Getting children on HIV treatment – the failure of the Global Plan
Ending paediatric AIDS is now within our reach thanks to the mass scale-up of prevention of mother-to-child transmission (PMTCT) services. However, the treatment needs for children already living with HIV must be urgently addressed.
Launched in 2011 by UNAIDS and the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the ‘Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive’ (Global Plan), accelerated the HIV response across 21 priority countries in sub-Saharan Africa – where, at the time, 90% of all HIV positive pregnant women lived.
Under the Global Plan, new HIV infections among children fell by 60% in these 21 countries, with six priority countries achieving a reduction of 75% or more. More than 2 million pregnant women were also started on antiretroviral treatment (ART).
In an analysis led by the World Health Organization’s Dr Martina Penazzato and published in the journal, AIDS, Penazzato praised the Global Plan for having “created the political environment to catalyse both the resources and commitment to end paediatric AIDS.”
The analysis attributed these catalysing effects on the mass scale-up of PMTCT services. However, the report finds that for children already living with HIV, improvements in access to treatment has been less robust. This has resulted in a clear divide between treatment coverage for mothers and treatment coverage for their children.
Despite this, the report highlights several countries such as Rwanda, South Africa and Uganda that have made significant progress in scaling up early infant diagnosis and increasing the proportion of infants and children under the age of two years who are on treatment.
It highlights decentralisation, in the form of task shifting and the integration of paediatric ART into other child health programmes, which was successfully implemented in countries including South Africa, Swaziland Zimbabwe and Tanzania.
Yet still, only half of children living with HIV in the 21 priority countries received HIV treatment in 2015, compared to 74% of pregnant women. This is the result of a lack of emphasis on testing outside of PMTCT services, an overall lack of integration and coordination with other services, a lack of training among providers, low confidence in caring for children living with HIV, and a lack of appropriate formulations for paediatric antiretroviral drugs (ARVs).
The widening gap between adult and paediatric treatment coverage was most notable in West and Central Africa. While countries such as Botswana and Namibia had been able to initiate half or more children living with HIV on ART, progress was slower in Cameroon, Chad, and Nigeria, the latter of which accounts for 37% of all new global paediatric infections every year.
Additionally, while the age at which children with HIV initiate treatment has improved under the Global Plan, falling from five years to 3.8 years, children are continuing to die from AIDS-related illnesses because they are not being identified and treated early enough.
The report urges “accelerated action” to ensure that HIV diagnosis and linkage to treatment for children happens as quickly and effectively as possible. It praises a number of initiatives stemming from the Global Plan that seek to do this, such as the Accelerating Children's HIV/AIDS Treatment initiative. This US$ 200 million programme is being implemented in Cameroon, the Democratic Republic of Congo, Kenya, Lesotho, Malawi, Mozambique, the United Republic of Tanzania, Zambia, and Zimbabwe to enable an additional 300,000 children to receive ART.
Researchers identify key lessons from the Global Plan which they say should inform future strategies on paediatric HIV and AIDS, namely: “that simplification is essential to successful decentralisation, integration, and task shifting of services; that innovations require careful planning; that the family is an important unit for delivering HIV care and treatment services.”
It proposes a number of actions now the Global Plan has ended. Crucially, it identifies the lack of age-appropriate paediatric ARV formulations as a key barrier to starting and retaining children on ART. With few market incentives existing to meet the needs of children, the report urges renewed political action to tackle this issue.
The authors also call for services to adapt to a new epidemic context in which children living with HIV are ageing into adolescence and identifies the “pressing need” to obtain better age-disaggregated data in order to inform age-appropriate programme planning, commodities forecasting and treatment targets.