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An AIDS-free generation: Fantasy or reality?
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The near-elimination of pediatric AIDS in the United States and other developed countries is a remarkable public health success story, a consequence of the wide availability of testing and treatment of pregnant women to prevent mother-to-child HIV transmission and the advent of combination antiretroviral therapy to prevent HIV disease progression among both children and adults. In the United States, the number of new pediatric AIDS cases declined from 961 in 1992 to just 23 in 2010. Annual death rates for infants and children with HIV in many US centers are less than 1%. Children with HIV are living longer and better than ever before.
AIDS-free generation in sight
The incredible advances in pediatric HIV prevention and treatment that have been observed in the United States since the mid-1990s were not immediately realized in the developing countries, especially across sub-Saharan Africa, where health care infrastructure and capacity were sorely lacking, and the cost of treatment was considered prohibitive. Nevertheless, tremendous progress has been made, and today the world stands on the cusp of what was unimaginable only a few years ago: an AIDS-free generation.
Sustained progress is being made in scaling up services to prevent mother-to-child HIV transmission. By the end of 2012, it was estimated that about 62% of pregnant women living with HIV in low- and middle-income countries were receiving effective antiretroviral prophylaxis or treatment. Four African countries hard hit by HIV/AIDS already have met the goal of providing ART to 90% or more of pregnant women living with HIV. As a result of progress in scaling up prevention services, the number of new HIV infections among children living in low- and middle-income countries dropped by 52% between 2001 and 2012, to 260,000. Some of these countries now are approaching the low mother-to-child HIV transmission rates observed in the United States and other high-income countries.
Mark W. Kline
Tremendous progress also has been made in expanding treatment coverage for children living with HIV/AIDS, but gaps in access still exist. By 2012, about 647,000 children younger than 15 years were receiving ART, an increase of about 14% in just 1 year. However, HIV treatment coverage for children (34%) still was only about half that of adults (64%), and in priority countries, only three in 10 children who needed it were receiving treatment. Infants with HIV/AIDS are particularly underserved in a great many settings worldwide.
Successful fight against the epidemic
So, what will it take to build on the progress and achieve an AIDS-free generation? Certainly, we will continue to need strong political leadership and community advocacy, particularly in an era during which HIV/AIDS is no longer viewed as the unfolding cataclysm that it was just a few short years ago. Botswana turned the corner on the world’s worst HIV/AIDS epidemic in the middle part of the last decade when President Festus Mogae made the rollout of HIV testing and treatment an urgent priority, publically submitting to an HIV test himself and saying, “We are threatened with extinction.”
Women and children were established as particular priority groups. By 2007, Botswana had achieved greater than 80% access to HIV treatment, and HIV/AIDS associated deaths declined by more than 50% in just 4 years. The number of new AIDS orphans declined by 40%. Today, Botswana is perhaps the single best example in sub-Saharan Africa of success in fighting HIV/AIDS.
At the same time and just across the border from Botswana in South Africa, President Thabo Mbeki questioned the association between HIV and AIDS and stonewalled pleas for the rollout of HIV testing and treatment programs, saying, “Personally, I don’t know anyone who has died of AIDS.” Eventually, under intense pressure from domestic and international advocacy groups, South Africa launched national programs for the prevention of mother-to-child HIV transmission and adult HIV treatment, but the delay had cost the lives of thousands of South Africans, 330,000 by one estimate. About 35,000 infants had been born unnecessarily with HIV.
More work to be done
Leadership does matter, but much more will be required if we are to achieve an AIDS-free generation. Global financial resources still will be required. Now is not the time for the global community to declare victory and retreat from the fight against HIV/AIDS. Additional essential clinical and laboratory infrastructure, health-professional capacity and innovative health care delivery strategies will be needed.
Programs specifically designed to meet the HIV prevention and treatment needs of infants and children never just happen. Children never are the low-hanging fruit. Pediatric catalysts almost always are necessary, often in the form of pediatricians, who can dispel myths that surround the care and treatment of children and inform program development. Here, US academic institutions and health professionals can play a pivotal role.
An AIDS-free generation may seem a distant dream, but effective treatment for US children with HIV/AIDS was a distant dream in 1990. Just 6 years later, children were being rescued from near-death by combination ART. Similarly, strategies for prevention of mother-to-child HIV transmission were only theoretical in 1990. By 1996, we had convincing data regarding practical prevention strategies utilizing antiretroviral medications, and routine testing and treatment of pregnant women with HIV was being rolled out nationally. The only difference now is that the tools we need to achieve an AIDS-free generation already are at our disposal. The question is, do we have the will and the commitment to make it a reality?
Mark W. Kline, MD, is J.S. Abercrombie Professor and Ralph D. Feigin Chair of Pediatrics at Baylor College of Medicine and Physician-in-Chief at Texas Children’s Hospital, Houston. Kline can be reached at: mkline@bcm.edu.
Disclosure: Kline reports no relevant financial disclosures.