Brief

To achieve an AIDS-free generation, optimal treatment options for all infants and young children living with HIV must be available, tolerable and most importantly, effective. Since 2013, the WHO has recommended that all infants and children under three years initiate ritonavir-boosted lopinavir (LPV/r)-based regimens. However, the transition to preferred pediatric regimens has been slow, and one-third of children remain on a sub-optimal regimen of zidovudine (AZT), lamivudine (3TC) and nevirapine (NVP).

Only 20 percent receive the WHO preferred regimen despite resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) becoming a major concern for infants and young children. While efavirenz (EFV) is increasingly used, NVP-based regimens are also very common in children older than three years. As a result, overall virological suppression reported in program settings continues to be sub-optimal and particularly poor in young children below five years.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more.

Adolescents and young people (AYP) (10-24 years) are being left behind in the HIV response, with high levels of new infections, and lower levels of diagnosis and treatment coverage than adults. National and local programming adapted to their specific needs is critical to ensuring their well-being and to reaching global targets to end AIDS by 2030.

AYP, including those living with HIV and from young key populations, are not just beneficiaries of programs, but are important stakeholders and agents of change. AYP leadership and partnership is an essential component of the design, delivery and evaluation of programs that affect them, leading to better decisions and policies. In accordance with principles of the greater involvement of people living with HIV, AYP have the capacity to identify approaches and solutions that best respond to their needs, making programs more effective and helping to ensure increased uptake of services and better outcomes.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more.

Paediatric HIV treatment coverage is stagnating. The most recent estimates suggest that only 46% of children living with HIV are on treatment, well below the AIDS Free target of 1.6 million by the end of 2018. A key challenge is to identify children who are living with HIV that have been missed through routine testing services.

For children in the 0-14 year age group, over 95% of HIV infections are acquired as a result of vertical transmission. As a result, historical approaches to pediatric diagnosis have tended to focus on early infant diagnosis (EID) within the context of prevention of mother-to-child-transmission (PMTCT) programs.

Testing the family of adult or child ‘index’ cases can serve as an entry point for identification of children living with HIV not identified through PMTCT program
testing. This type of family-based approach to HIV testing and service delivery enables parents and their children to access care as a unit. Such approaches may improve retention and offer a convenient service for families affected by HIV.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more. 

Urgent and ambitious 2020 global targets are on the horizon, yet there has been insufficient progress in paediatric and adolescent HIV to date. Scaling up HIV services for all children and adolescents is needed, in alignment with the UNAIDS super-fast-track framework. It’s time to make sure that nobody is left behind.

This series of 12 policy briefs by the Child Survival Working Group (CSWG) looks at scaling up key interventions for children and adolescents living with HIV. They present evidence, policy and monitoring considerations, implementation guidance and tools necessary to scale up 12 key interventions which have proven successful in identifying, linking and supporting children and adolescents to access and remain in quality care and treatment.

They are designed for program managers in government and civil society programs, particularly at country-level, and provide practical information and direction.

Learn more in the Foreword and download the briefs below. 

• Addressing the service delivery needs of children of key populations

• Strategies to improve retention of mother-baby pairs in PMTCT programs

• A child-centred approach for HIV programs

• Providing differentiated service delivery to children and adolescents

• Point-of-care testing as a solution for timely early infant diagnosis

• Complementary and connected: Engaging community and faith-based organizations to deliver PMTCT and pediatric HIV services

• Sensitizing health workers to providing responsive care for adolescents and young people living with HIV

• Family-based index case testing to identify children with HIV

• Meaningful engagement of adolescents and young people in national and local HIV programming

• Scaling up optimal antiretroviral treatment for children: A long overdue intervention

• Preventing and treating tuberculosis among children living with HIV

• Providing peer support for adolescents and young people living with HIV

The 95-95-95 targets will only be achieved with zero discrimination, including within healthcare settings. Health worker attitudes, including those of professional and lay providers, are essential in establishing the culture of a health service. Protecting confidentiality and treating adolescents and young people living with HIV (AYPLHIV) with respect are key elements of adolescent and youth-friendly health services (AYFHS). However, AYPLHIV report stigmatizing and unsupportive health worker practices, including imposed moral values, discrimination, shame and scolding and violations of confidentiality. To ensure health workers are equipped to deliver appropriate services, training and sensitization are required. While the importance of sensitization is increasingly acknowledged, a gap remains in documented interventions and models.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more. 

To reach global pediatric HIV targets, efforts must extend beyond clinic doors. Community-based organisations (CBOs), faith-based organisations (FBOs) and places of worship can play a pivotal role in accelerating and expanding services. However, for their contribution to be amplified, they must be engaged as integral implementing partners in service delivery and effectively linked to the health system. A systematic approach is required to formally establish and resource these linkages, as well as embed them in district planning and coordination.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more. 

Despite remarkable progress in prevention of mother-to-child transmission of HIV (PMTCT), 160,000 children were newly infected with HIV in 2016. Less than half of HIV-exposed infants (HEI) received early infant diagnosis (EID) within 6 weeks of life, a major challenge for early antiretroviral therapy for HIV-positive infants. Although introduction of dried blood spot (DBS) has increased EID access, conventional laboratory networks have relatively long (22-60 days) turnaround time, resulting in low proportions of results returned and missed opportunities for ART initiation. The WHO conditionally recommends introduction of point-of-care (POC)/ near-POC nucleic acid testing (NAT) for EID.

Recent encouraging evidence for POC/ near-POC EID warrants consideration of rapid adoption and strategic scale-up of this solution complementing the existing laboratory network.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more. 

Children and adolescents living with HIV (CALHIV) have a lifetime of antiretroviral therapy (ART) ahead of them. An estimated 95% of HIV service delivery is currently facility-based, largely undifferentiated for individual need. Differentiated service delivery (DSD) is a client-centred approach, simplifying and adapting services to better meet the needs of people living with HIV and reducing unnecessary burdens on the health care system. Differentiated ART delivery for clinically stable children and adolescents is supported by global agencies, and a growing body of evidence highlights how differentiated ART provides a significant opportunity to improve treatment adherence among children and adolescents living with HIV. However, CALHIV are still often not prioritized when scaling up differentiated ART delivery.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more.

As part of their basic human rights, children need access to the best health care possible, safe water to drink, nutritious food, and a clean and safe environment to grow and develop to their full potential. Optimal health, learning and behavior outcomes stem from laying healthy foundations early in life through exposure to the right health care, nutrition, relationships and environment. Whether because of exposure, infection and/or drug effects, HIV impacts health, nutritional, learning and development outcomes. HIV programs need to design and foster approaches that address the multidimensional needs of children living with and/or affected by HIV, recognizing that both exposure and infection carry risks that may affect survival, growth and development for children of different ages.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more. 

Approximately half of HIV infections among children take place during breastfeeding. While there has been success in retaining pregnant women on antiretroviral therapy (ART) during pregnancy, there has been inadequate focus on retention support to
mother-baby pairs (MBPs) during the breastfeeding period.

Literature shows that the majority of MBPs not retained in prevention of mother-to-child transmission (PMTCT) programs are due to loss to follow-up (LTFU) rather than death. These children are at higher risk of vertical acquisition of HIV compared to breastfeeding infants who remain in care. Current postpartum LTFU rates limit successful implementation of PMTCT programs in sub-Saharan Africa. Cumulative sub-Saharan Africa PMTCT LTFU rates in 2011 were estimated to range from 20-28% during antenatal care, then sharply increase to 70% at four months postpartum and reach approximately 81% six months after birth.

Given these staggering statistics, the quality and effectiveness of PMTCT services should include an assessment of the proportion of MBPs retained in care and early infant diagnosis (EID) rates.

This is part of a series of 12 policy briefs by the Child Survival Working Group on scaling up key interventions for children and adolescents living with HIV. Learn more.