The Impact of the HIV Pandemic on Children in South Africa

In the early 2000s, as the HIV/AIDS pandemic devastated communities across South Africa, paediatrician Refiloe Masekela witnessed a tragic surge in childhood deaths linked to the virus—deaths that occurred just before antiretroviral therapy became widely available through the public health system. Now, as Dean of the School of Medicine at the University of KwaZulu-Natal and a faculty member at the Africa Health Research Institute in Durban, Masekela is channeling that experience into a renewed focus on preventing and treating childhood lung disease, a leading cause of morbidity and mortality among young people in low-resource settings.

Speaking in a recent perspective piece published in The Lancet, Masekela reflected on her early clinical training at the University of Pretoria, where she treated children suffering from advanced HIV-related respiratory complications. “In the 2000s, when the AIDS pandemic hit South Africa, we were seeing a lot of children dying from HIV. That was just before antiretroviral treatment had become fully accessible for people in the state sector,” she recalled. Those formative years underscored the deadly intersection of infectious disease and lung health in children, particularly in settings where malnutrition, overcrowding and limited access to diagnostics compounded vulnerability.

Today, Masekela’s work centers on closing the gap in care for childhood lung conditions such as pneumonia, tuberculosis, and chronic lung disease stemming from preterm birth or HIV exposure. Despite global advances in vaccines and antibiotics, pneumonia remains the single largest infectious cause of death in children under five, according to the World Health Organization. In 2021, it accounted for over 700,000 deaths worldwide, with sub-Saharan Africa bearing a disproportionate share of the burden.

Her research at AHRI explores how early-life insults—including prenatal HIV exposure, maternal malnutrition, and recurrent respiratory infections—can impair lung development and increase susceptibility to severe disease later in childhood. Longitudinal studies from the institute have shown that even children who escape HIV infection but are born to HIV-positive mothers often exhibit reduced lung function, suggesting that the intrauterine environment plays a critical role in lifelong respiratory health.

Masekela advocates for integrating lung health screening into routine maternal and child health visits, arguing that early detection of impaired lung function could allow for timely interventions such as nutritional support, inhaled therapies, or vaccinations. She also emphasizes the need for context-appropriate diagnostic tools, noting that spirometry—while gold standard in high-income settings—is often impractical in rural clinics due to cost, training requirements, and lack of pediatric-specific reference equations.

To address this, her team has been involved in validating simpler, low-cost alternatives such as tidal breathing measurements and forced oscillation techniques, which require less cooperation from young children and can be administered by community health workers with minimal training. Pilot studies in KwaZulu-Natal have demonstrated promising correlation between these tools and clinical outcomes, supporting their potential use in screening programs.

Beyond diagnostics, Masekela stresses the importance of strengthening health systems to ensure consistent access to antibiotics, oxygen therapy, and follow-up care. She points to successful models where community-based management of pneumonia, supported by trained health workers and reliable supply chains, has reduced child mortality by up to 42% in some African settings.

Her perspective also highlights the long-term consequences of untreated childhood lung disease, including increased risk of chronic obstructive pulmonary disease (COPD) in adulthood—a finding supported by cohort studies linking early-life respiratory insults to diminished lung function decades later. This life-course approach, she argues, demands greater investment in primordial and primary prevention, starting with maternal health and extending through early childhood.

While acknowledging progress in HIV treatment access—now covering over 75% of eligible individuals in South Africa according to UNAIDS—Masekela warns that complacency could reverse gains. Emerging threats such as drug-resistant tuberculosis, the lingering respiratory effects of SARS-CoV-2 infection in children, and rising rates of preterm birth due to maternal infections underscore the need for sustained vigilance.

She calls for increased funding for pediatric respiratory research led by African scientists, better representation of children from low- and middle-income countries in global clinical trials, and policies that prioritize lung health as part of universal health coverage. “Building access to care for childhood lung disease isn’t just about treating illness,” Masekela states. “It’s about ensuring every child has the chance to grow up with healthy lungs—and a fair shot at a healthy life.”