Abstract: In the 30 years of the AIDS pandemic, the devastating effects of HIV on infants and young children have often been overlooked and neglected. However, the ability to prevent mother-to-child transmission of HIV (PMTCT), or vertical transmission, has been one of the most significant prevention success stories in the global AIDS response. New HIV infections in children have been virtually eliminated in high-income countries and programmatic efforts have shifted to low-income and middle-income countries, particularly in sub-Saharan Africa, home to the vast majority of pediatric AIDS cases.
Over the past decade, the dramatic scale-up of PMTCT programs has saved millions of lives and has provided a foundation for HIV prevention and care and treatment programs that are integrated within maternal and child health services. Although some countries in sub-Saharan Africa are now approaching universal PMTCT coverage, global access to PMTCT for HIV-positive pregnant women remains at nearly 50%. Recently, a new global plan has focused efforts and resources to keep HIV-positive mothers healthy and to virtually eliminate new pediatric infections by 2015.
What programmatic and technical innovations will be necessary to overcome current service gaps and implementation barriers? How can countries continue the current momentum with sustainable locally-led programs that address the epidemic in women and children? And how can the vital perspectives of communities and people living with HIV help drive these efforts? Successfully addressing these and other issues will be key to ending HIV infections in children and creating an AIDS-free generation within the next decade.
*Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC
†Ministry of Health and Child Welfare, Harare, Zimbabwe.
‡ICAP at Columbia University, Mailman School of Public Health, New York, NY.
Correspondence to: Charles Lyons, BA, Elizabeth Glaser Pediatric AIDS Foundation, 1140 Connecticut Avenue, NW (Suite 200), Washington, DC 20036 (e-mail: email@example.com).
The author F.N.A. received travel support from the Elizabeth Glaser Pediatric AIDS Foundation to attend and present on a panel discussion at Harvard AIDS @ 30 Symposium.
All other authors have no funding or conflicts of interest to disclose.
After 30 years and 30 million deaths, the world is poised to realize one of the greatest prevention success stories in the response to the AIDS epidemic: the virtual elimination of new HIV infections in children worldwide. This dramatic development will be the result of more than 20 years of sustained research achievements and a decade of programmatic experience.
After studies in the 1990s demonstrated that antiretroviral drugs administered to pregnant women and their babies could dramatically reduce the risk of HIV transmission from mother to child,1 new pediatric HIV infections declined dramatically in the United States and other high-income countries.2 When simplified regimens for prevention of mother-to-child transmission of HIV (PMTCT) were also proven to be effective in resource-poor settings,3,4 the stage was set for eliminating pediatric AIDS.
More than a decade ago, organizations such as the Elizabeth Glaser Pediatric AIDS Foundation and ICAP at Columbia University initiated the first PMTCT programs in sub-Saharan Africa, home to the vast majority of new pediatric HIV cases.5,6 These early programs created the foundation for the large-scale prevention and treatment initiatives that would follow, primarily funded by the United States President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.7–9
After 10 years of unprecedented programmatic scale-up and a transition to more-efficacious PMTCT regimens, the results are substantial. In 2010, nearly 50% of HIV-positive pregnant women had access to PMTCT services, up from just 7% in 2004.10 Pediatric HIV infections resulting from transmission from mother to child (or vertical transmission) declined by 26% from 2001 to 2009.10 Still, half of women in need of PMTCT services remain unreached, and the results are consequential: 1000 new HIV infections in children every day and more than 3 million children living with HIV, most of them in sub-Saharan Africa. In 2010, an estimated 250,000 children under 15 died from AIDS-related causes—and these deaths could have been averted by access to PMTCT services, early infant diagnosis, and pediatric HIV treatment.10
In recent years, political and financial momentum has coalesced to focus attention on reducing the number of new pediatric infections to virtually zero. In 2011, an aggressive global plan was launched at the United Nations with the goal of eliminating new HIV infections in children by 2015.11 The Global Plan towards the Elimination of New HIV Infections among Children by 2015 and Keeping Their Mothers Alive was developed in collaboration with more than 30 countries, including all 22 of the countries with the highest burden of new pediatric HIV infections, and 50 community groups and nongovernmental and international organizations.12 A global steering group was created to implement the Global Plan and a business leadership council formed to help fund it, and a growing number of governments, partners, corporations, and donors have added their support.13
Although many of the components necessary to end pediatric AIDS are now in place, success is not assured. The next few years will be critical in determining whether the current momentum to achieve the ambitious goal of an AIDS-free generation continues or whether efforts will be stalled at the halfway mark.
IMPLEMENTING TECHNICAL AND PROGRAMMATIC INNOVATIONS
Although the development of an HIV vaccine is still a critical long-term goal to protect children and adults from the virus, successfully implementing the scientific tools that already exist could prevent the vast majority of new pediatric infections. The Global Plan has identified 4 approaches using existing interventions: reducing primary HIV infections in women by 50%, reducing unmet need for family planning among HIV-positive women to zero, reducing the risk of mother-to-child transmission to less than 5%, and providing antiretroviral therapy for 90% of eligible HIV-positive women.11
Rapid and successful implementation of the 2010 World Health Organization prevention and treatment guidelines for resource-poor settings would achieve many of the Global Plan's objectives. The guidelines emphasize that all women who are eligible for antiretroviral therapy should receive it to maintain their health and to reduce the high risk of transmitting HIV infection to their infants if they become pregnant. The guidelines also extend the use of antiretrovirals for PMTCT for a longer period during pregnancy and throughout the breastfeeding period and recommend infant and young child feeding practices that make breastfeeding safer.14,15
Although many countries have made considerable progress toward implementing the new guidelines, significant gaps remain. For example, HIV programs must continue rolling out more efficacious PMTCT regimens and identifying and treating women eligible for antiretroviral therapy. Overcoming implementation challenges necessitates an approach that adapts to local settings, strengthens overall health systems, increases workforce capacity, and integrates HIV/AIDS prevention and treatment with services for antenatal care and maternal and child health.
To virtually eliminate mother-to-child transmission of HIV, more than 90% of pregnant women and their infants must be reached with PMTCT services. Antenatal and maternal and child health settings—often the entry point into the health system for mothers and children—have become a platform for providing comprehensive HIV services. The programmatic trend has shifted from providing episodic acute care to providing a continuum of family-centered care and integrated services in these settings. Integration of HIV and PMTCT services can help both identify HIV-positive mothers as they enter the system and prevent infections that occur during pregnancy or breastfeeding. Integration of early infant HIV diagnosis and pediatric treatment services is also necessary to achieve a truly AIDS-free generation of children and young adults.
To ensure that women and children are retained in care throughout the full sequence of PMTCT and care and treatment activities, key barriers and factors contributing to loss to follow-up must be addressed, such as distance to clinics, stigma associated with HIV/AIDS services, and lack of male involvement in PMTCT. Increased operations research and analysis of program models will help target interventions to overcome implementation barriers, local service gaps, and impediments to coverage and retention.
SUPPORTING AND SUSTAINING NATIONAL EFFORTS
Some countries in sub-Saharan Africa, including Botswana and Namibia, have been highly successful in achieving universal PMTCT coverage. Other countries in the region are also now approaching this goal—among them, Lesotho, Rwanda, Swaziland, and Zimbabwe. What many of these countries share is strong leadership on the issue at the national level and a commitment to implementing policies favorable to expansion of high-quality comprehensive PMTCT services.
Zimbabwe realized this progress in a very short time, providing hope that countries can achieve universal coverage by 2015. In 2009, PMTCT access for HIV-positive pregnant women in Zimbabwe was just 59%. Within 1 year, it had increased to 84%.16 Zimbabwe's National PMTCT Partnership Forum, led by the Ministry of Health and Child Welfare's PMTCT program, has brought together multilateral and bilateral agencies, implementing partners, and civil society to deliver integrated PMTCT services and to rapidly implement the 2010 World Health Organization guidelines in all facilities.
Zimbabwe has also shown country ownership of its AIDS response through financial investments such as the country's AIDS levy, which is administered by the National AIDS Trust Fund and funded by a 3% levy on income tax to help mitigate the costs of prevention, care, treatment, and support and national investments in infrastructure and human resources.17 Substantial financial resources have come from external sources, including PEPFAR through the United States Agency for International Development, the United Kingdom's Department of International Development, the Global Fund, and private sector organizations such as the Children's Investment Fund Foundation. With these significant investments, Zimbabwe is now focused on reaching the remaining 15% of HIV-positive pregnant women in need of PMTCT services and on addressing geographic and structural barriers to accessing PMTCT services in innovative ways.
After a decade of unprecedented programmatic scale-up throughout the region, the global AIDS response has shifted from emergency mode to an emphasis on sustainability and country ownership. This shift has been bolstered by approaches that work within national systems and that build capacity of public and private facilities, the health care workforce, and local organizations. As an example, the 8-year Track 1.0 prevention and treatment initiative under PEPFAR, led by the United States Centers for Disease Control and Prevention and the Health Resources and Services Administration, concluded with implementing nongovernmental organization partners transitioning their work to indigenous organizations. In February 2012, the 4 implementing organizations—AIDSRelief (Catholic Relief Services Consortium), Elizabeth Glaser Pediatric AIDS Foundation, Harvard University's School of Public Health, and ICAP at the Mailman School of Public Health, Columbia University—completed the transition of their work to new or existing locally controlled organizations and affiliates.18
To eliminate pediatric AIDS over the next few years, country ownership will be crucial, with strategic planning set by ministries of health and all sectors actively engaged, from civil society and the private sector to local communities and networks of people living with HIV.
ENGAGING COMMUNITIES AND PEOPLE LIVING WITH HIV
The active engagement of local communities and people living with HIV is critical to the success of efforts to prevent new pediatric infections and maintain the health of HIV-positive mothers. The experiences of women living with HIV should inform the development and implementation of policies at national, district, and local levels. This perspective is particularly needed to successfully address barriers to uptake of PMTCT services and retention in care, such as discrimination, lack of male partner involvement, and gender inequalities and violence.
In turn, educating communities about HIV treatment and about mother-to-child transmission will help create demand for high-quality comprehensive PMTCT services. Creating effective linkages between communities and health facilities will help both reach women who have not previously accessed services and reduce loss to follow-up. The use of peer counselors, mentor mothers, and community health workers has been an effective way to help engage and retain women and children in long-term HIV prevention and care and treatment and in addressing the systemic issue of shortages of health care workers.19 The use of community counselors in PMTCT services in Côte d'Ivoire has had a dramatic effect on uptake, increasing the offering of HIV testing to pregnant women attending antenatal care at one high-volume maternity center from 51% to 100%.19
In addition, conducting community-based psychosocial support groups can encourage participation of fathers and families in HIV programs, promote acceptance of HIV status, provide disclosure techniques, and support treatment adherence. Such engagement can also impart skills and empower women living with HIV to become active participants and leaders in their communities' HIV/AIDS response. Additional research and monitoring and evaluation of community-based HIV programming will help further increase the use, effectiveness, and sustainability of these critical interventions.
To end new HIV infections in children and maintain the health of HIV-positive mothers by 2015, sustained leadership and co-ordination will be necessary at all levels: at the local level, within communities, districts, and health facilities; at the national level, within governments and ministries of health; and at regional and global levels. In addition, sufficient resources must be dedicated to accomplishing the task: The Global Plan estimates that US $1 billion per year will be needed between 2011 and 2015, but only a fraction of that is currently available.11 To fill the funding gap, adequate resources must be marshaled from national budgets, multilateral and bilateral funding mechanisms, and private and corporate donors.
Now is a critical moment to fulfill the promise of eliminating pediatric AIDS globally, an achievement that would have a ripple effect through low-income and middle-income countries. It would address key causes of maternal and child morbidity and mortality, strengthen health systems, health workforces, families, and communities, and would promote economic development. The virtual elimination of all new pediatric HIV infections would also demonstrate that strategic evidence-based approaches to HIV can curb the pandemic and lead to an AIDS-free generation of children and adults. This is a promise to keep—and now is the moment to act.
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9. Salaam-Blyther T. The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Progress Report and Issues for Congress. Washington, DC: Congressional Research Service; 2008. Available at: http://assets.opencrs.com/rpts/RL33396_20080414.pdf
. Accessed February 1, 2012.
10. World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF. Global HIV/AIDS Response. Epidemic Update and Health Sector Progress Towards Universal Access. Progress Report 2011. Geneva, Switzerland: WHO; 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241502986_eng.pdf
. Accessed February 1, 2012.
12. Business Leadership Council for a Generation Born HIV Free. Two major anti-AIDS initiatives launched at WEF Davos to eradicate new HIV infection in children within four years [press release]. 2011. Available at: http://genhivfree.org/davos-press-release/
. Accessed February 27, 2012.