Why the Postpartum Period Is a Critical Gap in HIV Care: Elona Toska, MSc, DPhil

Adolescent girls and young women account for a disproportionate share of new HIV infections globally, and for those who become mothers in resource-limited settings, pregnancy and breastfeeding can mark periods of intensified vulnerability. At the Conference on Retroviruses and Opportunistic Infections 2026, Elona Toska, MSc, DPhil, an adolescent health researcher at the Centre for Social Science Research at the University of Cape Town in South Africa, brought this reality into focus, mapping the epidemiology of HIV among adolescent and young mothers aged 10 to 24 years in high-burden communities and challenging the field to rethink how risk is understood and addressed.

Toska’s presentation synthesized global and regional data on HIV incidence and prevalence during pregnancy and breastfeeding, framing these perinatal stages as critical windows for both HIV acquisition and treatment continuity. Although pregnancy and breastfeeding have long been recognized as periods of biological vulnerability, she emphasized that for adolescents and young women—already the group at highest risk of acquiring HIV globally—these risks are layered onto profound developmental, social, and structural challenges.

Biologically, pregnancy and breastfeeding are associated with hormonal fluctuations and changes to the vaginal mucosa that may increase susceptibility to HIV. However, Toska situated these physiological shifts within a broader life course perspective. Adolescence itself brings rapid physical, emotional, and social transitions. For many young women, early motherhood intersects with limited autonomy, unequal partnerships, and constrained access to health information and prevention tools.

Discussing how HIV risk shifts across pregnancy and breastfeeding, Toska underscored that exposure is shaped not only by biology but also by relationship dynamics and structural forces. Patterns of sexual activity, partner age disparities, economic dependence, and limited power to negotiate condom use or ascertain a partner’s HIV status all contribute. She also pointed to the importance of prevention modalities that are not solely partner-dependent, such as pre-exposure prophylaxis, particularly in contexts where negotiating condom use may not be feasible. Importantly, she cautioned against framing these dynamics as purely “behavioral,” noting that many risk factors are outside young women’s control.

Structural determinants further compound vulnerability. Restrictive age-of-consent laws can impede confidential access to HIV testing and prevention services. Gender-based violence, early marriage, and unintended or rapid-repeat pregnancies shape young women’s trajectories in ways that directly affect their ability to access and sustain care. Disclosure to partners and family members also remains fraught, influencing both treatment initiation and adherence.

On the treatment side, Toska highlighted meaningful progress: over the past 3 decades, global efforts have significantly improved antiretroviral therapy initiation during pregnancy. Many women who test positive are rapidly started on therapy, often motivated by a desire to protect their infants from vertical transmission. However, sustaining treatment through the postpartum and breastfeeding periods remains a major challenge. While coverage during pregnancy is relatively strong, continuity often drops off after childbirth—precisely when breastfeeding-related transmission risk and maternal health needs persist. The early postpartum months, she noted, are uniquely demanding, especially for young mothers navigating poverty, stigma, and unstable relationships.

Ultimately, Toska called for a paradigm shift, including reimagining the role of male partners—not only as beneficiaries of HIV services, but as partners and fathers whose engagement can shape maternal and child outcomes—and building integrated health systems that reflect the intertwined biological and social realities of young mothers’ lives.