PEDIATRIC HIV TREATMENT
When CHAI began working on pediatric HIV/AIDS in 2005, kids were being left behind. Only one in 40 children in need was on treatment, compared to one in eight adults. The cost of pediatric medications was prohibitively high and the dosing was difficult in part because young children could only use liquid formulations. Infant testing for HIV was almost non-existent. Despite phenomenal progress in scaling up adult treatment and testing, services for children were lagging.
Negotiate Lower Prices
To address the massive disparity between the number of adults and children on treatment, CHAI began by working to bring down the price of pediatric AIDS drugs. By pooling volumes across 34 countries and through our partner UNITAID’s support, CHAI has worked with drug manufacturers to reduce the price of new pediatric regimens by over 80 percent. The dramatic drop in costs has led to a robust annual increase in the number of children on treatment, but additional work is needed to achieve parity with adult treatment coverage.
Infant Testing and Child-Centered Medicines
Before CHAI got involved, treating children with HIV/AIDS was extremely complex. Beyond higher drug costs, their diagnosis was more difficult, their dosing more nuanced, and their medicines less patient-friendly than those for adults. By the end of 2005, fewer than 200 sites across countries where CHAI worked were equipped to conduct the specialized tests needed to diagnose HIV in children. To overcome this hurdle we worked with governments around the world to rapidly roll out infant testing. We helped establish testing guidelines for infants and equipped thousands of health facilities with the supplies and know-how needed to collect blood samples from babies.
In 2005, pediatric HIV drugs were only offered in liquid formulations, making them difficult to transport, store and dispense. One month of pediatric medicine once consisted of twelve bottles of syrup. Since then, CHAI helped develop formulations so today kids only have to take one pill twice a day.
Quality of Care and Retention
A landmark 2009 CHAI study found that over half of children who test positive for HIV are lost to follow-up before they receive proper treatment. One cause of this was the long period of time that elapsed between taking the test and receiving the diagnosis. Kids were getting lost in the system. Parents had them tested, but because they never got the results, they never knew whether their child was HIV-positive or not. By improving data management systems to monitor retention and equipping both testing sites and labs with SMS printers, we have been able to cut this delay in receiving results. Through these and other steps, such as strengthening the referral system between testing sites and treatment clinics, CHAI is helping countries keep kids who test HIV-positive alive and well.
ELIMINATION OF MOTHER TO CHILD TRANSMISSION
Eliminating mother-to-child transmission of HIV (eMTCT) is one of the most exciting goals in public health, and CHAI firmly believes that an AIDS-free generation is attainable. Between 2008 and 2011, CHAI worked with ministry partners in six countries—Ethiopia, Tanzania, Malawi, Lesotho, Cambodia, and Vietnam—to increase the demand for PMTCT services at the community level, and bring about significant improvements in service delivery across the PMTCT cascade. Efforts in these six countries helped achieve an average drop in transmission rates of over 40 percent between HIV-positive mothers and their infants at six weeks in high-burden areas; from around 20 percent to as low as 7 percent in some regions.
The launch of the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive in 2011 helped drive significant improvement in the coverage of PMTCT services. By 2013, 68 percent of pregnant women living with HIV in 21 priority countries in sub-Saharan Africa received PMTCT services, compared to 39 percent in 2009. New pediatric HIV infections reduced to 240,000 in 2013, representing a 40 percent decline since 2009. While this progress is commendable and has helped drive down six-week transmission rates, the job is far from done because 20,000 children are still infected every month. Half of all new episodes of HIV transmission to children occur during the breastfeeding period and until eMTCT coverage is extended to the end of the breastfeeding, we cannot achieve the elimination agenda. There are also 3.2 million children who already live with the disease, and pediatric treatment coverage continues to lag behind adult treatment coverage in many countries.
The good news is that we now have the technology, policies and even the funding to both prevent future infections and make sure that infected children receive the best possible care and treatment. ARVs turn HIV from a death sentence to a manageable chronic disease, and when taken during pregnancy and breastfeeding, virtually eliminate pediatric infection.
To get there, however, we must help our partner governments to focus on a number of specific priorities over the next 3-5 years.
o First, we must drastically reduce transmission during the breastfeeding period. We are getting better at reaching women during pregnancy, but once they deliver a healthy baby, many of them don’t come back, believing all is well. Keeping these women in care until weaning is perhaps the most important remaining barrier to elimination and an AIDS-free generation.
o Second, we must test all exposed infants, and link any HIV-positive baby to immediate life-saving treatment.
o Third, we must identify and treat the children who were infected over the past decade. Too many of them have died, but many are still alive. Those children need to be treated.
Ending pediatric AIDS is a dream that we can realize, but only if we take some critically important steps. Over the past few years, CHAI has invested time and resources in better understanding how we can address the challenging last mile of PMTCT. CHAI has supported partner governments to undertake operational research to identify effective interventions relative to standard practice of care, as well as assisted governments in scaling up known effective PMTCT and Pediatric HIV services and models of care. CHAI’s current eMTCT work centers around efforts to improve retention of mother and infant pairs; increase the uptake of PMTCT interventions; and better link PMTCT and Pediatric HIV services.
CHAI is renewing its commitment to pediatric HIV, focusing both on elimination and treatment. The ultimate goal of our pediatric HIV treatment scale-up work is to close the gap between adult and pediatric HIV coverage rates in countries with the highest gaps in pediatric treatment coverage over the next 3-5 years, while moving towards eliminating pediatric HIV in the long-term. CHAI will support ministry partners to implement country-specific activities that strengthen the entire pediatric HIV care continuum to achieve ambitious but achievable impact on new pediatric HIV infections, ART coverage, and HIV mortality.
Through this work, we will drive accelerated action to address the ‘unfinished business’ of pediatric HIV and AIDS in countries with the highest burden, while moving towards eliminating pediatric HIV in the long-term and achieving universal pediatric treatment coverage.