Maternal Engagement in HIV Care and Antiretroviral Therapy Uptake Among Children Living With HIV

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Importance: Children living with HIV (CLHIV) in sub-Saharan Africa have lower rates of antiretroviral therapy (ART) uptake and viral load suppression (VLS) than adults with HIV. The association of maternal engagement in HIV care with child VLS remains underexplored. Objective: To estimate the prevalence of ART uptake and VLS among CLHIV, and to examine the association between maternal engagement in HIV care and key steps in the pediatric HIV care cascade. Design, Setting, and Participants: This cross-sectional study was conducted from December 2025 to February 2026 using data from the nationally representative, cross-sectional, household-based Population-Based HIV Impact Assessment (PHIA) surveys administered in 13 countries in sub-Saharan Africa between 2015 and 2019. Participants were selected using a multistage stratified cluster sampling design and were restricted to mother-child dyads including CLHIV younger than 15 years with known ART and VLS status. Exposure: Maternal engagement in HIV care, defined as maternal ART uptake and VLS (assessed via participant self-report and laboratory blood specimen analysis). Main Outcomes and Measures: Country-specific prevalence of ART and VLS among CLHIV and the association between maternal care engagement and child VLS. Post hoc hypotheses were tested using logistic regression, which was adjusted for complex survey design and confounders. Results: Across the 13 surveys, 688 CLHIV (353 females [51.3%]; mean [SD] age, 8.3 [4.0] years) had data on ART uptake and VLS status and had linkable maternal data. Two mother-child dyads were excluded due to missing maternal survival data, resulting in a final sample of 686. Pediatric ART uptake and VLS were lowest among children aged 0 to 4 years (69 [48.6%] and 39 [27.5%]) and children with young mothers aged 15 to 24 years (19 [54.3%] and 8 [22.9%]). VLS was significantly higher among children whose mothers had viral suppression compared with those whose mothers did not (185 [59.5%] vs 26 [24.1%]). ART uptake among CLHIV ranged from 83.5% (95% CI, 70.7%-91.4%) in Namibia to 46.0% (95% CI, 35.0%-57.5%) in Zambia in surveys sampling all children younger than 15 years. VLS prevalence ranged from a high of 75.4% (95% CI, 60.7%-85.9%) in Namibia to a low of 30.4% (95% CI, 12.5%-57.3%) in Tanzania. In multivariable analyses, maternal ART uptake was associated with child VLS (odds ratio [OR], 3.99; 95% CI, 1.63-9.78), but this association was attenuated after adjusting for child ART uptake (OR, 0.88; 95% CI, 0.30-2.60); findings were similar for maternal VLS. However, children whose mothers were receiving ART had significantly higher odds of using ART themselves (OR, 20.42; 95% CI, 8.77-47.54) as did children of mothers with VLS (OR, 5.29; 95% CI, 2.95-9.48). Conclusions and Relevance: This cross-sectional study found that maternal ART uptake and VLS were associated with VLS in CLHIV primarily through the child's own ART uptake. Family-centered interventions integrating maternal and pediatric HIV care may support progress toward the UNAIDS 95-95-95 HIV targets.

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