Introduction With antiretroviral treatment more commonly available there is a gradual shift in the response to HIV from the emergency response to the management of a chronic condition. This requires that we shift our approach not only to treatment, but also to prevention and the protection of affected children. We examine through micro-simulation modelling the potential benefits of more highly integrated responses.

Methods Using South African data we undertake household level micro-simulation modelling examining the dynamic relationship between adult incidence, access to treatment and treatment adherence, and the long term impact on children, including in ways which increase their risk of HIV infection as adults. We simulate a cohort of women born in 1985 examining the consequences of the South African context for their and their children’s survival and their children’s HIV risk profile.

Results In the South African context over 35% of children will be affected by maternal HIV. This leads to lower rates of school completion (12 percentage points) and higher rates of adolescent mental health issues (10 percentage points). Both of these outcomes have been linked to HIV risk behaviours. The results are highly sensitive to adult treatment uptake and adherence, as both affect the timing of adult illness and death.

Conclusion The study highlights the links between adult and child outcomes, not only in terms of negative developmental outcomes for children, but in terms of the epidemics replications. This suggests the need to, when appropriate, treat the family as a unit and focus on addressing common household challenges to adult adherence and adolescent risk behaviour. The results suggest that the current silo approach, common in much of Africa, is economically inefficient.

Funding for this study was provided by USAID through Management Sciences for Health.