Priority Actions for Children and Adolescents living with & affected by HIV

Introduction

The global response for children and adolescents living with HIV has been gravely inadequate and that all of the paediatric targets set by the 2016 High Level Meeting (HLM) were missed and are well off-track. UNAIDS recently acknowledged that the gap between the treatment coverage rate for children (53%) and adult treatment coverage 68% “represents nothing less than a global failure…”[1]. Critically UNAIDS states in its new global strategy that “without a voice in the response, they [children] have an unequal opportunity to call for solutions to their needs”[2]. To make matters worse COVID-19 has created an unprecedented disruption in HIV services for children and families and threatened decades of progress made in reducing vertical transmission and improving access to paediatric testing and treatment. The High Level Meeting (HLM) in June 2021 will provide global leaders with an opportunity to set new targets and agree priority actions that can rapidly address this situation for children and adolescents living with HIV, particularly in sub-Saharan Africa. This policy brief outlines the targets and priority actions that must be included in the Political Declaration.

RIATT-ESA recommendations for the Political Declaration

The Political Declaration must agree new and ambitious targets for children, adolescents living with HIV and as a minimum should support the targets and priority actions included in the UNAIDS Global AIDS Strategy 2021-2026 related to ending AIDS in children (Annex 1). RIATT-ESA is calling for strong commitments to be made in the Political Declaration on four key issues:

1. Prevention of Vertical Transmission

Despite high PMTCT coverage in many countries, new infections in children persist with many infections occurring during the breastfeeding period. New paediatric HIV infections are on the rise in several African countries, jeopardizing the gains made towards eliminating paediatric AIDS. Progress has been uneven across geographic regions and sub-populations. For example, 43% of incident infections among pregnant and breastfeeding women occur among adolescent girls and young women, age 15-24, indicating a need more tailored services for this already vulnerable population.

Greater emphasis on comprehensive HIV prevention during pregnancy and breastfeeding is needed, including access to PrEP and other new prevention technologies. Per WHO guidelines, pregnant women need be tested for HIV multiple times during pregnancy, and women who test positive for HIV should immediately initiate ART for their own health and the health of the child. Increasing access to viral load testing for pregnant and breastfeeding mothers living with HIV is another important step for countries to take to ensure the health of the mother and potentially reduce vertical transmission.

RIATT-ESA is calling for the Political Declaration to commit to:

Urgently intensify tailored prevention service delivery for pregnant and breastfeeding women while they remain at risk of HIV, including increased utilization of PrEP and new prevention technologies.
Implement repeat HIV testing during pregnancy and breastfeeding per guidelines to identify women newly infected for rapid intervention with HIV treatment and prevention of vertical transmission.
Provide all pregnant and breastfeeding women living with HIV optimized treatment regiments that allow women to quickly achieve and sustain viral load suppression.
Scale-up use of point-of-care viral load testing among pregnant and breastfeeding women to enable faster action in response to poor viral load results.
Utilize differentiated and community-led services that meet the needs of women of reproductive age in all their diversity, including tailored PMTCT service delivery to meet the needs of the most vulnerable pregnant populations, such as pregnant key populations and adolescent girls and young women.
Address stigma, discrimination and unequal gender norms that prevent pregnant and breastfeeding women, especially adolescent girls, young women and key populations, from accessing HIV testing, prevention and treatment services for themselves and their children through differentiated support services.
Target adolescents and young people with a complete package of combination HIV prevention services that is tailored to their evolving needs and is integrated with comprehensive sexuality education (both in and out of school), and with sexual and reproductive health (including contraception) and rights for people of reproductive potential, and with HIV treatment and care.

2. Paediatric HIV Testing and Treatment

In 2019, 1.8 million children (aged 0-14 years) were living with HIV globally. Of these, 1.2 million i.e. 67% of these children were living in Eastern and Southern Africa (ESA). In 2019 there were 74,000 children newly infected with HIV in ESA and there were also 46,000 deaths due to AIDS among children aged 0-14 years in ESA. Treatment coverage for children in ESA is also still deplorably low at 58% compared with 72% coverage for adults and viral load suppression for children improved only very slowly at best. The urgency for ensuring that all children exposed to HIV are tested and those living with HIV are initiated on HIV treatment within 6 weeks of birth, is because peak mortality occurs at 6-8 weeks and without treatment 50% will die before they reach 2 years of age.

The excessive number of children living with HIV but not receiving treatment stems primarily from two testing gaps: (1) low coverage of early infant diagnostic (EID) services; and (2) the lack of testing options for older children who are missed by EID efforts, especially children who acquire HIV during breastfeeding. In 2019 in the ESA region only 40% (8/20) of countries had > 70% Early Infant Diagnosis (EID) coverage with HIV-exposed infants receiving a diagnostic test within the first 2 months of birth as recommended. Point-of-care (PoC) early infant diagnosis can reduce delays in sharing results, significantly decreasing the time before antiretroviral therapy is initiated (from a median of nearly two months to the same day) and significantly increasing the proportion of infants initiating therapy, as well as being cost-effective compared with laboratory-based testing. Index family–based testing is a high-yield and efficient strategy for identifying the children of adults living with HIV and initiating antiretroviral therapy. Offering HIV testing to all children living in the household of an adult living with HIV can identify children living with HIV who have been missed through earlier testing modalities.

Children living with HIV must navigate multiple transitions, including the transition from paediatric to adolescent care and then from adolescent to adult services. There is a need for innovations and child-centred support to facilitate smooth transitions, ensure continuity of care and tailor support as children grow older and develop.

RIATT-ESA is calling for the Political Declaration to commit to:

i. Ambitious testing and treatment targets:

a. 95% of HIV-exposed children are tested by two months of age and again after cessation of breastfeeding

b. At least 95% of infants tested for HIV receive their test results no later than 15 days after blood sample collection

c. At least 95% of infants diagnosed with HIV infection initiate ART no later than 15 days after receiving their test results

d. 85% of all CLHIV on ART have suppressed VL by 2023 and 95% by 2025

ii. Scale-up point-of-care EID early infant diagnostic testing starting with the hard-to-reach areas.

iii. Scale-up efforts to actively track mother-baby pairs using a digital register of positive results.

iv. Commit to greater use of family-based index testing and use of HIV oral tests for children 2-11 years of age.

v. Prioritize the rapid introduction and scale-up of access to the latest WHO recommended, optimized, child-friendly HIV treatment in order to achieve sustained viral load suppression

vi. Prioritise viral load and toxicity monitoring and provision of comprehensive packages of care transitioning for those children and adolescents who present with advanced HIV disease, disabilities or mental health issues.

3. Childhood TB and HIV

Tuberculosis (TB) is a major contributor to morbidity and mortality in children living with HIV (CLHIV), particularly in TB endemic settings, such as sub-Saharan Africa. Children under 15 years old account for around 11% of the 10 million tuberculosis (TB) cases globally. However, only about half of these 1.1 million children were diagnosed. When treated, children with TB rarely die, but under-detection is the major reason why 250,000 children died from TB in 2018. TB preventive therapy (TPT) is a proven and effective intervention, particularly in young children, but it remains underutilised. Only 27% of the 1.3 million eligible children under 5 years old received TPT in 2018[3].

For children and adolescents living with HIV, TB is the most common opportunistic infection and those with severe immune suppression have a 5-fold higher risk of TB compared to children with mild immune suppression[4]. Globally in 2019, 47% of the HIV-positive people who died from TB were men, 36% were women and 17% were children[5].

RIATT-ESA is calling for the 2021 Political Declaration to commit to:

Strengthen TB services for children and adults living with HIV and to ensure that all PLHIV who are on ART have access to adequate and client-friendly TB diagnostics, treatment, including treatment of drug-resistant TB, prevention, and care, so that 90% of PLHIV & CLHIV who are affected by TB are receiving treatment for both conditions by 2022.
Promote integrated TB/HIV at all levels, emphasising the scale up of family approaches to TB preventive treatment to achieve 100% TPT coverage for children, adolescents and adults, including HIV-negative household contacts of PLHIV; and have fully transitioned to short-course TPT regimens based on rifapentine and rifampicin.
Scale-up innovative approaches for diagnosis of children - including for example use of non-sputum biomarker-based samples such as stool, urine - while also investing in research and development.
Prioritise the implementation of the targets agreed at the UNGA 2018 High Level Meeting on TB, including those relevant to the diagnosis, prevention and treatment of child and adolescent TB.

4. COVID-19 and the response to children living with HIV

The COVID-19 pandemic has had a major impact on both government expenditure and on service delivery of HIV services and these are important elements that must be taken account in the Political Declaration. First, COVID-19 has had a severe negative economic impact on many economies which in turn has significantly reduced public health and social development expenditures. Public debt was rising prior to COVID-19 in many sub-Saharan countries and this has been exacerbated by the pandemic. A drop in economic activities and remittances have also translated into lower government revenues. With the pressure to service debt, some governments may opt to reduce spending on social development and public health, including paediatric HIV testing and treatment.

Second, the COVID-19 pandemic has exacerbated access services to paediatric testing and treatment in several ways: by limiting access to facility-based services; redirecting services to COVID-19 use; creating stock-outs of lab commodities and drugs, increasing the turnaround time for Early Infant Diagnosis and by decreasing treatment initiation. However, the pandemic has resulted in innovations in service delivery that should continue such as: the use of digital health tools and improved uninterrupted supply with multi-month ART prescriptions, as well as shifting testing services to community-based services and self-testing services for adolescents and male partners of pregnant women.

RIATT-ESA is calling for the 2021 Political Declaration to commit to:

i. Mobilize the political leadership and global solidarity needed to secure the resources needed to get the response on-track to end AIDS as a public health threat and to realize the right to health

ii. Maintain and increase donor funding, including for addressing the root causes of inequalities through community-led responses, particularly for low-income countries with limited fiscal ability, and for key population- and community-led responses, including in middle- and upper-middle income countries

iii. Recognise the importance of ring-fencing resources for paediatric HIV and AIDS response in order to sustain the gains achieved so far

iv. Promote the continuation and scale-up of promising interventions developed during the pandemic after COVID-19, including: multi-month dispensing of ARVs, shifting testing services to community-based services, prioritising HIV self-testing, telemedicine and strengthening virtual support groups.

Annex 1: End Inequalities. End AIDS. Global AIDS Strategy 2021-2026

The following targets and priority actions relate to ending AIDS in children and adolescents are included in the Global AIDS Strategy: https://www.unaids.org/en/resources/documents/2021/2021-2026-global-AIDS-strategy

Paediatric HIV Testing and Treatment

2025 High Level Targets:

· 95–95–95 testing and treatment targets are achieved within all subpopulations, age groups and geographic settings, including children living with HIV.

· 95% of HIV-exposed children are tested by 2025.

· 75% of all children living with HIV have suppressed viral loads by 2023 (interim target) 

Early Infant Diagnosis:

· 95% of HIV-exposed children are tested at two months and after the cessation of breastfeeding

· 95% of HIV-exposed infants receive a virologic test and parents are provided with the results by age 2 months

· 95% of HIV-exposed infants receive a virologic test and parents are provided with the results after cessation of breastfeeding

The Global AIDS Strategy includes the following priority action on early infant diagnosis and paediatric and adolescent treatment:

· Implement innovative tools and strategies to find and diagnose all children living with HIV, including point-of-care early infant diagnostic platforms for HIV-exposed infants and rights-based index, family and household testing and self-testing to find older children and adolescents living with HIV not on treatment.

· Prioritize rapid introduction and scale-up of access to the latest WHO-recommended, optimized, child-friendly HIV treatment and achieve sustained viral load suppression.

· Support transitioning of children through adolescence to adult care and address their complex, multiple and changing needs, including peer adherence counselling and psychosocial support.

Prevention of Vertical Transmission

2025 high level and disaggregated targets:

· 95% of pregnant and breastfeeding women living with HIV have suppressed viral loads:

· 90% of women living with HIV on antiretroviral therapy before their current pregnancy All pregnant women living with HIV are diagnosed and on antiretroviral therapy, and 95% achieve viral suppression before delivery

· All breastfeeding women living with HIV are diagnosed and on antiretroviral therapy, and 95% achieve viral suppression (to be measured at 6–12 months)

· 95% of pregnant women are tested for HIV, syphilis and hepatitis B surface antigen at least once and as early as possible. In settings with high HIV burdens, pregnant and breastfeeding women with unknown HIV status or who previously tested HIV-negative should be retested during late pregnancy (third trimester) and in the post-partum period

· 95% of pregnant women have access to maternal and newborn care that integrates or links to comprehensive HIV services, including for prevention of the triple vertical transmission of HIV, syphilis and hepatitis B virus

Priority Actions for Adolescents and Young People

· Scale up the meaningful engagement and leadership of young people in all HIV-related processes and decision-making spaces.

· Accelerate investments in youth leadership (particularly adolescent girls and young women and young key populations), capacity building and skills development at all levels in all aspects of the HIV response.

· Foster solutions and partnerships between youth-led organizations and governments, private sector, faith-based organizations, and other traditional and non-traditional partners to ensure sustainable investment in financing of programmes for young people.

· Strengthen access to high-quality, gender-responsive, age-appropriate comprehensive sexuality education programmes, both in school and out of school, particularly for adolescent girls and young women and young key populations in settings with high HIV incidence.

· Support policies and programmes focused on increasing the enrolment and retention in secondary schools for adolescent girls and young key populations in high-incidence locations, and provide linkages to social protection, “cash plus” initiatives, financial incentives, pathways to employment, and interventions to transform unequal gender norms and prevention of violence against adolescent girls and young women.

· Remove legal and policy barriers, including age-of-consent laws and policies, for adolescents and youth to access HIV services, and ensure access to other health and social services, including sexual and reproductive health services, condoms and other contraceptives, and commodities and wider health and social services relating to young people’s wellbeing.

· Redesign HIV services to meet the needs of young people and ensure adolescents and young people (particularly adolescent girls and young women and young key populations in settings with high HIV incidence) can access a full range of youth-centred and -led HIV services that

· holistically address their needs, including other health, protection and social services.