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Putting Children at The Center of the end of AIDS

The Lancet Global Health | January 15, 2016

Children in Zimbabwe. CREDIT: DFID (CC).

This article was written by Charles Lyons, president and chief executive officer of the Elizabeth Glaser Pediatric AIDS Foundation. It was originally published on October 2014.

In the 15 years since the Millennium Development Goals were adopted, the number of people accessing antiretroviral therapy (ART) for HIV/AIDS has dramatically increased, from less than 1 million people to 12.9 million in 2013. Despite the global effort to scale up treatment, children have largely been left behind. The consequences of this failure to act are grim: only one quarter of the 3.2 million children living with HIV were able to access treatment in 2013, and today, like every day, more than 500 children will die of AIDS. Quite simply, the global community has failed to adequately address and prioritize pediatric HIV treatment around the world.

This failure undermines efforts to tackle this disease and makes the global goal of ending the AIDS epidemic by 2030 effectively impossible. The challenges to reaching children with these life-saving services are numerous. Children born to HIV-positive mothers are often not tested for HIV, and those that are may still not be initiated on treatment. It is well established that without early HIV diagnosis and ART, half of all children living with HIV die by the age of two years, and 80 percent will die before their 5th birthday. Yet studies show that the average age of children initiating treatment hovers around four and a half years of age.

Stigma, lack of health workers trained in pediatric care, and long walks to clinics compound these challenges and raise barriers between children and lifesaving treatment. Additionally, children don't just need any treatment, they need therapeutics specifically tailored for their unique needs. There are limited drugs available for children today; new pediatric-specific formulations and medications are desperately needed. Many medications currently approved for children come in bitter-tasting liquids or large, hard-to-swallow pills, making children less likely to start taking them and to take them consistently.

Putting children at the center

Much like the epidemic at large, ending AIDS in children will not be accomplished if business continues as usual. Real change demands the rapid scale up of pediatric treatment initiatives and programs, including improvements for diagnosing children with HIV, developing new child-friendly drugs and drug formulations, increasing effective communication modalities, and creating new models for providing treatment services closer to where children live. We also need leadership and advocacy that puts pediatric HIV at the forefront of global conversations and decisions.

During 2014 there has been renewed interest in addressing this inequity and increasing international recognition of pediatric treatment as a high priority, as seen through ambitious target setting, pointed investments, and a focus on treatment innovation.

At the AIDS2014 conference in Melbourne, UNAIDS unveiled aggressive new treatment targets for children and adults. Known as 90/90/90, these targets call for 90 percent of all people living with HIV to know their status, 90 percent of all people diagnosed with HIV to be receiving ART, and 90 percent of all people on ART to achieve viral suppression. All of these are set to be met by 2020. The Elizabeth Glaser Pediatric AIDS Foundation is collaborating with UNAIDS, UNICEF, and the World Health Organization (WHO) on an action agenda around 90/90/90 targets, specifically for children, and on national-level efforts to integrate HIV and maternal, neonatal, and child health (MNCH) platforms in order to improve health services for HIV-infected and HIV-exposed children.

August 2014 saw the launch of the Accelerating Children's HIV/AIDS Treatment initiative during the Obama Administration's U.S.-Africa Leaders' Summit. This new partnership between the U.S. President's Emergency Plan for AIDS Relief and the Children's Investment Fund Foundation aims to double the number of children receiving ART in ten high-burden, priority countries during the next 2 years.

And in the spring of 2014, UNITAID, in partnership with non-profit organizations Drugs for Neglected Diseases initiative (DNDi) and Medicines Patent Pool (MPP) launched their new Pediatric HIV Treatment Initiative, with the goal of overcoming barriers to the development and distribution of pediatric drug formulations and combinations.

These initiatives and targets represent the kind of prioritization, investment, and recognition that pediatric HIV treatment needs. But to truly address the existing inequity, more must be done at a global scale.

The importance of ambition and prioritization

As the Millennium Development Goals expire at the end of 2015, discussions that will determine the final form of the Sustainable Development Goals and define the post-2015 development agenda are entering an important phase at the UN.

Whilst current proposals for the post-2015 framework do not include a stand-alone goal on HIV, there is strong international support for including ‘ending AIDS by 2030' under an overall health goal. Ending AIDS is an ambitious target, and ending AIDS in children is one of the most crucial components of achieving that target. Therefore the global community must embrace a more proactive approach to ending pediatric AIDS.

It is no longer acceptable for adult-focused HIV service delivery platforms to be the only way we find and care for HIV-infected children. In areas with a high burden of HIV, pediatric HIV testing and treatment services need to be available at key entry points where children are accessing health services, including maternal and child health clinics, outpatient clinics, and malnutrition centers.

Today, complacency is a very real enemy to our efforts to combat the HIV/AIDS epidemic. Too often, we encounter the sentiment that, with the incredible advances in treatment and prevention, the end of AIDS is all but inevitable, a simple matter of the passage of time. This could not be further from the truth.

Ending AIDS in children will require an even bigger global commitment in the years to come than ever before. Without investment now, the challenges will only grow more difficult and the obstacles harder to surmount. We must have the ambition to rise to meet this challenge, until no child has AIDS.

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