Over the past five years, there has been a rapid scale-up of services to prevent mother-to-child transmission of HIV. This has reduced the annual number of new infections among children by 50% worldwide since 2010. Globally, an estimated 77% of pregnant or breastfeeding women living with HIV were receiving antiretroviral medicines to prevent transmission of HIV to their children in 2015, up from 50% in 2010.
Antiretroviral medicines have averted 1.6 million new infections among children since 2000. There has also been a dramatic reduction in AIDS-related paediatric deaths. In the 21 priority countries that were the focus of the Global Plan towards the elimination of new HIV infections among children and keeping their mothers alive (Global Plan), AIDS-related mortality among children under 15 years of age dropped by 53% between 2009 and 2015. In countries such as Botswana, Burundi, Namibia, South Africa and Swaziland, even greater reductions, above 65%, were achieved.
However, this welcome news is tempered by some complex remaining challenges. In 2015, there were 1.8 million children under 15 years of age living with HIV worldwide. An additional 150 000 children acquired HIV globally in 2015 (2800 a week), and 110 000 children died of AIDS-related causes (300 a day). In some high-burden countries, such as Angola, Chad and Nigeria, less than half the pregnant or breastfeeding women living with HIV are receiving antiretroviral medicines.
Programmes to help women avoid HIV infection remain underdeveloped and fragile, leading to 900 000 new HIV infections among women over the age of 15 years in 2015. They joined the 17.8 million women already living with HIV, and when they decide to have children they will need services to prevent transmission to their children and maintain their own health. Programmes to help women living with HIV avoid unintended pregnancies also remain inadequate: a recent study in Kenya found that despite improvements in coverage of family planning, women living with HIV were more likely to have experienced an unintended pregnancy than other women.
The World Health Organization (WHO) now recommends treating everyone living with HIV, but it is also essential to maintain good adherence to antiretroviral medicines in order to ensure their efficacy. Good adherence suppresses viral load to undetectable levels, greatly reducing onward transmission to the baby while restoring the mother’s immune system for better health. However, many women gradually stop taking the medicines after the baby is born, increasing the risk of transmission during breastfeeding and placing their own health in jeopardy. In Malawi, a study showed that a third of 7500 pregnant or breastfeeding women did not adhere to antiretroviral therapy adequately, compromising the benefits of treatment and increasing their risk of developing drug resistance.
Access to diagnosis and treatment among children has improved, but much remains to be done. Among the 21 Global Plan priority countries, only half the children exposed to HIV received virological testing within two months of birth, as recommended by WHO. Since mortality among untreated infants is highest in the first three months of life, prompt diagnosis and linkage to treatment are crucial. Yet only half the children under 15 living with HIV in those countries were accessing treatment, compared to 80% of pregnant women living with the infection. This signals service delivery failure for children.
In order to address the unfinished agenda of the Global Plan, UNAIDS and the United States President’s Emergency Plan for AIDS Relief have launched a follow-up initiative known as Start Free, Stay Free, AIDS Free. With the goal of ending paediatric AIDS, this framework embraces the aspiration that every child should be born and remain HIV-free (start free), every adolescent and young woman should be able to protect themselves from HIV (stay free) and every child and adolescent living with HIV should have access to quality HIV treatment, care and support (AIDS-free).
Start Free, Stay Free, AIDS Free includes the targets endorsed in the 2016 United Nations Political Declaration on Ending AIDS of 95% of pregnant and breastfeeding women accessing antiretroviral medicines, reducing new HIV infections among children to 40 000 and 1.8 million children living with HIV accessing HIV treatment by 2018. It also aims to reduce new HIV infections among adolescents to under 100 000 and for 1.5 million adolescents to be on HIV treatment by 2020.
Start Free, Stay Free, AIDS Free promotes concerted and coordinated country-led action designed to close the remaining HIV prevention and treatment gap for children, adolescent women and expectant mothers. Its success will depend on tailor-made acceleration and implementation plans to respond to the country context, building on successful strategies to strengthen systems where necessary and identifying critical opportunities and actions to expand access to life-saving HIV treatment and prevention services. To support implementation, the framework also calls on industry, civil society and international partners to focus on investing in efficient and cost-effective solutions that maximize programme outcomes.
Like the Global Plan, Start Free, Stay Free, AIDS Free places women living with HIV at the centre of the response.
