Good progress, but situation remains grave for children
Africa is of particular concern, reveals Jeffrey O’Malley, UNICEF director of Data and Policy.
We seem to be getting the impression that we’re on a winning streak when it comes to fighting HIV in Africa. Will this be continuing in the future?
The number of people accessing life-saving drugs for HIV has increased — about 18.2 million people now around the world. So, there is a sense that we are near the end of AIDS as a public health threat. But for children and adolescents, the situation remains grave.
Only half of children living with HIV are accessing treatment today. And those who are on treatment are starting around age 4, which is very late. Without treatment, half of the children living with HIV will die before their second birthday.
Political commitment to fighting AIDS has weakened, and coupled with a lack of sustained funding — in fact, we have seen very deep cuts to AIDS funding just this past year — it’s a dangerous mix. AIDS is one of the leading causes of death for adolescents worldwide. And prevention efforts among adolescents are having limited impact. Adolescent girls remain vulnerable, accounting for three out of four new infections among adolescents aged 15-19 in sub-Saharan Africa, which bears serious implications for future generations.
The situation in Africa is of particular concern. Trends show that the total population of adolescents will more than double across the continent by 2060. If the rate of new HIV infections in this age group were to remain at 2015 levels, the increasing number of adolescents would mean an increasing number of adolescents becoming newly infected with HIV. The number of new HIV infections would increase from 250 000 annually in 2015, to 280 000 annually by 2020, and then to 390 000 annually by 2030. This could result in as many as 740 000 additional adolescents infected with HIV between 2016 and 2030.
What interventions have been the most effective for children against HIV?
HIV treatment is increasingly effective, affordable and available, and this has had a great impact on children. Globally, the number of children aged 14 and under on antiretroviral treatment doubled in the past five years, resulting in a 44% decrease in the number of AIDS-related deaths among children. People on effective treatment almost never transmit HIV to others. Advances in medicine have made other significant contributions to prevention as well. For example, prevention of mother-to-child transmission of HIV has most certainly been one of the most effective interventions in the global response, with 1.6 million infections averted since 2000. The scale-up of prevention of mother-to-child transmission programmes has been impressive indeed. And as an example of that, in 2009, the likelihood that a pregnant woman with HIV would transmit the virus to her child was about 22% in sub-Saharan Africa. In 2015, this was cut to about 9%.
Other powerful tools include medical male circumcision and pre-exposure prophylaxis, or PrEP, which we hope will curb HIV infection rates among sexually active adolescents who are at substantial risk of infection.
But advances in medical treatment have by no means replaced the need for action on other factors involved in the spread of HIV, such as social, economic or behavioural factors. We know that by reducing stigma around HIV we help encourage demand for and adherence to HIV testing, treatment and PrEP. Social protection for the poor, in particular small cash transfers, have a powerful impact on reducing HIV-related risk among adolescent girls. So have programmes to keep adolescent girls in school. And condom promotion remains important.
Will the same strategies continue to be as important in the next 20 years?
Simply put, yes, but this means we must continue to do more and not be complacent. Escalating numbers of people living with HIV and an increasing youth population in need of HIV prevention services will stress existing health, education and protection systems, all of which are necessary components of the HIV response. For already overwhelmed systems, strategies for building resilience and sustainability are more important than ever before.
Strategies that will continue to be important include simplifying treatment, for example. We have been able to bring the number of pills down to one a day, what is known as Option B+ for pregnant and breastfeeding women. Integrating HIV, TB, malaria, pneumonia and diarrhoea care with child health services creates synergies and efficiency in service delivery. For adolescent girls and women, HIV prevention services should be integrated with sexual and reproductive health services.
We must continue to decentralise services to the most hard-to-reach communities in the coming years. And, often solutions for decentralisation require innovations. Diagnostic technologies such as point-of-care deliver results within hours of testing and enable patients to access life-saving treatment in the quickest time possible.
Last but not least, we must continue to spread respect for human rights. Human rights issues, particularly stigma and discrimination, inequality and violence against women and girls, denial of sexual and reproductive health and rights, the use of punitive laws that discriminate against key populations and forced testing remain among the main barriers to effective HIV responses all around the world.
What will it take to end HIV in children?
Global commitments with targets and resources. We saw how this has worked with the Global Plan. Since its rollout, HIV programmes have expanded, services are better integrated, new ways of delivering those services have been introduced and antiretroviral treatment to keep children safe from HIV and maintain maternal health have improved.
The new Start Free, Stay Free, AIDS Free framework is even more ambitious in its goals to stop new infections in children, ensure access to life-saving treatment, and halt the cycle of new infections among adolescents.
Ending AIDS will require that we address the social and economic factors that continue to fuel the epidemic. Poverty, food insecurity, drug and alcohol use, social marginalisation, exclusion, stigma, inequity, gender inequality, violence and sexual exploitation all increase risk and decrease resilience in vulnerable populations. Social protection and the protection, care and support of children must underpin all efforts to scale up high-impact interventions through the first two decades of life.
Ending AIDS in children is within sight. With strong political commitment and adequate resources, we can continue to achieve dramatic change.