Recommitting to Children in the 2018 Global AIDS Agenda

Each new year affords an excellent opportunity to reflect on the previous one. What did we get right, what did we get wrong, and how can we improve? For those of us working in paediatric HIV, these questions have clear answers. Yet translating those answers into actions is a task requiring immense political will and concrete commitments.

Throughout last year, the world was confronted with irrefutable evidence that children are a woefully neglected and underserved population in the fight against HIV/AIDS. A UNAIDS report released in July revealed that only 43% of the 2.1 million children living with HIV have access to the lifesaving antiretroviral drugs (ARVs) they need. We also learned that up to two-thirds of HIV-positive children younger than 2 years are diagnosed too late, making them exceptionally vulnerable to infections that prey on weakened immune systems. Missing diagnoses during these early years can be fatal: without treatment, up to 30% of HIV-infected children die by their first birthday and half will not live to see their second. 2017 also saw the release of worrisome regional data: in December, UNAIDS and UNICEF released a report on the state of the epidemic in west and central Africa. In this region, the paediatric treatment rate is only 21%; fewer than half of pregnant and breastfeeding women are on medication to prevent transmission of the virus to their babies and improve their own health; and the number of new HIV infections among adolescents aged 15–19 years has not budged since 2010.

These figures, unacceptable as they are on their own, are mirrored by unconscionable paediatric death rates globally. Children under 15 represented 12% of AIDS-related deaths in 2016, despite making up only 5.7% of the global HIV-positive population. For children and adolescents aged 10–19, progress is intolerably slow: since 2010, AIDS-related deaths in this cohort have been reduced by a mere 5%, compared to a one-third reduction among the total population of people living with HIV over the same period.

Given these circumstances, it is no surprise that UNICEF closed out the year by sounding the alarm. Without “accelerated action”, the organization warned, the global health community will not meet its own 2020 targets for reducing new infections among youth, or its goal of providing HIV treatment to 2.4 million children and adolescents. Similarly, UNAIDS stressed that infection and mortality will remain high in west and central Africa “unless the HIV response… improves dramatically.”

International leaders agree that the global response to paediatric HIV/AIDS is insufficient, and that there is a strategic and moral imperative to better serve infants, children, and adolescents. The coming year holds promise that this consensus will be more than just rhetorical and will result in tangible improvements in the state of the epidemic.

For example, last November, the Vatican convened a meeting on scaling up early diagnosis and paediatric treatment. Representatives from, among others, the US President’s Emergency Plan for AIDS Relief, UNAIDS, WHO, Caritas Internationalis, and my organization, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), adopted a comprehensive action plan including solid, actionable commitments for 2018. Among these were detailed pledges by pharmaceutical companies and the US Food and Drug Administration (FDA) to accelerate development of child-friendly ARV formulations. Several drug manufacturers also promised to make paediatric formulations available in low-income countries for the cost of production until generics become available. These commitments will make it far easier—and more affordable—to improve ARV coverage for children this year and beyond.

As 2018 continues to unfold, we have reason to be cautiously optimistic about not just treatment options, but also expanded early infant diagnosis, which both UNICEF and UNAIDS identify as a crucial prerequisite for starting and keeping children on treatment. At the International Conference on AIDS and STIs in Africa (ICASA), held in Abidjan in early December, EGPAF and Unitaid presented promising results from a project that has brought point-of-care early infant diagnosis (POC EID) technology to nine countries. Unlike conventional testing, POC EID testing allows samples to be tested quickly, often at the same facility where they are collected—meaning caregivers can receive results when and where they bring children in for care. Under conventional testing, the median turnaround time for test results is 55 days, whereas POC EID results are delivered within hours. When caregivers receive results quickly, they are more likely to start HIV-positive children on treatment: 91.8% of children diagnosed through POC EID started treatment, compared to 70.0% of children diagnosed through conventional testing.

While commitments by international agencies and non-governmental organizations are important, it is leaders in the countries most burdened by HIV/AIDS whose actions could turn the tide as the year continues. Last December, over a dozen African countries sent Ministry of Health delegates and civil society representatives to attend a meeting at ICASA to build consensus around approaches for optimizing paediatric HIV treatment. This dialogue emphasized the “AIDS Free” component of Start Free. Stay Free. AIDS Free—a super-fast-track framework for ending paediatric AIDS that sets ambitious prevention and treatment targets for children, adolescents, and young women. At ICASA, participants endorsed detailed strategies for incentivizing and accelerating development and uptake of age-appropriate ARV formulations, as well as guidance to support introduction of POC EID. And earlier this week, the African Union and the Organisation of African First Ladies Against HIV/AIDS launched the Free to Shine campaign, which prioritizes action in ending paediatric AIDS and keeping mothers alive and healthy. As cultural leaders and role models, first ladies are uniquely capable of influencing the public’s knowledge of, attitudes about, and behaviours regarding HIV/AIDS. Using this considerable authority for the benefit of children demonstrates a sincere commitment to getting the paediatric HIV/AIDS response back on track, and we look forward to continued action on their part.

Recent steps towards improving paediatric ARV access and treatment, scaling up early infant diagnosis, and amplifying Africa-based advocacy are encouraging. If global leaders follow through on these key initiatives, we soon could—and should—usher in the first AIDS-free generation. Yet if we fail to deliver the necessary resources and political will, we may be facing another year of bad news for children. Let us learn from 2017 and, as we look ahead, approach the paediatric HIV agenda before us with the urgency it deserves and the tenacity it requires.

Originally published in The Lancet Global Health Blog.