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Editor's Note: In a recent interview with Craig McClure, Chief of the HIV/AIDS section at UNICEF New York’s headquarters, we discussed their latest report examining the progress being made in the response to HIV and AIDS for children. The report highlights key strategies to prevent HIV and to accelerate access to the treatment, care and support that children affected by AIDS need to remain alive and well. Read the report here.
In this new report on Children and AIDS, what are some findings that surprised you the most?
The efforts, both global and national, to prevent new HIV infections among infants due to mother-to-child transmission of the virus are nothing short of stunning, as shown in the latest Children and AIDS Stocktaking Report from November 2013. The number of infections has more than halved since 2005 from 540,000 to 260,000 in 2012 in low and middle income countries, and the pace of progress has accelerated particularly during the last three years.
We’ve seen remarkable progress in some of the highest-burden countries. For example, new infections among children aged 0–14 years old declined between 2009- 2012 by 76 per cent in Ghana, 58 per cent in Namibia, 55 per cent in Zimbabwe, 52 per cent in Malawi and Botswana, and 50 per cent in Zambia and Ethiopia. In other countries, progress has been slower and intensified efforts are needed to support them –Nigeria and DRC are two cases in point.
The pace at which research and innovations have been translated into practice has been surprising. For example, pregnant women living with HIV can now take a single pill once per day for lifelong treatment – replacing the previous regimen of several pills several times per day with less side effects and more protection – this new approach protects the mother’s own health as well as preventing transmission to her child and her sexual partner.
And yet, as remarkable as progress has been, we need to step up efforts to reach our joint global target of reducing mother-to-child transmission of HIV by 90 per cent by 2015. To achieve this goal, we need to MORE THAN double our current pace – so there is no resting on our laurels – its not over.
What were the most worrisome trends or insights that came out of the new country data from 2012?
Far too many children living with HIV are still not receiving the treatment they need. About 210,000 children (0–14 years) died from AIDS related illnesses in 2012 alone because they didn’t get treatment. Children are only half as likely as adults to receive treatment, without which, one in three infants born with HIV will die before their first birthday, and half will die before their second birthday.
We also need to give much more attention to adolescents, who have often been neglected in global and national HIV-response strategies. The new report shows that reductions in new HIV infections among adolescents (10- 19 year-olds) have been modest. Marginalized adolescents, including girls, adolescent males who have sex with males, adolescents who inject drugs, and sexually exploited adolescents are particularly vulnerable to HIV and need targeted support. In fact, adolescents are the only group in which the number of AIDS-related deaths increased between 2005 and 2012. While AIDS-related deaths for all ages dropped by 30 per cent, for adolescents, AIDS-related deaths increased 50 per cent during this period.
That is a huge worry, and makes us want to do more, and sooner.
At the same time, are there signs of hope and progress?
While testing and treating infants is more complicated, with innovations including new technologies for early infant testing in primary health-care facilities in communities, and greater attention to making services more available, we are confident that we can get treatment to more children - and to adolescents too. .
For adolescents, there are encouraging signs that behavior is changing among this age group. For example, more adolescents are waiting longer to start having sex, having fewer partners, and using condoms more often than before – but these changes have not been sufficient to make the impact needed on new HIV infections.
The trend is going in the right direction, but our best efforts have not been applied consistently enough to make a major difference in new infections. More investment in high-impact interventions such as condoms and antiretroviral treatment, and targeting the most at-risk adolescents is critical if we are to ensure that more adolescents are tested, treated and cared for.
What interventions are particularly effective when trying to address this issue?
The high-impact interventions in the AIDS-response for adolescents are clear. They include distribution and promotion of condoms, antiretroviral treatment, voluntary medical male circumcision in high HIV prevalence areas, as well as harm reduction interventions particularly for injecting drug use and behavior change communications and community-based efforts targeting the most at-risk adolescents. Needless to say, engaging young people themselves as agents of change is critical.
A new analysis featured in the report shows that two million adolescents could avoid becoming infected by 2020 if we increase investment in the mentioned proven high-impact interventions - balanced with investments in underlying structural factors like gender equality, education, social protection. This requires increasing the amount of investment for adolescents from the 2010 level of US$3.8 billion to about US$5.5 billion by 2014.
What has to happen for those interventions to scale up?
Political will and leadership are critical, along with directing investments towards the right interventions in a timely manner for adolescents. Speaking up on the sometimes difficult issues of sex and drug use among adolescents is an important role for leaders to play.
Historically, programming for adolescents has been overlooked – they are a group that falls between political priorities and policies – because they are neither children nor adults, but with distinctly different needs. This has to be recognized.
How does the issue of children and AIDS relate to the wider AIDS crisis, and indeed other issues affecting children, and how can we collaborate across sectors to deliver a holistic intervention?
The issue of Children and AIDS was not on the agenda when the Millennium Development Goals started, but now it is a central component of the AIDS response.
AIDS has to be taken out of isolation – and instead genuinely integrated across sectors - in so doing, recognizing the AIDS response as a priority for the world’s agenda beyond 2015. Education, social protection, gender equality and human rights are all essential elements in protecting the rights of all children. For adolescents, access to education is critical, particularly education about sexual and reproductive health. It is also important to remember that there are still almost 18 million orphans who have lost one or both parents to AIDS. Much greater collaboration across sectors can help alleviate hardship, reduce the risk of HIV infection and support long-term adherence to medication and continuity of care for children and their families.
Where do we go from here?
An AIDS-free generation will only be achieved through strong leadership from government, with partners aligning their work towards common objectives. The active role of civil society and affected communities has been a strength of the AIDS response that must continue – from planning, decision-making and implementation to awareness-raising and accountability.
Accurate data is critical to effective advocacy – and we must continue to improve the scope of the data we collect – especially in terms of adolescents.
Decentralization is a key issue – meaning, that we must bring services closer to communities, including by allowing nurses and community health workers to provide some services formerly provided by doctors, and by also engaging communities to be involved in raising awareness as well as direct delivery of some services.
We know what to do!
The challenge now is to apply the knowledge that already exists, continue to focus on the most vulnerable and marginalized children and adolescents, and pursue new opportunities and innovations—while using finite resources as efficiently and effectively as possible. Despite truly remarkable progress, the struggle isn’t over, but we are certainly on the right track.