«II. About the Global Plan The Global Plan aims to eliminate new HIV infections among children by 2015 and keep their mothers alive. There are now ...»
The Global Plan Towards the Elimination of New HIV Infections Among
Children by 2015 and Keeping Their Mothers Alive
Prepared for the iERG
May 15, 2015
This is a preliminary report to the independent Expert Review Group (iERG). It provides our most
recent complete data (2013) and updates on 2014 implementation activities reflecting the progress
of the Global Plan towards the elimination of new HIV infections among children and keeping their
mothers alive (Global Plan). Data cleaning and country validation of 2014 progress is ongoing, and the final country data sign-off will be in mid-June 2015. However we are aware that this may be too late for the iERG, and thus we have prepared a preliminary report for this purpose.
Our report to you is informed by your post-2015 vision for the future of women’s and children’s health and for the future accountability arrangements needed to ensure that commitments to that vision are met. http://apps.who.int/iris/bitstream/10665/132673/1/9789241507523_eng.pdf?ua=1.
II. About the Global Plan The Global Plan aims to eliminate new HIV infections among children by 2015 and keep their mothers alive. There are now approximately 230 days to the end of 2015, when the Global Plan’s full achievements can be assessed (these data will be available in 2016). When it was developed, the Global Plan recognized the need to revolutionize approaches towards preventing mother-to-child transmission of HIV. However significant challenges remain but there are also opportunities for these to be overcome. In 2009, the baseline year on which the Global Plan bases its progress, an estimated 15.7 million women above the age of 15 were living with HIV globally, of whom 1.4 million became pregnant. Nearly 90% of these expectant mothers were from 22 countries1 in sub-Saharan Africa and India. To provide prevention, care and support for these women, several simultaneous
actions were needed:
1. Extraordinary leadership
2. Up-to-date national plans
3. Sufficient financial investment
4. Comprehensive and coordinated approach to HIV prevention and treatment for mothers and their children
5. Greater programmatic synergies and strategic integration
6. Adequate human resources for health
7. Structural impediments to scale up addressed
8. Access to essential supplies strengthened
9. Simplification The 22 Global Plan countries are as follows: Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, South Africa, Uganda, United Republic of Tanzania, Swaziland, Zambia and Zimbabwe. Together these countries accounted for 90% of new HIV infections among children in 2009, the baseline year of the Global Plan.
The Global Plan was officially launched at the UN General Assembly High Level Meeting on AIDS, held in June 2011. It is implemented by countries, supported by a consortium of partners co-chaired by UNAIDS and PEPFAR. Its goal is to eliminate new HIV infections among children and keeping their
mothers alive. The Global Plan has two targets:
Global Target #1: Reduce the number of new HIV infections among children by 90% Global Target #2: Reduce the number of AIDS-related maternal and paediatric deaths by 50% This year (2015), the Global Plan management opted not to convene the ministerial accountability meeting, normally held on the sidelines of the World Health Assembly; options are under review to hold a similar event later in the year. The data pertaining to the 2014 Global Plan activities will be presented at the UNAIDS MDG report, embargoed for planned release in July 2015. Countries are in the middle of validating the data, and the validation process will end in mid June. Therefore the results presented in our report to you focuses on 2013, acknowledging it does not yet reflect the newest in-coming information.
III. Key results from 2013 Prophylaxis and treatment among pregnant women: The Global Plan continued to make progress in 2013, although gains were fragile and greater momentum is still needed. For the first time since the 1990s, the number of new HIV infections among children in the 21 Global Plan priority countries in sub-Saharan Africa dropped to under 200 000 ([170 000–230 000]; note that data for India was not available). This represented a 43% decline in the number of new HIV infections among children in these 21 countries in Year 3 of this accelerated effort, relative to the 2009 baseline, providing reasons for optimism as the Global Plan pushes towards its 2015 goals of 90% reduction. It is anticipated that the results for 2014, which are being validated, will show even greater progress. In 2013, eight of the 21 high-burden countries had already achieved over 50% reduction in new HIV infections among children, including Botswana, Ethiopia, Ghana, Malawi, Mozambique, Namibia, South Africa, and Zimbabwe.
However, there were also some reasons for concern, as the pace of progress slowed between 2012 and 2013. In 2013, although twice as many (68%) pregnant women living with HIV in the priority countries received antiretroviral medicines to reduce the risk of HIV transmission to their children, this represented a gain of only 4 percentage points above 64% in 2012. Progress appeared to stall in several countries including Botswana, South Africa, Tanzania, Uganda and Zimbabwe. Progress reversed in several other countries including Chad, Ghana, Lesotho and Zambia. The reasons for these outcomes vary, including bottle-necks in service delivery and supply systems. Improvements in data systems may also have allowed for more accurate estimates in 2013 compared to previous years. Countries such as Botswana and South Africa had ARV coverage of nearly 90 percent among eligible women in 2012 already, and large additional gains may have become difficult to achieve.
Countries have kept abreast of innovations in PMTCT and have quickly adopted the 2013 WHO guidelines that recommend the most efficacious antiretroviral medicines through breastfeeding (Option B), or life-long treatment for pregnant women living with HIV (Option B+). WHO no longer recommends Option A and countries are in various stages of phasing this regimen. At the end of 2014, all 22 Global Plan countries had officially endorsed Option B or B+. Sixteen (16) of these had adopted Option B+, five of which have now achieved full nationwide implementation (see Table 1).
Table 1: ART National Policy for Pregnant and Breastfeeding Women Among 22 Global Plan Priority Countries, February 2015
The risk of HIV transmission from an HIV-positive mother to her child if she is not receiving any antiretroviral medicines ranges between 30% and 45% depending, on the duration of breastfeeding.
One of the important goals of the Global Plan is to reduce this risk to less than 5% among breastfeeding populations, and to less than 2% among non-breastfeeding populations. In 2009, prior to the launch of the Global Plan, the overall transmission rate (including breastfeeding) was 26% in the 21 Global Plan countries. Since the roll-out of the Global Plan, the rate has dropped to 16% (2013 data). Further analysis suggests that priority countries had achieved a six-week mother-to-child transmission rate of 7%, but this rose to 16% by the end of breastfeeding. Because the scale-up of PMTCT and more effective regimens have reduced the risk of HIV transmission during the pregnancy and delivery periods, the risk of HIV transmission is now concentrated during the breastfeeding period. Therefore, it is urgent that programmes provide effective PMTCT regimens to breastfeeding mothers during this period, in order to prevent children who are HIV-free at birth from acquiring the infection during breastfeeding.
With a modelled transmission rate of 2% in 2013, Botswana appears to have reached the Global Plan milestone of under two percent. South Africa was close behind, with a final transmission rate of 6%.
The remaining 19 countries have a 2013 HIV transmission rate of over six percent, including ten with transmission rates of over 15 percent (data not available for India).
Prophylaxis and treatment among infants WHO recommends that children exposed to HIV be tested within four to six weeks of birth, so that those who are already infected can start treatment immediately. This is, in part, because babies who are infected in-utero or during the intra-partum period have worse prognosis; the earlier infants are identified and placed on therapy, the better their clinical outcomes. Infants less than 18 months of age still have their mothers’ antibodies, which means that the standard rapid HIV test used to diagnose adults is not appropriate. In this population, HIV infection can only be definitively confirmed using a virological test. Currently the virological test is most often performed on dried blood spot specimens collected at local sites and then transported and analyzed in large centralized laboratories. This has sometimes led to long waiting periods before the results are returned to the caregiver, resulting in increased rates of loss to follow-up and failure to initiate treatment among those diagnosed as seropositive.
Infant diagnosis rates (both early diagnosis and final diagnosis after 18 months) remain poor in many countries, creating a bottleneck to scaling up treatment for children especially those younger than 18 months of age. Despite significant investment, among the priority countries 39% of children exposed to HIV received HIV virological testing within the first two months of life (2013 data). Only six of the priority countries were providing early infant diagnosis to more than 50% of children exposed to HIV: South Africa (94%), Swaziland (89%), Botswana (58%), Namibia (56%), Zambia (55%) and Zimbabwe (50%) (see Figure below). In the remaining priority countries, the number of infants receiving virological testing was less than 50%, unchanged or decreasing slightly from previous years.
In nine priority countries, the number of children exposed to HIV receiving virological testing was less than 25%. Follow-up care for mothers and their children must be strengthened post-partum and for the duration of breastfeeding, using appropriate opportunities in child health services, immunization and nutrition programmes for infant testing, in order to determine final HIV transmission status at the end of breastfeeding.
Effective 2013, UNAIDS estimates for paediatric HIV treatment are based on a denominator of all children living with HIV, and not only those eligible for HIV treatment, as was done previously. This is to allow greater comparability across countries with different antiretroviral eligibility criteria and to account for changes in those criteria over time. The results show that since 2009, the number of children receiving antiretroviral therapy had increased in all priority countries. Botswana had achieved universal access (defined as 80% coverage), with 84% of infected children receiving HIV treatment. Three priority countries – Namibia, South Africa and Swaziland – were providing treatment to nearly half the children living with HIV. However, most priority countries have a long way to go – Cameroon, Chad, Côte d’Ivoire, the Democratic Republic of Congo and Ethiopia provided treatment to less than 10% of their children living with HIV. In total, only 22% of children living with HIV were receiving HIV treatment in the 21 priority countries. Although this represents an increase from the 8% baseline in 2009, it is much lower than the 39% adult treatment coverage of in the 21 priority countries.
Low treatment coverage for children living with HIV is related to multiple factors, including challenges unique to children’s medicines, diagnosis, case-finding and linkage, and retention in care.