Towards a Transformative and Disruptive Action to Accelerate Efforts to End HIV in Children, Adolescents, and Families

An AIDS -free generation is not only possible; it is a human rights imperative, and it is achievable with leadership and strategic interventions.

But we are concerned that after years of highlighting the unique needs of pregnant women, children, and adolescents, momentum towards this goal has slowed dramatically.

Today, 1.8 million children live with HIV. New pediatric HIV infections are on the rise in a handful of countries, jeopardizing the gains made towards eliminating pediatric AIDS. Pediatric treatment coverage has stalled, and we have failed to identify and reach almost half of the children living with HIV. Although there has been global progress, none of the targets set out for 2018 or 2020 have been reached.

UNAIDS’ past and current strategies mobilized leadership, built initiatives, and scaled up innovations to respond to HIV among children and adolescents. However, instead of using 2020 to charge towards achievement of the fast track targets for children and youth, our pace has slowed and our resolve has weakened. We need UNAIDS political advocacy to prioritize children and pregnant women; increase the sense of urgency; and mobilize global, country, and local leadership to achieve an AIDS-free generation.

UNAIDS is in the process of developing the next Global AIDS Strategy beyond 2021. This Strategy will set a vision for the HIV response for the coming years. We must ensure maternal and pediatric HIV remain high on the global agenda, and that new leadership emerges to achieve an AIDS-free generation by 2025. In this context, EGPAF, together with PATA and Aidsfonds, co-hosted a global virtual focus group discussion to inform the UNAIDS Strategy beyond 2021 on issues related to maternal and pediatric HIV.

We need transformative and disruptive action to accelerate efforts to end HIV in children, adolescents, and families now, with no further delay. This was the main message of an impassioned, rich, and informative discussion, with more than forty experts and leaders from the global, country, and local contexts. Some of the key messages that resonated at the end of the three-hour dialogue include:

1.) UNAIDS must build a strong HIV response that fully leans into the needs of pregnant women, children, and young women.

This needs to come hand-in-hand with stronger leadership. The next strategy needs more relevant targets at the regional and country level, and to re-think our metrics to ensure our data are actually helping to inform our programs. We have to move from PMTCT to viral suppression in pregnant and breastfeeding women, from a focus on all women to a focus on young women and key populations, from EID to final outcome testing of exposed children, and from child ART coverage to viral load suppression among children.

2.) Ensure a person- and rights-centered approach to maternal and pediatric HIV.

Evidence shows when women and their newborns receive person-centered and supportive services, including adherence support provided by trained, equipped HIV-positive “mentor mothers” who are paid a living wage for their work, they and their children are more likely to be retained in care with good clinical outcomes. We need to question whether we are focusing on the right models of care. To achieve better health outcomes, we need to support differentiated service delivery models that adapt to the reality in which people live. This needs to be accompanied by a more strategic approach to the unique, specific needs of school aged-children, pre-teens, and adolescents.

3.) Accelerate integration.

It is happening at a very slow pace and in very limited settings. Strengthening the linkages between HIV/AIDS and other health services, such as sexual and reproductive health care, antenatal care, tuberculosis, cervical cancer, nutrition, triple elimination, and immunization programs is absolutely essential. We must explore opportunities to move faster towards integration of services: better coordination between the different disease programs; innovative financing mechanisms for combining disease responses; adoption of innovations to support strengthening of linkages, such as routine use of dual rapid diagnostic tests (RDTs) for HIV/syphilis; among others.

4.) Ensure a quicker introduction of innovative technologies like new pediatric formulations, point-of-care early infant diagnosis, and PrEP.

Increased investment and collaboration are needed to make sure that the pediatric formulations that come to market are optimized for pediatric patient use (e.g. dispersible, taste-masked, etc.). Some ground-breaking pediatric innovations that have been introduced, such as POC EID, have not been sustained due to insufficient funding. We also need bolder efforts to block HIV transmission during breastfeeding through access to repeated infant testing, PrEP for HIV negative pregnant and breastfeeding women, and quality treatment programs that support women to ensure retention in care with suppressed viral load for their health and the health of their families. Ensuring availability and affordability of quality treatments and diagnostics is critical to ensuring children and their mothers receive quality treatment, and are not only able to survive but to thrive. We are encouraged by interesting initiatives and collaborative partnerships, such as the Rome Action Plan, that support a multi-stakeholder approach to advocate for and coordinate rapid access to innovative treatment and diagnostics for children. We are also excited by the progress in long-acting injectable and multipurpose prevention technologies for HIV and family planning.

5.) The next strategy must emphasize prevention, both primary (e.g. PrEP) and secondary (e.g. safe conception) prevention for pregnant women.

Why is pediatric HIV falling out of the policy agenda? The 90-90-90 targets by definition exclude much of the prevention cascade, so we have to better integrate prevention tools within the cascade, through methods such extending the PMTCT cascade to ensure pregnant women who are HIV-negative are provided with prevention services such as PrEP throughout the pregnancy and breastfeeding period; and tailoring services–particularly PMTCT services–to specific sub-populations, such as pregnant AGYW, and pregnant key populations.

6.) Finally, we must continue to improve data collection and use, and accountability.

 It is vital that we are collecting and analyzing information that can help us better understand the current situation, improve our programs, and plan for the future, such as through data-driven Global Fund proposals. We must listen to what data countries and service providers need to improve their work. The UNAIDS stacked bar analysis is allowing us to improve every step of EMTCT programming. But we still do not see sufficient data disaggregated by age and other key factors. This disaggregation is essential for better understanding the nature of the epidemic. As age-disaggregated data are more commonly collected and data on vertical transmission are reviewed, we are getting a clearer picture of where the old ways of doing things are not working, and where we need to redouble our efforts. Age-disaggregated viral load suppression rates in children have illuminated issues around the quality of pediatric treatment service, not just the availability of those services.

We are convinced that with strong leadership, we will move towards the Endgame. The next strategy must lay out the foundation for a world free of pediatric HIV in 2025.

AMBITIOUS, VISIONARY, and EVIDENCE-BASED

UNAIDS Strategy beyond 2021 must remain AMBITIOUS to accelerate progress on pediatric HIV and improve the health of every child; must be VISIONARY to adapt the HIV response to the changing health and political context; and must be EVIDENCE-BASED to apply the most effective interventions for all age groups to finally end HIV in women, children, and youth–once and for all.