Counseling a newly diagnosed HIV patient in Kinshasa, Democratic Republic of Congo.

Counseling a newly diagnosed HIV patient in Kinshasa, Democratic Republic of Congo. / Tommy Trenchard for NPR

In 2015, global groups set ambitious goals to stem the HIV/AIDS epidemic. They aimed to bring down the number of new cases, particularly among children, teens and young women, by 2020 – and to bring up the number of people on HIV treatment.

On July 21, the final report came out. No targets were met.

This 5-year campaign is called "Start Free, Stay Free, AIDS Free" and was run by the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF, the World Health Organization and the United States President's Emergency Plan for AIDS Relief.

Here's a rundown of some of their key targets and the estimated outcomes:

  • Target number of children newly infected with HIV in 2020: 40,000
  • Number of children newly infected with HIV in 2020: 150,000
  • Target number of adolescents and young women newly infected with HIV by 2020: 100,000
  • Number of adolescents and young women newly infected with HIV by 2020: 260,000
  • Target number of HIV-positive children getting HIV medication by 2020: 1.4 million
  • Number of HIV-positive children getting HIV medication by 2020: 920,000

Dr. Mary Mahy, who is lead of the epidemiology team at UNAIDS and one of the report authors, is particularly alarmed by the HIV medication statistics for children. In 2019, the group estimated 940,000 children would be on anti-retroviral drugs compared to 920,000 in 2020.

"We've always [previously] managed to get more children on treatment," she says "That's what's shocking and upsetting me."

The Pandemic Hurt — But It Wasn't The Only Obstacle

So what happened?

Mahy and others familiar with the HIV/AIDS epidemic cite several possible reasons for the failure to meet its targets.

The report notes that the global COVID-19 crisis has "severely disrupted" the delivery of services to youth as well as older populations.

But there are other pre-pandemic issues: It has always been difficult to identify children and adults who are infected and need treatment. The report authors also believe governments around the world are not doing enough to make a dent in the epidemic.

Dr. Chewe Luo, associate director and chief of the HIV/AIDS section at UNICEF, believes, "To improve access to treatment starts with being able to identify the infected."

Especially during the pandemic, it's been hard to test pregnant women to see if they're HIV-positive and then to provide treatment to prevent their children from being infected. The report's data suggests that 99,000 children were infected with HIV in 2020 because pregnant or breastfeeding HIV-positive women didn't get diagnosed and treated. Babies born with HIV are at extremely high risk for dying from AIDS. Without treatment, half of these children die by age 2.

Finding and testing breastfeeding women is another important step in ending the HIV epidemic for children. Children infected through breastfeeding are easily missed because they seem fairly healthy to their families; their immune systems are already stronger and better at fighting infections than a newborn's. So these kids don't show up to doctors with characteristic AIDS-defining symptoms like failure to grow, chronic severe diarrhea and repeated bouts of pneumonia. The children might grow up and not even know their HIV status until they become sexually active themselves, says Dr. Gilles Van Cutsem, current lead of the international AIDS working group and a senior HIV adviser for Doctors Without Borders not affiliated with the report.

And then there's the issue of identifying kids who need HIV treatment. Even if they are tested, it can take days for diagnostic results to come back — and families don't always follow up to get the diagnosis, making it hard to start treatment.

Luo also thinks that governments and donors simply aren't doing enough to address the HIV/AIDS epidemic in kids.

Faster Testing

Yet the report authors aren't resigned to a future of minimal progress. They are excited about several strategies already in practice that, if ramped up, could turn the tide in the fight against the HIV/AIDS epidemic.

Family testing is one such approach that could lead to more accurate diagnosis of children. Here's how it works: Parents who are picking up their own HIV medicines are asked to bring their children along to be tested. Experts think scaling up family testing can help get more at-risk children screened, especially in countries with high rates of HIV infection.

The report also describes new, simple "point-of-care" testing machines that make fast, same-day HIV results possible at clinics. These machines have been perfected over the last 3 to 4 years, according to Luo. Now more financial support is needed for countries to obtain and roll out these machines.

Tastier (And Less Onerous) Kid Meds

HIV-positive children and adolescents also struggle with taking HIV medicines, which can taste horrible and cause vomiting and skin rashes. In addition, parents have to keep track of multiple daily medications, and some are hard to administer. "Syrup [medications] are nightmares," says Van Cutsem, since parents need to keep them fresh in fridges (which aren't often in the home) and must measure the syrup into a syringe to drip into a baby's mouth.

A new medication called dolutegravir has been transforming the battle against HIV and AIDS for both kids and adults. Dolutegravir comes in a berry flavor and dissolves in water, making it easier for kids to take. In 2020, the World Health Organization officially recommended dolutegravir as first-line treatment for everyone, including infants as young as 4 weeks old.

The ODYSSEY clinical trial, conducted in several countries, just concluded in June 2021 with positive results too. This study showed that HIV-infected children and adolescents who took dolutegravir-based regimens had better control of their disease and more suppressed viral load. Van Cutsem says that dolutegravir is "positive news for once," boding well for the countries that have adopted it as the backbone of their HIV treatment.

The report also highlights how communities can help bridge the gaps in finding and treating kids and teens with HIV. Countries like Eswatini and Malawi lean on the important relationships between mothers, who can be sources of comfort and advice for each other. The continuing global growth of cell phone usage has enabled many women to connect with each other. Acting as "mentor mothers," they provide much-needed support for women who are just learning how to navigate their own diagnosis and treatment, Luo says. "They're a testimony—'I'm fine. My baby is fine. See!' It's absolutely phenomenal to watch."

Now What?

Though the 2020 results of the "Start Free, Stay Free, AIDS Free" final report are disappointing, the groups involved have set even more ambitious targets for 2025 — to not only reverse current trends but make true progress.

They propose a "95-95-95" Global AIDS Strategy to get back on track in wiping out the HIV/AIDS epidemic among children, adolescents and young women. Their targets for 2025 include:

  • 95% of pregnant women get HIV testing
  • 95% of HIV-positive pregnant and breastfeeding women achieve suppressed HIV viral load through treatment
  • 95% of at-risk children get HIV testing at age 2 months and after breastfeeding ends.

And they want to persuade local governments and communities around the world to do more to end this global health threat.

"When it comes to children," reflects Luo, "that voice is void sometimes at the country level."

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Tags: HIV treatment  HIV epidemic  HIV-AIDS  HIV prevention