Essajee S and Bains A Journal of the International AIDS Society 2023, 26:e26191

http://onlinelibrary.wiley.com/doi/10.1002/jia2.26191/full | https://doi.org/10.1002/jia2.26191

VIEWPOINT

Getting back on track to ending AIDS in children: it could just be

easier than you think
Shaffiq Essajee§, * and Anurita Bains*
§ Correspondingauthor: Shaffiq Essajee, UNICEF - HIV/AIDS, Health Programme Goup, 3, United Nations Plaza, New York, NY 10017, USA.
Tel: +1 212 326–7100. ([email protected])

Received 26 October 2023; Accepted 30 October 2023

Copyright © 2023 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.

The UNAIDS Global AIDS Strategy released in 2021 places erate progress. In 2022, the Global Alliance to end AIDS in
ending inequity as the top priority to end AIDS. It recog- Children by 2030—a partnership with governments, networks
nizes the importance of a rights-based approach to address of people living with HIV, UNICEF, WHO, UNAIDS, the Global
the needs of populations that have long been neglected in Fund, PEPFAR and key implementers—was launched at the
the global AIDS response [1]. Among all people living with International AIDS Conference in Montreal. Six months later,
HIV, children and adolescents have faced perhaps the great- the inaugural 12 countries* reaffirmed their shared commit-
est inequities in terms of access to treatment and care. ment to reach the goal of ending AIDS in children in the Dar
By the end of 2022, only 57% of children living with HIV es Salaam Declaration for Action [3]. The Global Alliance is
worldwide were accessing antiretroviral therapy (ART). For bringing much-needed attention and visibility to the forgot-
adolescents, treatment coverage was below 60% in every ten population of children and adolescents living with HIV.
region except for Eastern and Southern Africa. By contrast At the national level, governments have convened relevant
among adults, treatment coverage was much higher at 77% stakeholders to develop Alliance Action Plans to end AIDS
[2]. Globally, an estimated 700,000 children (0–14 years) and in children, including identifying the technical and financial
400,000 adolescents (15–19 years) living with HIV were not resources needed to implement them. These plans mirror the
on ART in 2022. Across the cascade of care, from testing four pillars of the Alliance’s work: (1) identifying and treat-
to treatment to viral suppression, children fared worse than ing undiagnosed children and adolescents; (2) going “the last
adults (Table 1). mile” to eliminate vertical transmission of HIV to children; (3)
The equity gap between adults and children has persisted preventing incident HIV in adolescent girls and young women
since the start of the epidemic. Children with AIDS-like ill- who are pregnant or breastfeeding; and (4) addressing the
nesses were first reported in the literature almost 40 years stubborn structural barriers that hinder access to services.
ago, signalling that AIDS was not linked to toxins or environ- All four pillars are essential elements of a sustainable
mental factors but caused by an infectious agent that could and comprehensive response to end AIDS in children by
pass from mother to child. And yet, at almost every mile- 2030, and for each of them, Alliance partners have defined
marker along the course of the AIDS response, children and evidence-based interventions for national implementation.
adolescents have lagged behind adults. Lifesaving drug reg- Among these are three strategies that if implemented at scale,
imens were not approved for children for years after they could quickly close the gaps between adults and children
were in widespread use among adults. Unlike HIV services for across the treatment cascade of testing, treatment and viral
adults, treatment for children living with HIV continues to be suppression and jumpstart progress towards the goal of end-
centralized even in high HIV burden countries. And in most ing AIDS in children by 2030.
parts of the world, adults can readily access free, confidential,
while-you-wait HIV testing, but this is not true for children Strategy 1
and adolescents. HIV-exposed infants need specialized diag- The first gap is the low number of children who know their
nostic assays which are often not available or take months to status. Scale up of HIV testing for children and adolescents
process. While older children and adolescents can be tested should include virologic testing of HIV-exposed infants as well
using standard rapid tests, they depend on their caregivers to as serologic testing of older children and adolescents who
request testing and provide consent. The widening treatment may have been missed by infant Angola testing programmes.
gap has had dire consequences. Children aged 0–14 years One of the most promising ways to do this is through family-
contribute a full 13% of all deaths due to AIDS despite rep- based index testing. This approach involves inviting adults liv-
resenting only 4% of all people living with HIV [2]. ing with HIV who are enrolled in care to test their children—
Focusing on children and adolescents living with HIV either in facilities or in their homes or community. Several
requires dedicated resources and tailored strategies to accel- studies have shown that family-based index testing is well

1
 17582652, 2023, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/jia2.26191 by Nat Prov Indonesia, Wiley Online Library on [28/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Essajee S and Bains A Journal of the International AIDS Society 2023, 26:e26191
http://onlinelibrary.wiley.com/doi/10.1002/jia2.26191/full | https://doi.org/10.1002/jia2.26191

Table 1. The treatment cascade among adults and children liv- dren living with HIV continue to widen across the treatment
ing with HIV in 2022 [2] cascade. The reasons for this are complex but the solutions
do not have to be. A concerted effort is needed now so that
Adults aged Children aged every child living with HIV has access to diagnosis and high-
15+ years 0–14 years quality treatment and care. Global cooperation, and targeted
action by donors, implementers and national partners are key
Proportion who know they are 87%a 63%a to ending the inequities and ultimately ending AIDS for future
living with HIV generations.
Proportion receiving ART 77%a 57%a
Proportion virally suppressed 72%a 46%a E N D N OT E S
Abbreviation: ART, antiretroviral therapy. * Angola, Cameroun, Cote-d’Ivoire, Democratic Republic of
a Percentages represent those who know their status/on ART/virally
Congo, Kenya, Mozambique, Nigeria, South Africa, Tanzania,
suppressed relative to all people living with HIV by age group.
Uganda, Zambia and Zimbabwe.
†
Unpublished data provided courtesy of UNICEF Tanzania.
accepted and results in a high “positivity” rate—even in low
prevalence settings [4, 5]. In 2022, a UNICEF-led family-
based index testing initiative in just two districts in Tanzania A U T H O R S ’ A F F I L I AT I O N S
found 120 new cases of children living with HIV out of 866 HIV/AIDS, Health Programme Group, UNICEF, New York, USA
children tested—a yield of almost 14%.† Expanded models of
family-based index testing to include children whose parent(s) COMPETING INTERESTS
may have died of AIDS-related causes could help to ensure
The authors declare that they have no competing interests.
that additional undiagnosed HIV cases are identified, and chil-
dren and adolescents are linked to treatment, care and sup-
port. AUTHORS’ CONTRIBUTIONS
Strategy 2 The authors have contributed equally to the development of this Viewpoint.
Linking all newly diagnosed children to treatment is essen-
tial to address the second gap in the treatment cascade—
ACKNOWLEDGEMENTS
the low numbers of children and adolescents living with HIV
who are on ART. One important advantage of testing chil- The authors acknowledge the valuable contribution of UNICEF staff including
Chibwe Lamba and Ruslan Malyuta.
dren in a family where other individuals are living with HIV
is that parents and caregivers are more likely to ensure that
children with a positive test are brought to care. In settings FUNDING
where paediatric HIV services remain centralized, national No donor or other funds were used in the writing and research for this Viewpoint.
programmes should harness community systems to ensure
that families receive the support they need to initiate children
DISCLAIMER
on timely treatment following a positive diagnosis.
The views expressed in this Viewpoint are the opinions of the authors.
Strategy 3
To address the final gap of poor rates of viral suppression
among children, outdated paediatric treatment regimens must REFERENCES
urgently be replaced with optimized therapy for all children. 1. Global AIDS Strategy 2021–2026: End Inequalities End AIDS. Geneva:
The approval of generic child-friendly dolutegravir (DTG) in UNAIDS; 2021. https://www.unaids.org/sites/default/files/media_asset/global-
AIDS-strategy-2021-2026_en.pdf
both single-drug tablets and more recently fixed-dose combi-
2. The path that ends AIDS: UNAIDS Global AIDS Update 2023. UNAIDS; 2023.
nations is a significant breakthrough that could transform pae- https://www.unaids.org/sites/default/files/media_asset/2023-unaids-global-aids-
diatric outcomes. To date, 89 countries are procuring paedi- update_en.pdf
atric DTG, and it is estimated that 62% of children on ART are 3. The Dar es Salaam Declaration for Action to end AIDS in Children. https://www.
receiving DTG-containing regimens. This estimate is based on unaids.org/en/topic/alliance-children/dar-es-salaam-declaration
4. Gross J, Medley A, Rivadeneira E, Battey K, Srivastava M, Grillo M, et al. Consid-
data from 17 countries which together represent two-thirds erations to improve pediatric HIV testing and close the treatment gap in 16 African
of the global population of children on ART [6, 7]. Coverage of countries. Pediatr Infect Dis J. 2023;42:110–18.
paediatric DTG has almost doubled since 2021 but is still far 5. Mugo C, Wang J, Begnel ER, Njuguna IN, Maleche-Obimbo E, Inwani I, et al.
short of adult DTG coverage which is in excess of 90%. DTG- Home- and clinic-based pediatric HIV index case testing in Kenya: uptake, HIV
prevalence, linkage to care, and missed opportunities. J Acquir Immune Defic
containing regimens are clinically superior, present a higher
Syndr. 2020;85(5):535–42.
genetic barrier to resistance and have fewer side effects than 6. Medicines Patent Pool. Access to medicines tracker: Interactive map.
other treatment options. Rapidly transitioning all children on https://medicinespatentpool.org/progress-achievements/access-to-medicines-
ART to these regimens would significantly improve paediatric tracker#Interactive-Map. Accessed 6 Nov 2023.
treatment outcomes and rates of viral suppression. 7. HIV Market Report 2023: The state of the HIV market in low- and
middle-income countries. Clinton Health Access Initiative. Available at:
https://www.clintonhealthaccess.org/report/2023-hiv-market-report-the-state-
In conclusion, while we have made considerable progress in
of-hiv-market-in-low-and-middle-income-countries/
preventing HIV in children, the gaps between adults and chil-