Rapid-Repeat Pregnancy and HIV Vulnerability: Elona Toska, MSc, DPhil

Pregnancy and adolescence are each periods of rapid change. When they overlap—as they often do for young women in high HIV-burden, resource-limited settings—the implications for HIV risk and treatment continuity become more complex. 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, presented a life course analysis of HIV epidemiology among adolescent and young mothers aged 10 to 24, highlighting where health systems are making progress and where critical gaps remain.

Drawing on global data, Toska examined HIV incidence and prevalence during pregnancy and breastfeeding, identifying these prolonged perinatal periods as key windows for both prevention and sustained treatment. Biological factors, including hormonal shifts and changes to the vaginal mucosa, may increase susceptibility to HIV during pregnancy and breastfeeding. However, Toska emphasized that these physiological changes are only part of the picture. Adolescence itself brings evolving relationships, limited autonomy, and social pressures that shape HIV exposure and care engagement.

Importantly, she cautioned against reducing risk to “behavior.” Many drivers of HIV exposure among young mothers are structural and relational: age-disparate partnerships, economic vulnerability, difficulty negotiating condom use, and limited access to independently controlled prevention options such as pre-exposure prophylaxis. Legal and socio-cultural determinants—including restrictive age-of-consent laws, gender-based violence, and early marriage—further constrain access to confidential, youth-responsive services and undermine continuity of care.

On the treatment side, Toska acknowledged the substantial gains achieved through prevention of mother-to-child transmission frameworks. Antiretroviral therapy (ART) initiation during pregnancy has improved significantly over the past decades, with many women starting treatment promptly after diagnosis. Yet sustaining adherence through the postpartum and breastfeeding periods remains challenging. Although pregnancy often brings strong engagement in care, continuity can decline after delivery, particularly for adolescents managing the demands of new motherhood alongside unstable relationships, stigma, or financial strain.

When asked what health systems should measure to safeguard not only infant outcomes but also maternal health, Toska argued that tracking vertical transmission alone is insufficient. Metrics should include fertility intentions, pregnancy timing, and birth spacing. Early age at first birth is one of the strongest predictors of rapid-repeat pregnancies—especially those occurring within 2 years, which carry heightened risks for both mother and child. Systems need better ways to identify young women who repeatedly cycle through antenatal services and to provide sustained support between pregnancies, including contraception, HIV prevention, and ART continuity.

Her call for a paradigm shift centers on adolescent-responsive care. Effective biomedical tools are essential, but they must be delivered in ways that reflect the realities of young people’s lives. Adolescents are navigating school, relationships, peer dynamics, and mental health challenges; HIV prevention is rarely their only concern. Toska urged clinicians, researchers, and policymakers to offer genuine choice and flexibility, grounded in respect and an understanding of young mothers as whole individuals.

Ultimately, she argued that improving long-term maternal and child outcomes requires integrated systems that address both biological vulnerability and the social conditions shaping young women’s lives.