Is the eradication of HIV-Aids, especially among children and adolescents, within reach?
The latest data set released a few days ago by UNaids, Unicef and their partners on a disease that has plagued the world since the early 1980s and has claimed over 40.4 million lives to date suggests that progress is attainable but tempered with a fragmented reality, and in general bereft of the required strong political will and commitment and financial investment flows to end Aids as a public health threat once and for all.
“A sad reality,” says Unicef, “is that a child or adolescent died every five minutes due to Aids in 2022, and approximately 274 children died every day from Aids-related causes, mostly because of inadequate access to HIV prevention, care and treatment services.”
According to the World Health Organization (WHO), there were an estimated 39 million people living with HIV at the end of 2022, two-thirds of whom (25.6 million) were in the WHO African region, overwhelmingly in southern Africa.
Lest there be any complacency and misplaced euphoria about neutralising a wily pathogen, whose resilience has persisted for over four decades and for which there still is no cure, in contrast to the record timeline in developing Covid-19 vaccines, we are still seeing ongoing transmission in all countries globally, with some countries reporting increasing trends in new infections when previously on the decline.
The fact that “the epidemic is still evolving, and transmission patterns are changing throughout the world” suggests that the over-reliance on vigilance, monitoring, general prevention, containment and antiretroviral therapy (ART) especially for prevention of mother-to-child-transmission (PMTCT) may be in need of a fundamental rethink, not to detract from the fantastic gains already achieved thus far, but to consolidate and accelerate these gains by doing what is necessary towards taking that great leap forward towards eradication.
This can be done through a massive injection of funds in vaccine-related and other threads in HIV R&D and equally crucially in changes in the behavioural dynamics of policies such as a ban on diversifying allocated funds from HIV strategies as in the case of Covid-19; economic prioritisation of targeted health system development, preferably with the involvement of not-for-profit private sector initiatives in inner city urban and rural areas; and in societal and social-sexual mores that have had a devastating impact on infants, children, adolescent girls and women, especially in South Africa where sex between adolescent girls or young women and older men is the prevalent HIV transmission route.
In addition, infants born to mothers living with HIV are at risk of becoming infected if their mothers are not on effective treatment or retained in care.
The changes in transmission dynamics of HIV suggest that the Damascus road to Aids eradication is bound to remain elusive at least in the near-to-medium term, especially if new competing pathogens and pandemics continue to emerge, which may be likely.
At best the trajectory of progress seems to have mutated from “one step forwards and two steps backwards” to “one step backwards and two steps forwards”. But the overall picture remains one of anomalies, contradictions, deficits, aspirations and limited gains.
Whether this momentum is enough in pushing Aids towards that holy grail of eradication in line with WHO, the Global Fund and UNaids global HIV strategies that are aligned with the SDG target 3.3 of ending the HIV epidemic by 2030, only time will tell.
Failure to deliver will only exacerbate perceptions prevalent in many affected developing countries, especially in sub-Saharan Africa (SSA), of a two-tier global approach to HIV Aids – one pandering to the needs of resource- rich and advanced health architecture developed economies, and the other to the vagaries of developing countries with under-invested and failing health systems bereft of the institutional and care capacity needed to deal with the challenges of a pandemic of the size and complexity of HIV.
HIV disproportionately affects persons who inject drugs, men who have sex with men, and sex workers.
Changing patterns in transmission are a growing concern because it necessitates allocating already scarce resources to additional targeted awareness campaigns and to revised anti-progression strategies.
In Eastern Europe and Central Asia, says Unicef, “HIV epidemics are now increasingly characterised by significant sexual transmission (as opposed to drug injection). In parts of Asia, HIV is transmitted more and more among heterosexual couples, and infections are steadily spreading into lower-risk populations through transmission to the sexual partners of those most at risk.”
The HIV metrics of shame continue to burden SSA, particularly in southern Africa. In 2022, the region accounted for about 66% of people of all ages living with HIV, and 85% of children and adolescents living with HIV worldwide.
But it is the Unicef data sheet on children and adolescent incidence of HIV-Aids that is most disconcerting and unacceptable, despite increased investment and support from governments, international agencies and global health charities.
Of the estimated 39 million people living with HIV worldwide in 2022, 2.58 million were children aged 0-19.
Each day in 2022, around 740 children became infected with HIV. About a quarter of all pregnant women or mothers living with HIV and needing ART are aged 15-24 years.
The majority of paediatric HIV infections are due to new mothers not receiving ART, dropping off ART, or becoming infected during breast-feeding, and some 660 000 children aged 0-14 years living with HIV (out of 9.2 million overall) are missing out on life-saving treatment. Overall, 1.3 million people acquired HIV in the year and about 630 000 people perished due to HIV-related causes.
South Africa, with the highest incidence of HIV in the world, has made steady progress in its response, albeit more so in the adult cohort with many children and adolescent groups still disproportionately being left behind.
According to WHO, there has been a remarkable 69% reduction in new HIV infections in southern Africa among children 0-14 years since 2010 and a 58% reduction among adolescents and young people 15-24 years, primarily among girls and young women during the same period.
In South Africa, the estimated incidence rate (new HIV infection per 1 000 uninfected population) and the estimated rate of annual Aids-related deaths (per 100 000 population) for children aged 0-19 have effectively bottomed out.
Unicef’s estimate for the number of new HIV infections (adolescents and young people aged 15-24 years) in South Africa at the end of 2021 is 67 000 – only 4 000 fewer than in 2020. The estimated figure for children aged 0-19 is 43 000. The standout features are that the overwhelming number of children affected are girls and young women, and that the estimates are a mean figure spanning low, medium and high bands.
Similarly, the number of children in South Africa living with HIV receiving ART totalled 123 000 in 2022. But this figure has remained static for the last three years at around 54%, suggesting very little upward movement.
The gender bias in the incidence of HIV infections reinforces the entrenched patriarchy of transmission patterns and sexual norms. Unicef estimates the distribution of new HIV infections among adolescents aged 10-19 years in 2022 is a staggering 86% for girls and only 14% for boys.
Unicef strongly advocates early diagnosis and timely initiation of treatment, which are particularly critical in the case of infants.
“The Children with HIV Early Antiretroviral Therapy study from South Africa demonstrated a 76% reduction in mortality when treatment was initiated in the first 12 weeks of life among infants who test positive for HIV.”
Three years after he was elected president in 1994, Nelson Mandela acknowledged that the future of the new democratic South Africa depended on its children, warning that “the true character of society is revealed in how it treats its children”.
While the governing ANC should be commended for some of the gains in the fight against Aids at home, albeit some of its past leaders had a callous disregard for the disease and lack of empathy for those afflicted, by Madiba’s very metric it has its work cut out at the realisation that in South Africa especially the road to HIV eradication is still fraught with huge obstacles and challenges.
Parker is an a writer based in London
Cape Times