Forty years after the first AIDS cases were reported, the harsh reality is that deep inequalities continue to exist in the global response to HIV and AIDS, with gaps in rights and services preventing real progress.
And while it is painful to admit, one of the most overlooked segments of the population has been children.
As the “End Inequalities, End AIDS” strategy proposed by the Joint United Nations Program on HIV and AIDS (UNAIDS) makes clear, “One of the most glaring disparities in the HIV response is the failure to meet the needs of children living with or at risk of HIV.”
The final progress report on the “Start Free, Stay Free, AIDS Free” initiative just released by our organizations, UNAIDS (B.W.), and the Elizabeth Glaser Pediatric AIDS Foundation (C.L.), and partners, offers a grim look at HIV and children. Approximately 1.7 million children are currently living with HIV. Every week nearly 2,000 of them die and 5,900 children and adolescents are newly infected with the virus. Only 54% of children living with HIV have access to the treatment that will save their lives. Although children accounted for just 5% of people living with HIV in 2020, they represented 15% of all AIDS-related deaths. Almost 90% of all children living with HIV globally are located in Africa.
Without a voice in the response, children have an unequal opportunity to call for solutions to their needs. Covid-19 has further intensified existing inequities, diverting funds and other resources away from critical health services.
Yet even before Covid-19 took hold, the picture was troubling. New pediatric HIV infections were on the rise in a handful of African countries, pediatric treatment coverage had stalled, and the global community had failed to identify and reach almost half of the children living with HIV. None of the “Start Free, Stay Free, AIDS Free” targets set for 2020 were achieved and were, in fact, missed by a wide margin.
World leaders gathered in June for the UN High-Level Meeting on HIV and AIDS to chart the future course of the global AIDS response. As leaders of organizations committed to ending HIV and AIDS, we were encouraged by the inclusion of a new global pledge in the resulting political declaration to eliminate transmission of HIV from mother to child and to end pediatric AIDS by 2025.
Commitments are meaningless without action. As global, national, and community leaders move to develop an action framework, we call upon them to intensify efforts for children in real and meaningful ways, catalyzing momentum to achieve the first AIDS-free generation, with specific focus in four key areas:
Find the children. Improving efforts to “find” and diagnose children of all ages living with HIV is an essential gateway to increasing the number of children accessing medicine and ensuring viral load suppression. The effectiveness of point-of-care early infant diagnosis is a well-documented game changer, yet adoption and scale-up of this strategy is stalled and must be scaled up in countries around the world.
Help children access lifesaving treatment. Without treatment, one of every two babies with HIV will die before their second birthday. Children living with HIV require age-appropriate, effective, and accessible formulations. Yet children in low- and middle-income countries often wait years to access the same medications as adults, eroding their health, or even resulting in preventable deaths. The development and uptake of optimal, child-friendly HIV treatment lag far behind such work in adults, leading to poorer health outcomes for the youngest patients. Recent UNAIDS data indicate that 800,000 children living with HIV went without medication in 2020, a deeply concerning reversal of recent progress. Rapid transition to better pediatric formulations, in combination with improved HIV diagnosis for children is desperately needed.
Focus on prevention. Mother-to-child transmission rates of HIV have been cut in half over the past decade. But that success has plateaued in troubling ways. Ending mother-to-child transmission requires HIV testing and support for adolescent girls and young women that includes prevention of unintended pregnancies and intensified primary prevention efforts for both pregnant and breastfeeding women — including pre-exposure prophylaxis (PrEP) — as the global community seeks to advance President Biden’s call to “restore a government-wide focus on lifting up women and girls around the world.”
Address structural barriers for women at the community level. A range of socioeconomic and structural factors that include unequal power dynamics and gender norms, gender-based violence, poverty, stigma, and discrimination undermine the ability of many women to access and remain engaged clinical services and psychosocial support. Women’s needs must be at the center of every effort. Stakeholders must recognize the obstacles to drug adherence or consistent clinic visits and respond with improved options and community-level support.
To end AIDS in children, governments, civil society, and other stakeholders must act with urgency, following up the political declaration with concrete action to match its aspiration. That means providing resources and services to protect the unique rights, needs, and perspectives of children and young women — and doing so with a clear focus on human rights and equity.
Ending pediatric AIDS is both ambitious and achievable. Let us make 2021 another turning point in the history of ending AIDS — and in the process, create the first AIDS-free generation.
Winnie Byanyima is the executive director of UNAIDS and under-secretary-general of the United Nations. Chip Lyons is the CEO of the Elizabeth Glaser Pediatric AIDS Foundation.