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Prior to the outbreak of Covid-19, efforts to dramatically decrease the number of new pediatric HIV infections and initiate children living with HIV on treatment had shown recent success. While this momentum confirmed for many that the long-held goal of eliminating HIV infections among children was, indeed, possible, it was clear that progress toward meeting ambitious global targets was decidedly off-track. In 2015, the “Start Free, Stay Free, AIDS Free” initiative, a joint effort between PEPFAR and the Joint United Nations Programme on HIV/AIDS (UNAIDS), had set bold goals of reducing new pediatric HIV infections per year to less than 40,000 by 2018 and to less than 20,000 by 2020. But in 2019, an estimated 150,000 children worldwide were newly infected, and just half of all HIV-infected children were on treatment.
By diverting funds and other resources away from critical health services, the Covid-19 pandemic is now putting the goal of eliminating and fully treating HIV in children even further out of reach. As the U.S. government, UNAIDS, and the Global Fund set new HIV-related goals and develop strategies to reach them over the next several years, it is not enough to talk about getting back on track with respect to pediatric HIV. Recognizing that Covid-19 threatens to undermine recent progress and make the goal of an AIDS-Free Generation even more elusive, the new administration, along with leadership at UNAIDS and the Global Fund, should elevate the prevention of HIV infections in infants and the early testing and initiation of treatment of all positive children to the highest level of importance. Prioritizing the scale-up of high-impact, cost-effective tools and integrating innovative program adaptations from the outbreak response should catalyze a bold new effort to prevent HIV infections in children and ensure those who are positive have access to effective treatments to enable them to live full and productive lives.
In March of 2020, the World Health Organization (WHO) declared the outbreak of Covid-19 to constitute a pandemic. As governments worldwide responded by mandating quarantines, closing non-essential businesses, and instituting social distancing measures, people avoided going to clinics and accessing social services out of fear of contracting the novel coronavirus within the healthcare setting. At the same time, economic contractions and the interruption of transportation routes and supply chains for essential health commodities have disrupted patients’ access to diagnostic and treatment services.
Yet well before Covid-19 hit, the global community was struggling to reach the goal of an AIDS-Free Generation, a concept first elaborated by Festus Mogae, the former president of Botswana, in 2008 and brought to the attention of U.S. policymakers by then-secretary of state Hillary Clinton in 2011. The year 2015 saw the launch of the “Start Free, Stay Free, AIDS Free” initiative, a joint effort between the President’s Emergency Plan for AIDS Relief (PEPFAR) and UNAIDS, which set bold goals of reducing new pediatric HIV infections per year to less than 40,000 by 2018 and to less than 20,000 by 2020. With attention focused on programs ensuring pregnant women living with HIV have access to antiretroviral therapies (ART), new HIV infections due to maternal to child transmission (MTCT) have been halved over the last 10 years. However, in 2019 alone, 150,000 children worldwide were newly infected with HIV reflecting persistent challenges in ensuring pregnant women and breastfeeding mothers are routinely tested and initiated on treatment if necessary.
The failure to reach global targets with respect to preventing new pediatric HIV infections is compounded by limited successes in testing children and enrolling HIV-positive children in treatment programs. Children under the age of 15 make up just 5 percent of all people living with HIV, but they account for 14 percent of all AIDS-related deaths. Children under the age of one are especially vulnerable to AIDS-related diseases. Without treatment, one-third of children living with HIV will die before their first birthdays and almost half by their second.
Early HIV diagnosis and the timely initiation of treatment could reduce AIDS-related deaths by 76 percent, but as of 2017, only 51 percent of HIV-exposed infants were tested within the first two months of life, as recommended. While many clinics use available rapid diagnostic tests to assess adults, these tests do not effectively detect HIV infection in infants under 18 months. Instead, a virological test must be used to detect the virus in infants accurately. Until recently, early infant diagnosis (EID) technologies required access to a laboratory, increasing the cost and training needed to complete the tests, as well as the turnaround time for getting results back to mothers. With delays in sending samples to the lab and in getting results back—and delivered to parents—one 2012 study from Malawi showed that just 60 percent of mothers in the study group had received the results of their child’s initial HIV test and only 58 percent of children with confirmed HIV infection were actually initiated on treatment.
One promising alternative to laboratory-based diagnostics for infants is point-of-care testing. Point-of-care diagnostic technology allows for shorter times for results, including same-day results, and requires less training for clinical staff to learn to administer. In 2015, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), with support from Unitaid, began working on a project to scale up the use of point-of-care tools to improve early diagnosis of HIV in infants. EGPAF has incorporated point-of-care diagnostic tools into existing country clinical networks in nine countries, resulting in an additional 123,902 children being tested and the rate of HIV-positive infants initiated on ART increasing by 25 percentage points. In 2018, the WHO updated its guidelines to recommend the use of point-of-care approaches. But despite evidence that the comparatively expensive point-of-care technology is cost-effective compared to laboratory-based tests –and that it improves survival and life expectancy– uptake of this technology by national AIDS programs has been slow, and most infant tests are still performed in laboratories.
In 2017, representatives of multilateral agencies, civil society and faith-based organizations, governments, research institutions, and companies developing pharmaceutical and diagnostic interventions met in Rome to commit to a set of activities designed to improve children’s access to HIV medications. Convened by the Vatican, the meeting built on previous international discussions organized by Caritas, UNAIDS, and PEPFAR to accelerate the adoption of new pediatric diagnostic tools and pharmaceutical interventions and resulted in the Rome Action Plan. Key priorities included ensuring pediatric formulations of HIV treatment regimens are registered and affordable, investigating innovative financial mechanisms such as advance purchase commitments, and supporting efforts to reduce stigma and discrimination faced by children living with HIV.
Thanks to these and other international efforts, the number and diversity of pediatric formulations of ART has increased in recent years. Child-friendly ART delivery methods, such as pellets, tablets, and syrups, make medications more palatable for younger populations, and guidance on appropriate dosing for pediatric patients has improved the safety of their delivery. But these formulations are more expensive than adult treatments, and without early diagnosis, many infants will not get the chance to start treatment. Indeed, just half of children living with HIV worldwide were on treatment in 2019.
The Covid-19 pandemic now threatens to undermine and roll back this fragile progress on pediatric HIV prevention, testing, and treatment. Although recent data suggests that the Covid pandemic has had less of a negative impact on HIV treatment access than some experts had originally projected, limited access to health facilities, disruptions to supply chains, and an increase in teenage pregnancies have all negatively impacted pediatric HIV treatment and prevention.
Many health facilities were closed down during the early months of the pandemic or were used as Covid sites, leading to a sharp decline in HIV testing and ART refills. In Kenya, testing volumes fell by 32.9 percent between March and April. In Nigeria, ART initiation declined 34 percent between March and April, and health officials noted a drop in ART refill rates, as well. Both countries have since seen a slow increase in uptake of testing and treatment, and UNAIDS reports that just five countries worldwide continued to experience decreases in ART between May and July.
Countries throughout Africa are reporting a rise in teenage pregnancies in part a consequence of strict lockdowns, increased vulnerability to sexual violence, and limited access to sexual and reproductive health services. HIV-positive adolescent girls in sub-Saharan Africa have been shown to have lower prevention of mother-to-child transmission (PMTCT) service uptake than adults and may transmit HIV to their infants at higher rates. This will almost certainly lead to more children born with HIV during a time of limited access to care, making it less likely those children would be identified early to access ART.
Now that many people have resumed accessing HIV services, national AIDS programs find themselves grappling with stark challenges to ART supply. More than 80 percent of generic antiretroviral medicine worldwide is produced in India. When India began a 21-day, country-wide lockdown in March, restrictions on manufacturing activities and transportation routes curtailed production and the shipments and procurement of raw materials. With the pediatric ART market already facing cost and supply chain challenges prior to Covid, it is conceivable that manufacturers will respond to production challenges by prioritizing the production of adult ART, for which there is greater worldwide demand, further widening the gap between adults and children in terms of access to medications.
Despite the obvious challenges posed by the pandemic for realizing progress toward pediatric HIV prevention and treatment goals, the Covid-19 crisis has offered some opportunities for improving children’s access to lifesaving commodities—when they are available. Whereas in the pre-Covid period, some health providers had been reluctant to offer patients multi-month dispensing of ART, concerns about requiring people to return to health facilities and risk exposure to Covid have led to the loosening of these restrictions. In April, PEPFAR updated its technical guidance to recommend dispensing three-month ART supplies to parents of children living with HIV. Better use has also been made of networks of people living with HIV who can both encourage mothers to take children to clinics for HIV testing and treatment and link families struggling under the pandemic with social services, such as food or cash support for housing or school fees. And given that widespread fears of visiting health clinics may have made some pregnant or breastfeeding women reluctant to seek testing, more programs have encouraged self-testing, a practice that has proven popular among adolescents, in particular.
Several key organizations focused on HIV prevention and treatment are in the process of formulating new multi-year strategies, offering opportunities to reinforce a focus on pediatric approaches. The 2017-2020 PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control emphasized the importance of ensuring adolescents in high-burden countries have access to HIV prevention messages and programs, but the strategy’s efforts to address HIV’s effects on younger children have tended to place greater emphasis on protecting orphans and other children made vulnerable because of the impact of HIV on their families than on testing and treatment initiation for HIV-infected infants. The development of the new PEPFAR strategy represents a critical opportunity for highlighting and reinforcing the United States’ commitment to testing and treating children living with HIV.
The 2016-2021 UNAIDS strategy, On the Fast-Track to end AIDS, notes that despite good progress between 2000 and 2014 in decreasing the number of children acquiring HIV each year, there was still “deplorably low treatment coverage for children living with HIV,” underscoring persistent challenges in effectively testing infants and initiating them on treatment. For 2020, Target 2 envisioned “Zero new HIV infections among children and mothers are alive and well.” The recent strategy has emphasized the importance of EID services for all children exposed to HIV and draws special attention to children’s experience of stigma and discrimination. Prioritizing continued progress towards eliminating HIV infections in children in the post-2021 period will help sustain global focus on the needs of this uniquely vulnerable population.
Planning is also underway for the Global Fund’s next phase of work, which will begin in 2023, with ongoing open consultations through the end of 2020 and a more formal process for soliciting input from policymakers and advocates during the first quarter of 2021. As a key donor to the Global Fund and member of the board, the United States can insist on greater attention to pediatric populations as it deliberates and approves the new strategy in the spring of 2021.
As these plans move ahead, along with the work of the World Bank and Global Fund-led Health Systems Connector of the ACT Accelerator, which is focused on strengthening countries’ laboratory, training, community engagement, and product distribution strategies, it will be important to ensure that pediatric HIV programs are integrated into pandemic response and preparedness activities. The diagnostic and treatment innovations associated with the global Covid-19 response, such as greater use of self-testing or reliance on telemedicine, can inform new approaches to pediatric HIV programs, as well.
As the U.S. government, multilateral organizations and public-private partnerships, and implementing agencies articulate new HIV/AIDS goals, targets, and strategies, reducing new pediatric infections and ensuring children living with HIV have access to appropriate treatments should be among the very highest priorities. Considering the immediate and likely longer-term social and economic impacts of the Covid-19 pandemic, activities in support of pediatric testing and treatment should emphasize efficiency and cost-effectiveness and ensure that pandemic response activities enhance rather than undermine HIV programs for children. These include:
While Covid-19 response activities have diverted funds and other resources away from many health services, several high-impact, cost-effective tools for diagnosing and treating pediatric HIV infections are available and should be scaled up. Innovative program adaptations from the Covid-era can suggest ways to improve the delivery of pediatric HIV services within the healthcare setting. The incoming administration should renew the United States’ commitment to pediatric HIV within the Covid-19 context and elevate the tasks of preventing and treating HIV infections in children to the top of its list of global health priorities.
Katherine E. Bliss is a senior fellow with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Margaret V. McCarten-Gibbs is a program manager for the CSIS Global Health Policy Center.
This commentary is part of a larger project on pediatric HIV, made possible by the generous support of ViiV Healthcare.
Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
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