Children with HIV are not simply small adults.
Their biology, their dependency on caregivers, and their relationship with health systems are all different. So when those systems break down, the consequences for children are uniquely severe.
Recently, the U.S. Department of State released program data for the final quarter of fiscal year 2025 for the President’s Emergency Plan for AIDS Relief (PEPFAR).
Every single indicator in the pediatric HIV cascade shows decline:
- HIV testing among children fell 34%, more than twice the adult decline.
- Children newly initiated on treatment fell 13%.
- Most starkly: the number of children currently on ART fell by 54,000, a 10% drop.
We do not yet know how many have died, how many have aged into adult care, or how many have simply fallen through gaps in systems that are no longer intact. And not knowing is a significant problem, one we cannot accept.
Pediatric treatment failure progresses rapidly and is often invisible until a child is severely ill. The PEPFAR data show that viral load testing (measuring the amount of HIV in a blood sample) among children fell 16%, and that 64,000 fewer children have documented viral suppression compared to the same time frame in the prior year.
Yet, among children who did receive a viral load test, the suppression rate improved to 90.2%. Where the program reaches children, it works. But the data tell us that far fewer are now being reached.
The U.S. government suggests that declines in pediatric treatment numbers are reflective of the success of programs to prevent mother-to-child transmission (PMTCT).
Though PMTCT progress is real, and EGPAF has been proud to be part of it, it does not explain such a dramatic and sudden drop of 54,000 children already on treatment. This, alongside simultaneous declines in testing, diagnosis, and viral load monitoring across all pediatric age groups, indicates that children are losing access to care.
A Foundation Built on Data
The latest data release covers just a single quarter, July through September 2025. PEPFAR’s historic practice has been to release data every quarter, enabling civil society, researchers, policymakers, and program implementers to track trends, identify gaps, and respond. A single quarter in isolation makes meaningful trend analysis nearly impossible.
From the outset, PEPFAR established a discipline of systematic data collection, reporting, and review that few global health initiatives have matched. The program separated results by age and sex, and distinguished between pediatric and adult performance so that the unique needs and vulnerabilities of children would never be obscured by aggregate numbers.
This level of detail has been transformative. When country teams, comprised of government ministries and implementing partners working side by side, convene to review quarterly data, they are not looking at a single headline figure. They are interrogating the cascade indicator by indicator, population by population: where are children being tested but not linked? Where are adults initiating treatment but not being retained? Where is viral load coverage falling behind?
That level of specificity turns data into a diagnostic tool, allowing teams to identify gaps precisely, target resources efficiently, and course-correct in real time rather than waiting for annual reviews or anecdotal evidence.
Where the program reaches children, it works. But the data tell us that far fewer are now being reached.
Dr. Doris macharia, president, elizabeth glaser pediatric aids foundation
An Informed Transition
As PEPFAR transitions to bilateral memoranda of understanding (MOUs) with partner country governments, the centralized data infrastructure that has formed the backbone of the program’s success is being replaced by national reporting systems with no comparable standardization. That means cross-country analysis will be impossible. It means early warning signals will go undetected. And it means that pediatric-specific declines that are already harder to see may disappear entirely.
The MOU transition is a structural change of historic significance. It is happening at a moment when the data show the program is already under stress, particularly for children. That transition must be anchored in what the data tell us. Complete quarterly, fully disaggregated data is necessary to inform the design of bilateral MOUs.
Making Sure Children are Seen
For more than three decades, EGPAF has advocated for the proposition that no child should be born with or die from HIV. We know that when children become invisible to the data, they become invisible to policy, to funding, and eventually to care.
A recent national poll found that 81% of voters across party lines support funding to help children in Africa orphaned and made vulnerable by AIDS. This makes clear that there is political will. What is needed now is the data transparency to act on it.
Ending pediatric HIV depends on more than effective treatment. It depends on the political will to see — and count — every child. Congress can ensure that happens by requiring full quarterly PEPFAR data releases across all indicators.
Children cannot be protected by systems that don’t see them.
