This open-access article is distributed under
Creative Commons licence CC-BY-NC 4.0. GUEST EDITORIAL
Will global warming undo the hard-won gains of
prevention of mother-to-child transmission of HIV?
During pregnancy, women have a markedly diminished ability to Africa (SA) also seldom have air conditioning, and temperatures in
tolerate heat stress. [1] Increased internal heat production due to some facilities can exceed outdoor temperatures by as much as 4°C.[9]
fetal growth and metabolism occurs alongside a reduced capacity to There are numerous self-reinforcing and bidirectional interactions
dissipate heat, stemming from fat deposition and a decreased ratio between HIV and climate change.[10] These impact directly on
of body surface area to body mass. Heat intolerance of pregnant the health of HIV-infected people, but also on the socioeconomic
women is exacerbated by rises in ambient temperature, particularly determinants of HIV transmission, such as migration, gender
during heatwaves. By implication, pregnant women and developing inequities and poverty. Given mounting evidence of HIV-climate
fetuses may be especially susceptible to the unfolding impacts of interactions, connecting heat exposure and risks of mother-to-child
global warming. Globally temperatures are already rising, and future transmission (MTCT) of HIV may not be as implausible as it might
increments in southern Africa are expected to be twice the global first appear (Fig. 1).
rate.[2] Just as the causes of low birth weight and preterm birth are
Many studies have linked heat exposure during pregnancy to a complex, so too are the reasons why some children but not others
range of adverse birth outcomes, including prematurity, stillbirth, low acquire HIV. Overwhelmingly, however, the most important factor
birth weight and congenital defects.[3-5] Although less is known about affecting risk of MTCT is whether a woman receives and adheres to
the effects of heat on maternal health, associations have been reported antiretroviral treatment. Extreme weather events, such as floods and
with antepartum haemorrhage, hypertension, genital infections, and wildfires, could undermine already fragile drug supply systems in SA.
mental health conditions such as anxiety and depression.[4,6,7] There The mental health effects of hot weather and other consequences of
are very few studies in Africa,[8] where heat sensitivity may be even climate change are considerable – though under-appreciated – and
greater given that few women can afford air conditioning or other may well worsen drug adherence during the postpartum period,
adaptation measures. Labour wards in the public sector in South for example.[11] Obstetric factors remain important determinants of
Potential impacts of heat exposure in Risk factors for transmission of HIV from mother to
pregnancy child
Interruptions in medical supplies during
heatwaves*
Wastage of heat-sensitive drugs
Interruptions in antiretroviral treatment and non-
Worsening of women’s economic
adherence to therapy, with treatment failure
circumstances, reducing resources available
for attending healthcare, which often incurs
substantial user fees and other costs*
Indirect effects through migration and Poor maternal health, raised socioeconomic vulnerability
conflict* and barriers to accessing antiretroviral treatment Risk of
Heatwaves
HIV
or raised
Overburdened emergency transport during Home deliveries without a skilled birth attendant infection
ambient
heatwaves, with less capacity to transport Newborns exposed to HIV do not receive antiretroviral in
temperature
women to facilities during labour* prophylaxis after birth infants
Increased infections with temperature-
HIV transmission increased by chorioamnionitis or
sensitive microbes during pregnancy and
prolonged rupture of membranes
Heatwaves or labour Risk of HIV
raised ambient infection
temperature Increased risk of malaria during pregnancy* Placental malaria in infants
Dehydration in pregnancy, due to increased Low birth weight
sweating andinepisodes
Dehydration of diarrhoea
labour, with reduced uterine Prematurity
Prolonged labour, with longer exposure to maternal
constriction and decreased uterine blood flow HIV fluids during childbirth
Dehydrationand
constriction in labour, withuterine
decreased reducedblood
uterine
flow Prolonged
fluids labour,
during with longer exposure to maternal HIV
childbirth
Mental health conditions in pregnancy and Reduced visits to health services before and after
postpartum, especially anxiety and pregnancy
depression* Non-adherence to antiretroviral drugs, with viral rebound
Inflammation raises amount of HIV present in breastmilk,
Increased bacterial and fungal mastitis
and thus HIV exposure
Increased liquid requirements in infants Increased intake of breastmilk, with consequent exposure
during heat exposure to larger volumes of breastmilk containing HIV WJSVT
Food shortages* Malnutrition, especially micronutrient deficiencies
Fig. 1. Potential pathways between climate change and risk of mother-to-child transmission of HIV and other adverse birth outcomes. (*These impacts may
also be caused by other manifestations of climate change, such as wildfires, storms, flooding and droughts.)
287 May 2019, Vol. 109, No. 5
GUEST EDITORIAL
MTCT, especially in women who have not had HIV testing during Acknowledgements. I thank members of the
pregnancy. Five percent of pregnant women in SA do not attend Maternal Health and Climate Change Research
antenatal care, and the figure is considerably higher in some high- Group for their contribution to this work.
risk settings.[12,13] The outcomes of hot weather in pregnancy, such as
prematurity, prolonged rupture of membranes and genital infections,
are important risk factors for MTCT.[14,15] Additionally, during hot Matthew Chersich
weather infants’ in take of breastmilk is raised, increasing the total Wits Reproductive Health and HIV Institute,
amount of HIV virus the infant is exposed to. Mastitis, which may Faculty of Health Sciences, University of the
occur given the close ties between raised temperatures and infection, Witwatersrand, South Africa
is also a risk factor for MTCT.[15,16] [email protected]
It would be possible to assess these putative associations between
temperature and MTCT using the large data sets on the HIV status
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analysis. AIDS 2012;26(16):2039-2052. https://doi.org/10.1097/QAD.0b013e328359590f
Estimates of the effect of heat exposure on birth outcomes could 12. Statistics South Africa. South Africa Demographic and Health Survey 2016: Key Indicator Report.
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South Africa and its associations with birth outcomes: Analysis of data from birth registers at three
Burden of Disease report[18] presents data on an array of diseases facilities. BMC Public Health 2017;17(Suppl 3):443. https://doi.org/10.1186/s12889-017-4347-z
14. World Health Organization/Joint United Nations Programme on HIV and AIDS. HIV in pregnancy:
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the energy sector. Moreover, as has occurred many times in the past,
focusing on harms to children may well be the best strategy to galvanise
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