Treating Pediatric Patients With HIV: We Can Still Do Better

In this issue of Pediatrics, Rosen et al¹  quantify the increased treatment coverage for children with HIV and the corresponding decreased mortality rates using data obtained from 91 different countries over an 11-year period before and after the adoption of the “Treat All” approach. The policy shift to a Treat All approach occurred in 2015, making all patients eligible for antiretroviral therapy (ART) once they were diagnosed with HIV without the need for CD4 T-lymphocyte–based clinical staging.

At the International AIDS Conference held in South Africa in 2000, an 11-year-old boy stood before a packed auditorium, disclosed his diagnosis of AIDS, and challenged governments to start providing therapy to pregnant women with HIV to prevent the transmission of the virus to their infants.²  Since that time, we have made significant progress in the reduction of new pediatric infections in many high-burden areas such as Botswana. In 2021, Botswana became the first high-burden country in the world to be certified by the World Health Organization for being on the Path to Elimination, having brought their mother-to-child transmission rate to <5%, providing antenatal care and ART to >90% of pregnant women, and achieving an HIV case rate of <500 per 100 000 live births.³  Even though Botswana has shown that elimination of mother-to-child transmission is possible, it is but one small win in a battle we are losing.

In the 4 decades since the HIV pandemic began, millions of HIV infections and deaths have been averted because of prevention of mother-to-child transmission, as well as increasing access to ART for children. Yet, we are still missing the global targets set to establish an AIDS-free generation. The Joint United Nations Programme on HIV/AIDS (UNAIDS) adopted a target of having 90% of people living with HIV on ART by the end of 2020 and 95% by 2030 in an attempt to end the AIDS epidemic. Of the nearly 1.7 million children (aged 0–14 years) living with HIV globally in 2021, only 52% were receiving ART, leaving ∼800 000 without treatment and that is not counting the 160 000 new infections acquired that year.⁴  This stands in contrast to the 81% of pregnant women and 76% of adults who are receiving ART. This treatment gap between adults and children has continued to grow since 2010. In addition, children accounted for 15% of all AIDS-related deaths in 2021, despite the fact that only 4% of the total number of people living with HIV are children.⁴ 

In the summer of 2022, because of data such as these, a new strategic initiative named the Global Alliance to End AIDS in Children was announced, with a goal of ending AIDS in children by 2030. This program, which is co-led by UNAIDS, the World Health Organization, and the United Nations Children’s Fund, also includes the Global Fund, the US President's Emergency Plan for AIDS Relief, communities of people living with HIV, civil society, and other nongovernmental organizations.²  The inaugural 12 countries with high HIV burdens leading this initiative met for the first time in February 2023, where they developed and unanimously endorsed the Dar es Salaam Declaration for Action to End AIDS in Children.⁵  The focus is placed on the following 4 pillars: (1) early testing and optimal treatment, (2) eliminating vertical transmission, (3) preventing new HIV infections among pregnant and breastfeeding women, and (4) addressing the social and structural barriers that hinder access to services.

In the current study, Rosen et al¹  provide data showing a marked increase in ART coverage (16%–54%) and substantial declines in mortality over the 11-year period (240 000–99 000) in the 91-country cohort. Unfortunately treating all positive patients, instead of using CD4 T-lymphocyte–based criteria, did not accelerate ART coverage, nor decrease mortality in the pre- versus postimplementation period.¹  There were marked differences between geographic regions. The Asia-Pacific region had the largest increase in treatment (23%–81%), whereas West and Central Africa had the smallest increase (7%–35%). Also, a bit of a surprise was to see that after the Treat All was implemented in these countries, the rate at which ART coverage increased actually slowed by 6% and the rate at which mortality declined also slowed by 8% when compared with preimplementation levels. These are certainly disturbing trends.

The authors discuss possible reasons for these results, which include interventions being made by many high-burden countries to increase ART coverage in children even before Treat All adoption. But their last point is probably the most important. In many areas of the world, children at risk are hard to identify and reach with HIV testing/treatment services, especially if they are not living with their biological parents. Therefore, additional efforts are needed to optimize case-finding and enhance linkage to care and treatment to close the gaps in pediatric ART coverage and AIDS mortality. Although the authors highlight reasons the conclusions from these data might be limited, the treatment and the mortality data are consistent with the UNAIDS data recently published.⁴ 

Four decades of this HIV pandemic is a career for many of us but only a blink of an eye in the world’s history, so we should feel good about where we are now, but it is hard to do that when there are still children dying needlessly in many parts of the world, including in our own country. The stigma associated with the disease and the politics involved continue to drive patients away from medical care. In addition, the full impact of the coronavirus disease 2019 pandemic on the identification, diagnosis, and treatment of children with HIV is unknown, but it would be safe to say that it has not gotten better. The data from Rosen et al show us that, despite our significant progress, we have plenty of areas where we can improve; but even as we continue to do so, more infections will occur, and more children will die, and that is what is so frustrating and unnecessary. Now is not the time to slow down because of waning political will and HIV fatigue; now is the time to push for global equity in health care for children so that we can save future generations of children and families.

ART

antiretroviral therapy

UNAIDS

Joint United Nations Programme on HIV/AIDS