDS Clinical Trials Group
Protocol 152 Study Team. Pediatr Infect Dis
J. 1996;15(11):10251036

e1342

21. Neurologic signs in young children with

human immunodeciency virus infection.
The European Collaborative Study. Pediatr
Infect Dis J. 1990;9(6):402406
22. Ojukwu IC, Epstein LG. Neurologic manifestations of infection with HIV. Pediatr Infect
Dis J. 1998;17(4):343344
23. Newton HB. Common neurologic complications of HIV-1 infection and AIDS. Am Fam
Physician. 1995;51(2):387398
24. Johann-Liang R, Lin K, Cervia J, Stavola J,
Noel G. Neuroimaging ndings in children
perinatally infected with the human immunodeciency virus. Pediatr Infect Dis J.
1998;17(8):753754
25. Lacroix C, Vazeux R, Brousse N, Blanche S,
Tardieu M. A neuropathological study of 10
HIV-infected children [in French]. Rev Neurol (Paris). 1993;149(1):3745
26. Letendre S, Marquie-Beck J, Capparelli E,
et al; CHARTER Group. Validation of the CNS
Penetration-Effectiveness rank for quantifying antiretroviral penetration into the
central nervous system. Arch Neurol. 2008;
65(1):6570
27. Patel K, Ming X, Williams PL, Robertson KR,
Oleske JM, Seage GR III; International Maternal Pediatric Adolescent AIDS Clinical
Trials 219/219C Study Team. Impact of
HAART and CNS-penetrating antiretroviral
regimens on HIV encephalopathy among
perinatally infected children and adolescents. AIDS. 2009;23(14):18931901
28. Chiriboga CA, Fleishman S, Champion S,
Gaye-Robinson L, Abrams EJ. Incidence and
prevalence of HIV encephalopathy in children with HIV infection receiving highly
active anti-retroviral therapy (HAART). J
Pediatr. 2005;146(3):402407
29. McCoig C, Castrejn MM, Castao E, et al.
Effect of combination antiretroviral therapy
on cerebrospinal uid HIV RNA, HIV resistance, and clinical manifestations of
encephalopathy. J Pediatr. 2002;141(1):36
44
30. Nachman SA, Chernoff M, Gona P, et al;
PACTG 219C Team. Incidence of noninfectious conditions in perinatally HIVinfected children and adolescents in the
HAART era. Arch Pediatr Adolesc Med. 2009;
163(2):164171
31. Connor EM, Sperling RS, Gelber R, et al.
Reduction of maternal-infant transmission
of human immunodeciency virus type 1
with zidovudine treatment. Pediatric AIDS
Clinical Trials Group Protocol 076 Study
Group. N Engl J Med. 1994;331(18):1173
1180
32. Mayaux MJ, Teglas JP, Mandelbrot L, et al.
Acceptability and impact of zidovudine for
prevention of mother-to-child human im-

LE DOAR et al

Downloaded from by guest on March 6, 2016

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

munodeciency virus-1 transmission in

France. J Pediatr. 1997;131(6):857862
European Collaborative Study. Mother-tochild transmission of HIV infection in the
era of highly active antiretroviral therapy.
Clin Infect Dis. 2005;40(3):458465
Townsend C, Schulte J, Thorne C, et al; Pediatric Spectrum of HIV Disease Consortium, the European Collaborative Study and
the National Study of HIV in Pregnancy and
Childhood. Antiretroviral therapy and preterm delivery-a pooled analysis of data
from the United States and Europe. BJOG.
2010;117(11):13991410
Townsend CL, Tookey PA, Newell ML, Cortina-Borja M. Antiretroviral therapy in
pregnancy: balancing the risk of preterm
delivery with prevention of mother-to-child
HIV transmission. Antivir Ther. 2010;15(5):
775783
Shapiro RL, Hughes MD, Ogwu A, et al.
Antiretroviral regimens in pregnancy and
breast-feeding in Botswana. N Engl J Med.
2010;362(24):22822294
Powis KM, Kitch D, Ogwu A, et al. Increased
risk of preterm delivery among HIV-infected
women randomized to protease versus
nucleoside reverse transcriptase inhibitorbased HAART during pregnancy. J Infect Dis.
2011;204(4):506514
van der Merwe K, Hoffman R, Black V,
Chersich M, Coovadia A, Rees H. Birth outcomes in South African women receiving
highly active antiretroviral therapy: a retrospective observational study. J Int AIDS
Soc. 2011;14:42
Olagbuji BN, Ezeanochie MC, Ande AB, Oboro
VO. Obstetric and perinatal outcome in HIV
positive women receiving HAART in urban
Nigeria. Arch Gynecol Obstet. 2010;281(6):
991994
Engle PL, Black MM, Behrman JR, et al; International Child Development Steering
Group. Strategies to avoid the loss of developmental potential in more than 200
million children in the developing world.
Lancet. 2007;369(9557):229242
Grantham-McGregor S, Cheung YB, Cueto S,
Glewwe P, Richter L, Strupp B; International
Child Development Steering Group. Developmental potential in the rst 5 years
for children in developing countries. Lancet. 2007;369(9555):6070
World Health Organization. WHO Recommendations on the Diagnosis of HIV Infection in Infants and Children. WHO Library
Cataloguing-in-Publication Data; Geneva,
Switzerland; 2010
Moher D, Liberati A, Tetzlaff J, Altman DG;
PRISMA Group. Preferred reporting items
for systematic reviews and meta-analyses:

REVIEW ARTICLE

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

the PRISMA statement. Int J Surg. 2010;8(5):

336341
Pollack H, Kuchuk A, Cowan L, et al. Neurodevelopment, growth, and viral load in
HIV-infected infants. Brain Behav Immun.
1996;10(3):298312
Nozyce M, Hittelman J, Muenz L, Durako SJ,
Fischer ML, Willoughby A. Effect of perinatally acquired human immunodeciency
virus infection on neurodevelopment in
children during the rst two years of life.
Pediatrics. 1994;94(6 pt 1):883891
Chase C, Vibbert M, Pelton SI, Coulter DL,
Cabral H. Early neurodevelopmental growth
in children with vertically transmitted human immunodeciency virus infection.
Arch Pediatr Adolesc Med. 1995;149(8):850
855
Chase C, Ware J, Hittelman J, et al; Women
and Infants Transmission Study Group.
Early cognitive and motor development among infants born to women
infected with human immunodeciency
virus. Pediatrics. 2000;106(2). Available
at: www.pediatrics.org/cgi/content/full/
106/2/E25
Culnane M, Fowler MG, Lee SS, et al. Lack of
long-term effects of in utero exposure to
zidovudine among uninfected children born
to HIV-infected women. Pediatric AIDS Clinical Trials Group Protocol 219/076 Teams.
JAMA. 1999;281(2):151157
Raskino C, Pearson DA, Baker CJ, et al.
Neurologic, neurocognitive, and brain
growth outcomes in human immunodeciency virus-infected children receiving
different nucleoside antiretroviral regimens. Pediatric AIDS Clinical Trials Group
152 Study Team. Pediatrics. 1999;104(3).
Available at: www.pediatrics.org/cgi/content/full/104/3/e32
Smith R, Malee K, Charurat M, et al; The
Women and Infant Transmission Study
Group. Timing of perinatal human immunodeciency virus type 1 infection and rate
of neurodevelopment. Pediatr Infect Dis J.
2000;19(9):862871
Blanchette N, Smith ML, King S, FernandesPenney A, Read S. Cognitive development in
school-age children with vertically transmitted HIV infection. Dev Neuropsychol.
2002;21(3):223241
Llorente A, Brouwers P, Charurat M, et al;
Women and Infant Transmission Study
Group. Early neurodevelopmental markers
predictive of mortality in infants infected
with HIV-1. Dev Med Child Neurol. 2003;45
(2):7684
Williams PL, Marino M, Malee K, Brogly S,
Hughes MD, Mofenson LM; PACTG 219C
Team. Neurodevelopment and in utero

54.

55.

56.

57.

58.

59.

60.

61.

62.

63.

antiretroviral exposure of HIV-exposed uninfected infants. Pediatrics. 2010;125(2).

Available at: www.pediatrics.org/cgi/content/full/125/2/e250 doi:10.1542/peds.20091112
Alimenti A, Forbes JC, Oberlander TF, et al. A
prospective controlled study of neurodevelopment in HIV-uninfected children exposed to combination antiretroviral drugs
in pregnancy. Pediatrics. 2006;118(4).
Available at: www.pediatrics.org/cgi/content/full/118/4/e1139
Lindsey JC, Malee KM, Brouwers P, Hughes
MD; PACTG 219C Study Team. Neurodevelopmental functioning in HIV-infected
infants and young children before and
after the introduction of protease
inhibitor-based highly active antiretroviral
therapy. Pediatrics. 2007;119(3). Available
at: www.pediatrics.org/cgi/content/full/
119/3/e681
Levenson RL Jr, Mellins CA, Zawadzki R,
Kairam R, Stein Z. Cognitive assessment of
human immunodeciency virus-exposed
children. Am J Dis Child. 1992;146(12):
14791483
Fishkin PE, Armstrong FD, Routh DK, et al.
Brief report: relationship between HIV infection and WPPSI-R performance in
preschool-age children. J Pediatr Psychol.
2000;25(5):347351
Brackis-Cott E, Kang E, Dolezal C, Abrams EJ,
Mellins CA. The impact of perinatal HIV infection on older school-aged childrens and
adolescents receptive language and word
recognition skills. AIDS Patient Care STDS.
2009;23(6):415421
Jeremy RJ, Kim S, Nozyce M, et al; Pediatric
AIDS Clinical Trials Group (PACTG) 338 &
377 Study Teams. Neuropsychological
functioning and viral load in stable antiretroviral therapy-experienced HIV-infected
children. Pediatrics. 2005;115(2):380387
Smith R, Malee K, Leighty R, et al; Women
and Infants Transmission Study Group.
Effects of perinatal HIV infection and associated risk factors on cognitive development among young children.
Pediatrics. 2006;117(3):851862
Blanchette N, Smith ML, Fernandes-Penney
A, King S, Read S. Cognitive and motor development in children with vertically
transmitted HIV infection. Brain Cogn. 2001;
46(1-2):5053
Bisiacchi PS, Suppiej A, Laverda A. Neuropsychological evaluation of neurologically
asymptomatic HIV-infected children. Brain
Cogn. 2000;43(1-3):4952
Caplo A, Sa CA, Rubini N, Silva E, Azevedo
M, Kalil R. The importance of early neurological delay detection of vertically HIV-

PEDIATRICS Volume 130, Number 5, November 2012

Downloaded from by guest on March 6, 2016

64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

infected children. In: AIDS 2008 - XVII

International AIDS conference; August 38,
2008; Mexico City, Mexico. Abstract Number WEPE0227
Foster CJ, Biggs RL, Melvin D, Walters MD,
Tudor-Williams G, Lyall EG. Neurodevelopmental outcomes in children with
HIV infection under 3 years of age. Dev Med
Child Neurol. 2006;48(8):677682
Koekkoek S, de Sonneville LM, Wolfs TF,
Licht R, Geelen SP. Neurocognitive function
prole in HIV-infected school-age children.
Eur J Paediatr Neurol. 2008;12(4):290297
Thomaidis L, Bertou G, Critselis E, Spoulou
V, Kafetzis DA, Theodoridou M. Cognitive
and psychosocial development of HIV pediatric patients receiving highly active antiretroviral therapy: a case-control study.
BMC Pediatr. 2010;10:99
Ferguson G, Jelsma J. The prevalence of
motor delay among HIV infected children
living in Cape Town, South Africa. Int J
Rehabil Res. 2009;32(2):108114
Kandawasvika G, Gumbo F, Kurewa E,
Mapingure P. Risk factors for neurodevelopment impairment among infants
born to HIV infected mothers in Harare,
Zimbabwe. IAS 2011; July 1720, 2011;
Rome, Italy. Abstract No. WEPE0068
Laughton B, Grove D, Kidd M, et al. Early
antiretroviral therapy is associated with
improved neurodevelopmental outcome in
HIV infected infants: Evidence from the
CHER (Children with HIV Early Antiretroviral
therapy) trial. Vancouver, Canada: IAS; 2009
Potterton J, Stewart A, Cooper P, Goldberg
L, Gajdosik C, Baillieu N. Neurodevelopmental delay in children infected
with HIV in Soweto, South Africa. Vulnerable Child Youth Stud. 2009;4(1):4857
Smith L, Adams C, Eley B. Neurological and
neurocognitive function of HIV-infected
children commenced on antiretroviral
therapy. South African Journal of Child
Health. 2008;2(3):108113
Van Rie A, Mupuala A, Dow A. Impact of the
HIV/AIDS epidemic on the neurodevelopment of preschool-aged children in
Kinshasa, Democratic Republic of the
Congo. Pediatrics. 2008;122(1). Available at:
www.pediatrics.org/cgi/content/full/122/1/
e123
Gay CL, Armstrong FD, Cohen D, et al. The
effects of HIV on cognitive and motor development in children born to HIVseropositive women with no reported
drug use: birth to 24 months. Pediatrics.
1995;96(6):10781082
Leartvanangkui C, Voramongkoi N, Jungpanich P, Chunhakuntarose P, Pattarakulvanich S. Growth and development of

e1343

75.

76.

77.

78.

79.

children born to HIV-positive pregnant

women in 4 provinces in Thailand, 2072008. In: 5th IAS Conference on HIV Pathogenesis and Treatment; July 2009; Vancouver, Canada. Abstract number CDC025
Bayley N. Bayley Scales of Infant Development. San Antonio, TX: Psychological
Corporation; 1993
Blanche S, Tardieu M, Duliege A, et al.
Longitudinal study of 94 symptomatic
infants with perinatally acquired human
immunodeciency virus infection. Evidence
for a bimodal expression of clinical and
biological symptoms. Am J Dis Child. 1990;
144(11):12101215
Wechsler D. Wechsler Intelligence Scale for
Children-Revised. New York, NY: Psychological Corporation; 1974
McCarthy D. McCarthy Scales of Childrens
Abilities. San Antonio, TX: Psychological
Corporation; 1972
Boivin MJ, Green SD, Davies AG, Giordani B,
Mokili JK, Cutting WA. A preliminary evaluation of the cognitive and motor effects of

e1344

80.

81.

82.

83.

84.

pediatric HIV infection in Zairian children.

Health Psychol. 1995;14(1):1321
Msellati P, Lepage P, Hitimana DG, Van
Goethem C, Van de Perre P, Dabis F. Neurodevelopmental testing of children born
to human immunodeciency virus type 1
seropositive and seronegative mothers:
a prospective cohort study in Kigali,
Rwanda. Pediatrics. 1993;92(6):843848
Frankenburg WK, Dodds JB. The Denver
Developmental Screening Test. Denver, CO:
LADOCA; 1969
Kube DA, Wilson WM, Petersen MC, Palmer
FB. CAT/CLAMS: its use in detecting early
childhood cognitive impairment. Pediatr
Neurol. 2000;23(3):208215
Grifths R. The Abilities of Babies: A Study
in Mental Measurement. New York, NY:
McGraw-Hill; 1954:229
HIV Paediatric Prognostic Markers Collaborative Study. Predictive value of absolute
CD4 cell count for disease progression in
untreated HIV-1-infected children. AIDS.
2006;20(9):12891294

LE DOAR et al

Downloaded from by guest on March 6, 2016

85. Janssen N, Ndirangu J, Newell ML, Bland

RM. Successful paediatric HIV treatment in
rural primary care in Africa. Arch Dis Child.
2010;95(6):414421
86. UNAIDS. 2008 report on the global AIDS
epidemic. Updated 2008. Available at:
http://www.unaids.org/en/dataanalysis/
knowyourepidemic/epidemiologypublications/
2008reportontheglobalaidsepidemic/. Accessed
March 17, 2011
87. Ndirangu J, Newell ML, Tanser F, Herbst AJ,
Bland R. Decline in early life mortality in
a high HIV prevalence rural area of South
Africa: evidence of HIV prevention or
treatment impact? AIDS. 2010;24(4):593
602
88. Patel K, Hernn MA, Williams PL, et al; Pediatric AIDS Clinical Trials Group 219/219C
Study Team. Long-term effectiveness of
highly active antiretroviral therapy on the
survival of children and adolescents with
HIV infection: a 10-year follow-up study. Clin
Infect Dis. 2008;46(4):507515

Neurodevelopment in Children Born to HIV-Infected Mothers by Infection and

Treatment Status
Kirsty Le Doar, Ruth Bland and Marie-Louise Newell
Pediatrics 2012;130;e1326; originally published online October 1, 2012;
DOI: 10.1542/peds.2012-0405
Updated Information &
Services

including high resolution figures, can be found at:

/content/130/5/e1326.full.html

References

This article cites 74 articles, 20 of which can be accessed free

at:
/content/130/5/e1326.full.html#ref-list-1

Citations

This article has been cited by 3 HighWire-hosted articles:

/content/130/5/e1326.full.html#related-urls

Subspecialty Collections

This article, along with others on similar topics, appears in

the following collection(s):
Infectious Disease
/cgi/collection/infectious_diseases_sub
HIV/AIDS
/cgi/collection/hiv:aids_sub

Permissions & Licensing

Information about reproducing this article in parts (figures,

tables) or in its entirety can be found online at:
/site/misc/Permissions.xhtml

Reprints

Information about ordering reprints can be found online:

/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on March 6, 2016

Neurodevelopment in Children Born to HIV-Infected Mothers by Infection and

Treatment Status
Kirsty Le Doar, Ruth Bland and Marie-Louise Newell
Pediatrics 2012;130;e1326; originally published online October 1, 2012;
DOI: 10.1542/peds.2012-0405

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/130/5/e1326.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on March 6, 2016