Eliminating Pediatric AIDS: What It Will Take and What It Will Bring

This extraordinary achievement is a result of sustained research successes during the first two decades of the AIDS epidemic, an unprecedented expansion of HIV prevention and treatment programs during the last decade, and increased global attention and leadership in recent years. Early epidemiologic research has been critical to this victory. Researchers were able to describe the magnitude and distribution of the global pediatric AIDS epidemic, determine that the risk for mother-to-child transmission of HIV is 25 to 40 percent, and identify the primary ways children get infected with HIV: in utero, during labor and delivery, and through breastfeeding. Clinical research proved that the risk of mother-to-child transmission of HIV could be dramatically reduced with antiretroviral (ARV) drugs that decrease viral load in HIV-positive pregnant women and provide pre- and post-exposure prophylaxis to their infants. Implementation research has demonstrated that facility-based programs utilizing rapid HIV testing that target ARVs to HIV-positive pregnant women and their newborns could be effectively implemented outside of clinical research settings. National monitoring systems documented the virtual elimination of new HIV infections in children in several countries that have adequate resources and strong health systems. More recently, World Health Organization (WHO) guidelines released in 2010 helped resolve longstanding questions about how giving HIV prophylaxis to HIV-positive mothers or to their infants can improve the safety of breastfeeding. In response to this steady progress on the research front, donors and governments began mobilizing resources to support a dramatic expansion of prevention of mother-to-child transmission of HIV (PMTCT) programs, extending their reach to women throughout the world. The Elizabeth Glaser Pediatric AIDS Foundation's Call to Action program, launched in 1999, was followed by Columbia University's MTCT-Plus Initiative in 2001 and the U.S. Government's Mother and Child HIV Prevention Initiative in 2002. Resources and programs then increased dramatically under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Through these efforts, substantial progress has been made. Globally, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that half of all HIV-positive pregnant women received ARVs in 2010, and PEPFAR estimates that 200,000 infant infections were averted in fiscal year 2011. Nonetheless, the glass is still only half full—the other half of HIV-positive pregnant women are not on ARVs, programs are still catching up in adopting the most effective PMTCT regimens, and more than 1,000 infants are still infected with HIV each day. A new global movement with aggressive targets to virtually eliminate pediatric AIDS has recently emerged. The combined efforts of key stakeholders led to the development in 2011 of a Global Plan for eliminating new HIV infections in children and the subsequent establishment of a Global Steering Group to mobilize leadership and resources and coordinate activities. The effort is based on a four-pronged approach: reducing HIV incidence in women by 50 percent, reducing the unmet need for family planning among HIV-positive women to zero, reducing the risk of mother-to-child transmission of HIV to less than 5 percent, and providing antiretroviral therapy (ART) for 90 percent of eligible HIV-positive women. Optimal interventions are critical to achieving the elimination of mother-to-child transmission of HIV. Recent research and the new WHO guidelines offer ways to optimize necessary interventions, including the use of new prevention tools such as voluntary medical male circumcision, treatment as prevention, pre-exposure prophylaxis, and couples testing with treatment for the infected partner in a discordant couple. The guidelines also recommend that all women who are eligible for ART should receive it to maintain their health and to reduce the risk that they will transmit HIV to their infants. High coverage and retention are also essential to achieving the elimination of mother-to-child transmission of HIV. Models show that achieving this goal will require reaching more than 90 percent of pregnant women with a sequence of PMTCT services, which entails women accessing the health system followed by continued retention across multiple encounters, along with community support. Key barriers to uptake and retention include factors such as distance, competing demands, illness, stigma, unattractive facilities, and disempowerment. Careful analysis will help interventions overcome local service gaps and barriers to coverage and retention. Strong health systems are necessary to support integrated, client-centered delivery of PMTCT, ART, and maternal and child health (MCH) services. A national plan to eliminate pediatric AIDS that organizes and coordinates a systematic response among all involved stakeholders is essential. Strong management systems at the national, district, facility, and community levels are also necessary to carry out the plan. Financing systems that promote performance towards targets, supply chain systems for reliable access to test kits, drugs, and other necessary commodities, and quality improvement systems to promote both quality and innovation in programs are also critical.