he latest global report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) includes much to celebrate. But it also demonstrates how far we still must go to protect the millions of children living with HIV.
First, the good news. Today, more than half of all people living with HIV are accessing the treatment they need to survive. A handful of countries and several major cities have already met the 90-90-90 targets. That means 90 percent of people living with HIV know their status; of those, 90 percent are getting treatment; and of those on treatment, 90 percent have achieved viral suppression — meaning the virus is undetectable in the bloodstream.
As UNAIDS executive director Michel Sidibé wrote in the forward to the new UNAIDS report, when the 90-90-90 targets were announced three years ago, “many people thought they were impossible to reach. Today, the story is very different.”
Yet amid victorious declarations that “the scales have tipped” in a positive direction in the fight against HIV, the report highlighted several major areas in which they haven’t — and ways in which they may even be tipping the wrong way.
Several of these shortcomings affect a chronically underserved population: infants and children. While there has been tremendous progress in recent years toward preventing mother-to-child transmission of HIV, the report shows that global access to antiretroviral therapy (ART) for women with HIV who are pregnant or breastfeeding is plateauing at around 75 percent. That’s well below the level needed to eliminate infections before and soon after birth.
A substantial number of children infected with HIV as infants are not brought for treatment until they reach adolescence, at which point many already suffer from HIV-related health problems. These include infectious diseases such as tuberculosis and malaria, which take advantage of weakened immune systems.
Perhaps the most glaring problem in this year’s report is the slowing scale-up of pediatric treatment.
When it comes to accessing lifesaving ART, children are being left behind. While more than half of people living with HIV are now on treatment, that rate is far lower for children: globally, only 43 percent of infants and children up to age 14 with HIV were on ART in 2016. Even more troubling, the initiation of ART treatment among children is slowing, with 10 percent increases in previous years now down to a 6 percent increase last year. This deceleration puts the global target of 1.6 million children on ART by 2018 dangerously out of reach.
Another heartbreaking revelation is that up to two-thirds of children under age 2 who are infected with HIV are diagnosed after the two-month testing window recommended by the World Health Organization. That means they don’t begin treatment until their immune systems are severely compromised, putting them at high risk of dying. Without treatment, up to 30 percent of HIV-infected children die by their first birthday; 50 percent die by their second birthday.
Progress toward enhanced early diagnosis is “limited,” according to the UNAIDS report. In 21 countries where HIV rates are particularly high, the percentage of infants exposed to HIV in utero or through breastfeeding who underwent testing within two months of birth actually dropped for the first time since the 90-90-90 targets were announced.
These worrisome trends reflect the inadequate attention that children have traditionally received in the global response to HIV/AIDS.
The problems documented in “Ending AIDS: progress towards the 90–90–90 targets” — from the stalling progress of preventing mother-to-child transmission of HIV to the lethargic expansion of pediatric treatment — spurred UNAIDS and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to launch a new framework last year to galvanize the fight to end AIDS in children. Start Free, Stay Free, AIDS Free sets ambitious targets for eliminating new infections among infants throughout pregnancy, birth, and breastfeeding; for preventing new infections among adolescents and young women; and for protecting HIV-positive children from developing AIDS by providing lifelong treatment.
Yet such goals are unlikely to be met largely because they have not received the relentless action and urgency they require from political and policy leaders. These important objectives need the stewards of the global AIDS response to press for creative ways to test children and adolescents and initiate treatment in those who are HIV-positive, a course of action that is yet to be taken up.
We cannot be truly satisfied with our victories against HIV/AIDS when we are failing the most vulnerable among us.
Reversing these shortfalls will require hard work and innovative approaches. At the recently concluded International AIDS Society Conference on HIV Science, my organization, the Elizabeth Glaser Pediatric AIDS Foundation, shared early results from a project funded by Unitaid that aims to scale up early infant diagnosis in nine countries by introducing on-site testing machines at key health facilities. These machines, otherwise known as point-of-care early infant diagnosis devices, differ from traditional testing, which requires patients’ blood samples to be collected at one site and transported, often over great distances, to facilities with testing capabilities.
The early indicators from this project were promising: The percentage of results returned to the parent or guardian of children who were tested increased from 77.4 percent under conventional testing to 99.6 percent under point-of-care testing. The median turnaround from the time a blood sample was taken to when a caregiver was given the results dropped from 53 days to 0 days — meaning results were delivered on the same day as the test was administered. Under this dramatically improved and accelerated system for diagnosis, children are much more likely to be put on treatment at the critical early stage of disease progression.
To get back on track to meet its goals pertaining to children, the global health community will need to tap into other new strategies. Index testing, which targets family members and partners of people living with HIV, is one strategy that could promote testing among at-risk individuals who might otherwise be unaware of the need. Equipping providers to suggest testing to patients receiving non-HIV services — such as nutrition assistance and immunizations — is another promising means to increase testing rates. Decentralized or community-based systems for identifying, testing, treating, and counseling children and caregivers may also help accelerate progress against pediatric HIV.
There’s no question that the global community has made great strides in preventing new HIV infections among children. But we must also safeguard the lives of those 2.1 million children who are already living with the virus. To keep the promises that have been made to the world’s HIV-positive youth and their parents, we need to redouble our commitment to game-changing strategies for them. Until that promise is kept, claims that the “scales have tipped” ring hollow for children worldwide.
Charles Lyons is the president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation, the world’s leading organization committed to the global elimination of pediatric HIV and AIDS.