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Lessons learned for child survival: HIV/AIDS

Watch Professor Peter Piot describe the progress made in reducing child deaths from HIV/AIDS.
PETER PIOT: Of the 10 causes of child deaths that are reducing the fastest, there are nine infections. And the infection that is reducing the fastest is HIV/AIDS, which is the most recent new infection that has been added as a cause of child death. And we will discuss how that came about, how the AIDS movement really brought a radical change, and one of the great success stories in global and public health over time. And it’s very well described in this volume by UNAIDs, where the lessons from the MDGs and the AIDS movement are being discussed in detail. And this is actually very useful also when we talk about reducing child deaths.
I’m Peter Piot and I am the director of the London School of Hygiene & Tropical Medicine. And I was the founding executive director of UNAIDS. Child deaths from AIDs are falling by close to 7% per year. They’ve actually halved over the last 15 years. And most of these reductions are happening in just one country and that’s South Africa. Also because that’s the country with the largest number of people living with HIV, a majority being women. Now how did that come about? And there are three strategies to reduce child deaths from AIDS. First of all, it’s preventing mother-to-child transmission. And here, we have a remarkable success story.
With now, about 2/3 of all pregnant women having access to the necessary services to prevent their babies from becoming infected with HIV. That didn’t come easy. The intervention is straightforward. It’s making sure that women know that they’re living with HIV. That has to happen in health services during antenatal clinic visits. It’s making sure that they have access to antiretroviral drugs for prophylaxis. And that there is follow up also with the baby. That took quite a long time, and sometimes required court action like in South Africa. But we’re here now and that coverage has resulted in major reduction in babies being born with HIV infection. So that’s the first strategy.
The second strategy is for those babies and children who, unfortunately, were born with HIV where prevention failed, or their mothers did not have access to testing or to the necessary treatment, these children need treatment –antiretroviral therapy. Here we are doing less well. Only one third of children in need have access to antiretroviral therapy, which is like only half of what adults are getting. So we have a problem here. And it’s a combination of issues. One diagnosis of HIV infection in children is far more difficult than in adults. And often a doctor or a paediatrician would not even think of it, that this child could have HIV infection. And it’s usually identified through actually a diagnosis of HIV in the mother.
Secondly, the drugs are not that great. Paediatric formulations don’t exist for every single antiretroviral. They’re how to administer. And very often, they’re far more expensive than the adult formations, even if you need to give much lower dose. That is all improving, but we still have a long way to go here. And then the third strategy is preventing adolescence and young people, particularly young women, from becoming infected with HIV. And here I would say we see a massive failure of prevention. There are up to 800,000 adolescents and young adults under 24 who become infected with HIV every single year.
And that’s particularly the case for young women, girls, and in South Africa, where again, we see the largest number of adolescence and young women becoming infected with HIV. The reasons for that are complex. Complex because they are rooted in gender norms, in societal norms, from violence, to the role of women. Many of these girls are infected, not by boys of their age, but by older men. And that has to do with poverty, with masculinity, with how we look at the position of girls and women in society and about sexuality. And the biggest problem is that there is massive denial about this.
Massive denial that young people have sex, massive denial that it’s only through intervening some of the really fundamental and longstanding behaviours, particularly of men, that we can change this. And massive denial of providing young people with the necessary tools from condoms to sex education, and I would say, in a very high incidence population such as in southern Africa, with pre-exposure prophylaxis with antiretrovirals. So here, we definitely have to do better. And if we ever want to end the epidemic, the key for me is in southern Africa, stopping HIV transmission in young women and in young men and boys.
Therefore, we need to act in multiple ways because this is an issue about society, societal norms, stigma, discrimination, about service delivery, about the inavailability of new tools of innovation. And what can we learn from the AIDS movement? What can the child health movement learn from the AIDS movement and vice versa, I should say. It’s only when the stars are aligned that we can move mountains. Because that’s what we need to do. Let me mention a few points that I think have been absolutely instrumental in the achievements of the AIDS movement. First of all, innovation and science.
That brought us the drugs that are saving millions of lives now and we have now 15 million people in low and mid-income countries on antiretroviral therapy, coming from a couple of hundred thousand, around 2000. And when everybody said this is not possible. So the second point I would say was that this leadership and being very ambitious. If you’re not ambitious, you can never reach your goals. If you don’t have that kind of ambition, one you will set your goals too low. You’ll be content with half-hearted solutions. And you will never end this big problem of child mortality. But that requires leadership. The third issue is that we also need innovation in delivery.
It’s not just better health systems because that’s going to take quite a while. And it was one of the big arguments that was used by health systems experts that antiretroviral therapy is not possible in low and middle-income countries because it’s going to take a long time to fix these health systems. Now, we have innovation in delivery, where you have so called task shifting, people who are not doctors or nurses. They can be trained to do some specific aspects of providing treatment, providing prevention, and above all, it’s involving the people themselves, people living with HIV, activists, communities. And we need to do that also when it comes to reducing child mortality.
And then, of course, after innovation, the science, the delivery systems, and the leadership, there’s always a need for money. Without money, even if you have the best strategy, we’re not going to make it. And for AIDS, we’ve established dedicated financing mechanisms for providing not only treatment, but also prevention. The Global Fund to Fight AIDS, TB, and Malaria, is not only about AIDS, so there’s some collateral benefits, particularly for malaria, which is also such an important cause of child mortality. So let’s make sure that also for child health, all the stars are getting aligned and they’re all in place.

The next three steps are concerned with the progress made in child survival rates, and contemplate three major infectious causes of child deaths. HIV/AIDS is the newest major cause and yet is also among the fastest reducing. In this video Professor Peter Piot discusses how this headway has been made.

Child deaths from AIDS are now reducing by 6.7% annually. This has been achieved in two ways:

  • prevention of mother-to-child transmission (PMTCT) through use of anti-retroviral therapies
  • Treatment of children with HIV through provision of anti-retrovirals.

This has not, however, been easy. It has required major health system investment, innovation and leadership. Cast your mind back to the steps on HIV programming for adolescents in Week 1. Would interventions for children be similar to those for adolescents? How would they differ?

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