Treating HIV in sub-Saharan Africa: Closing the gap on life-saving care for mothers and children

In sub-Saharan Africa, the number of pregnant women living with HIV receiving antiretroviral therapy (ART) has almost tripled over the last decade. But children living with HIV are being left behind. How can we do a better job providing the life-saving interventions they need and reaching every woman and child?

Since 2010, we have seen great success in the prevention of mother-to-child transmission (PMTCT) of HIV across the globe. The World Health Organization’s 2012 global guidelines on ART and their ambitious target to put all HIV-positive mothers on triple antiretroviral drugs for life have played a critical role. Today, almost 100 per cent of regimens used for PMTCT use this approach, known as Option B+, compared to only 36 per cent prior to 2012. But statistics show that children are not benefiting at the same rate, a situation particularly pronounced in sub-Saharan Africa.

 

Results for children

In sub-Saharan Africa, ART coverage among pregnant women has climbed 70 percentage points since 2010, compared to just 34 percentage points for children aged 0–14 years over the same period. Of the world’s 2.8 million children and adolescents aged 0–19 years living with HIV in 2018, 9 of 10 were in sub-Saharan Africa. Only half of sub-Saharan children aged 0–14 living with HIV receive treatment. This gap in treatment requires urgent attention from ministries of health and global partners to ensure these children live the healthy, long lives they deserve.

Figure 1 below – based on statistics developed by UNAIDS, UNICEF and WHO – illustrates how children in the region are being left behind in the HIV response. These data demonstrate the vital – and necessary – opportunity for the global health community to close this gap and ensure mothers and children alike are reaping the rewards of lifelong ART.

 

 

Though the data show a steady increase over time in paediatric ART coverage, as shown in Figure 2, the pace of increase is far slower than for mothers and still far behind reaching universal coverage. The good news is that the number of children living with HIV is on the decline – this is partly due to global wins in ART coverage levels among pregnant women, which is reducing mother-to-child transmission. But as the number of children infected with HIV during pregnancy, childbirth or breastfeeding decreases, case detection of the remaining cases becomes more challenging. Efforts to test all children at risk must be redoubled and prevent unnecessary hardship and loss of life due to the virus.

Meeting our vision

Children living with HIV must be reached with timely diagnosis and life-saving treatment before their disease progression worsens or they pass the virus onto others. Without adequate testing and treatment for HIV, the prospect of an AIDS-free generation by 2030, as set by Sustainable Development Goal 3, Target 3.3, is unattainable. At the current slow rate of performance, we already know that the 2020 target set by the Joint Programme for HIV/AIDS for paediatric HIV treatment will not be met. As 2020 dawns, we face the challenge ¬– and opportunity – of achieving the 2030 Agenda’s vision over the next decade.

To treat these children, we must find them. Detection is relatively easy for children below 18 months, since many mothers receive post-partum care for up to six weeks, and many children return for immunization and check-ups after that. Children continue to interface with the health system for different services, especially immunization and growth monitoring, until age 5. Case finding after that age is one of the most significant challenges in the global HIV response for children, which is why it is a key focus of the new paediatric service delivery framework developed by UNICEF and partners.

If countries are to eliminate paediatric HIV infections occurring during pregnancy, birth and breastfeeding, no HIV-positive pregnant woman can be left behind. This goal is why UNICEF and partners are outlining guidance to go the “last mile” towards elimination of mother-to-child HIV transmission.

 

A closer look at progress

We must do more to implement a more equitable HIV response for women and children in sub-Saharan Africa. Progress in increasing maternal ART coverage in the region has stagnated over the last three years, hovering around 80 per cent. This slower progress is concerning given the 2020 Super-Fast-Track Framework target of 95 per cent. Of concern is the sub-regional variation in coverage levels, ranging from 5 per cent to over 95 per cent. For example, PMTCT coverage has reached 92 per cent in Eastern and Southern Africa, but only 59 per cent in West and Central Africa. Similarly, 61 per cent of children in Eastern and Southern Africa receive treatment compared to just 28 per cent of children in West and Central Africa. Furthermore, only 29 per cent of HIV-exposed infants in West and Central Africa receive a timely diagnosis after birth.

 

The way forward

UNICEF supports various proven activities to improve paediatric case finding and enrol children living with HIV on life-saving treatment. Several key interventions have been tested and shown to improve HIV case finding and treatment access in both younger children and adolescents:

  • Family-centred testing: By testing families as a whole, we can identify children living with HIV who have not yet been diagnosed and link them to care.
  • Point-of-care testing: testing at the time and place of patient care allows for early diagnosis of HIV-exposed infants and ART to be initiated immediately.
  • Peer support: When those who are living with HIV and receiving ART can offer social support to others living with HIV, health-seeking behaviours improve, and people feel empowered to make choices about their health care. This can increase demand for HIV services and improve access to treatment programmes.
  • Targeted community outreach: By reaching the right people – especially those who are highly vulnerable or hard to reach – we can increase entry points to HIV services for children older than 5. These efforts might include establishing drop-in centres for adolescents or child health days to bring medical check-ups to the community.

 

It’s time to look at the data – and take action to make a difference for children in sub-Saharan Africa and close the HIV treatment gap.

 

 

 

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