By Carole Leach-Lemens
A generation of children free from AIDS is possible, according to the Children and AIDS, Fourth Stocktaking Report released on November 30th by UNICEF in partnership with the joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO) and the United Nations Population Fund ( UNFPA). However, the authors note the world is not yet on track to meet targets for prevention, treatment, care and support.
Issuing a call for action they urge that in a climate of economic uncertainty long-term targets are kept in mind and short-term commitments are honoured if women, children and young people are to have opportunities to live and thrive in a world free of AIDS.
“Wise investment in HIV and AIDS at the country level will require us to ‘know the epidemic’, how to respond appropriately and the associated costs of that response, and how that response is affecting the health and wellbeing of women and children, ” says UNICEF.
In 2005 UNICEF, UNAIDS and other partners launched Unite for Children, Unite against AIDS to focus attention and resources dedicated to putting children at the heart of the global response. The partnership has published a series of annual stocktaking reports to track progress towards the goal of universal access to prevention, treatment and care.
Interventions including early infant diagnosis and antiretroviral therapy for the prevention of mother-to- child transmission are now a part of the global response and have helped save and improve lives. Yet progress remains uneven revealing gaps in service coverage and inequities in access.
The report highlights the need for systems strengthening – health, political, legal and social welfare – linking them with communities to improve delivery and uptake of HIV/AIDS interventions.
This fourth annual report examines progress made in the global response for children in four programme areas known as the ‘Four Ps’:
- Preventing mother-to-child transmission
- Paediatric HIV care and treatment
- Preventing HIV infection among adolescents and young people
- Protecting and supporting children affected by HIV and AIDS
According to UNICEF $5.9 billion annually is a best estimate of the resources needed to adequately address the requirements of women, children and young people to meet the targets of the Four Ps.
Progress towards universal access goals, in the 20th anniversary year of the Convention on the Rights of the Child, is examined through the perspective of a standard of care and treatment for all that ensures the most-at-risk and vulnerable children and families do not fall through the cracks.
Prevention of mother-to-child transmission
Nineteen (of 192 United Nations member states) countries reached the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) goal of reaching 80 percent of pregnant women living with HIV with antiretroviral therapy to prevent transmission of HIV to their infants in 2008.
In 2008 45 per cent of HIV-positive pregnant women received antiretroviral drugs to prevent transmission of the virus to their infants. While the number of women reached has almost doubled since 2006 only 21 per cent of the estimated pregnant women living in low- and middle-income countries were tested for HIV in 2008.
On average in low- and middle-income countries 32 per cent of infants born to HIV- positive mothers were given antiretroviral prophylaxis for PMTCT at birth, up from 20 per cent in 2007 and 18 per cent in 2006. This ranges from a low of 10 percent in West and Central Africa, 20 per cent in South Asia, 40% in Eastern and Southern Africa to 54% in Latin America and the Caribbean.
While some progress has been made, few pregnant women are taking ART for their own health and the majority of pregnant women and children do not have access to basic PMTCT services.
Evidence-based strategic approaches for PMTCT scale-up that have proved successful in resource-limited settings include: Decentralisation, health systems strengthening and integration within maternal, newborn and child health services, scaling-up innovative service delivery, (for example mobile technology and motor-bikes) and making community-based interventions an integral part of national scale-up plans.
Paediatric HIV care and treatment
In 2008 approximately 275,000 (38%) of children under 15 in need of antiretroviral treatment received it. Early testing and immediate treatment in infants is critical, because evidence suggests AIDS-related deaths are at their highest at two to three months of age. However, improved access to early infant diagnosis viral DNA testing of dried blood spots does not necessarily mean access to life-saving treatment. A Clinton Foundation study in eight countries revealed an estimated 53 per cent loss-to-follow-up after testing positive among mothers and children (following birth).
Cotrimoxazole prophylaxis is a life-saving intervention when started in HIV-exposed children within two months of age, and is highly cost-effective However, coverage in low- and middle-income countries in 2008 was only 8 per cent, up from 4 percent in 2007.
Preventing infections among adolescents and young people
Young people (aged 15-24) represent 45 percent of all new adult infections. Of the estimated 4.9 million young people living with HIV 60 percent live in Eastern and Southern Africa while 23 percent live in West and Central Africa. Young women are especially vulnerable when understood within a social, cultural and economic context that places them at high risk of HIV exposure. They account for close to 75% of infections in young people in sub-Saharan Africa. In South Asia, Latin America and the Caribbean more young men than young women are becoming infected, due to the concentrated nature of HIV epidemics taking place largely among injecting drug users and men who have sex with men.
In all regions gender discrimination and gender-based violence limit access to services and reduce people’s ability to make choices in risk reduction.
Men who have sex with men, sex workers and injecting drug users all face multiple barriers in accessing services.
Knowing the epidemic at the local level to be able to design and tailor interventions that address behaviours that marginalise and put adolescents at risk for infection is fundamental. Although girls who attend school for more years are at lower risk of HIV infection, evidence on how to use schools effectively to reduce HIV risk within a national framework is still lacking.
Protection, care and support for children affected by HIV and AIDS
A median of 12 percent of households caring for orphans or vulnerable children in 2008 received any kind of basic external support. The current economic climate further adds to the additional stresses that poverty brings to the well-being of children affected by HIV.
The report highlights how child-sensitive social protection is a key intervention to reaching children affected by AIDS, and includes: social transfers (cash and in-kind transfers and vouchers), social insurance, social services and social policies and legislation designed to be AIDS sensitive.
Programme monitoring and evaluation
Evidence-based programmes that show what works (or does not) and how to make improvements are key to scale-up. Monitoring and evaluation of PMTCT and paediatric HIV programmes must keep up with advances in science and programming.
Call to action
For women, children and young people to have the opportunities to live and thrive in a world free of AIDS there are ten priorities, UNICEF says:
- Accelerate the scale-up of PMTCT services and early infant diagnosis to contribute to the elimination of HIV transmission to young children.
- Continually seek out new evidence to inform HIV prevention.
- Support and empower adolescents, particularly girls, to identify and respond to their own vulnerabilities.
- Protect the rights of adolescents and young people living with HIV to receive good quality support and services.
- Ensure that adolescents who are in situations of the greatest risk are reached by HIV prevention, treatment, care and support services.
- Make sexual violence against girls and women socially unacceptable.
- Scale-up child-sensitive social protection, a necessary part of the response for children affected by AIDS.
- Strengthen the community capacity to respond to the needs of children affected by AIDS by preventing the separation of families and improving the quality of alternative care.
- Strengthen whole systems so that gains made on behalf of women and children affected by AIDS can be extended and sustained.
- Improve data gathering and analysis to achieve results for children, and identify gaps in equitable coverage of and access to services.
The Fourth Stocktaking Report can be downloaded at http://www.aidsmap.com/en/news/www.uniteforchildren.org
UNICEF. Unite for Children, Unite against AIDS. Children and AIDS: The fourth stocktaking report, November 2009.