In 2018, more than half of the children and adolescents living with HIV globally are in Eastern and Southern Africa and, according to UNICEF, by 2030 this will not have changed.
Aids kills 76 adolescents around the world every day, and some 360,000 will die by 2030 unless “urgent” action is taken. A Daily Maverick report says this is according to the UN International Children’s Emergency Fund (UNICEF) which released research to mark World AIDS Day. “The report makes it clear, without the shadow of a doubt, that the world is off track when it comes to ending Aids among children and adolescents by 2030,” said UNICEF’s executive director Henrietta Fore about the international commitment to end the epidemic as a public health threat in just over a decade.
In 2018, more than half of the children and adolescents living with HIV globally are in Eastern and Southern Africa. The research noted that, by 2030, despite comparatively faster declines in prevalence, these two regions “will still be home to the majority of those aged 0-19 years living with HIV”. While infection rates have dropped around the world “this downward trajectory is too slow, particularly among adolescents”, UNICEF said.
According to the organisation, the major “shortfalls” in fighting HIV in young people are the failures in preventing infection and in addressing the “structural and behavioural drivers of the epidemic”. “Many children and adolescents do not know whether they have HIV or not, and among those who have been found HIV-positive and put on treatment, very few adhere to that treatment,” it noted.
Dr Lee Fairlie, director of child and adolescent health at the Wits Reproductive Health and HIV Institute, said in the report that treating HIV in adolescence is particularly challenging and is the one life-stage where “adherence does deteriorate”. “There are lots of complexities – children’s busy lifestyles with school and sport – and sometimes trying to fit antiretrovirals in is a challenge,” she said. According to Fairlie, sometimes young people, especially those who are unemployed or face socioeconomic issues at home, struggle to physically get to clinics.
In children who acquired HIV perinatally, or just before, during or after birth, relatives sometimes choose to delay disclosing their HIV status to them until adolescence, which “has a direct impact on adherence”. “And often, if they are feeling well, taking medication is a reminder of their illness,” she said. “In the end there are many different reasons why adolescents may not take their treatment.”
The report quotes Fairlie as saying that while South Africa is doing relatively well in terms of treating children and preventing HIV around birth, UNICEF noted that, today, there are 3m children and adolescents living with HIV around the world, which will drop to 1.9m by 2030. To meet the global targets the figure needs to drop to at most 1.4m.
UNICEF’s Fore said that prevention of mother-to-child infection programmes are “paying off but haven’t gone far enough, while programmes to treat the virus and prevent it from spreading among older children are nowhere near what they should be”. The slowest decline in the number of children living with HIV is expected to be in Central and West Africa. According to Médecins Sans Frontières (Doctors Without Borders), countries in West and Central Africa face a “major overall funding gap”. The resources needed to end Aids in the region by 2030 were 81% greater than was available in 2017, yet this is where 30% of the world’s Aids-related deaths occur, said the organisation.
The report says to its credit South Africa has the largest HIV treatment programme in the world. But deputy director-general at the Health Department, Dr Yogan Pillay is quoted in the report as saying that only 3,011 young people are receiving one of the most effective prevention interventions, termed pre-exposure prophylaxis or PrEP. The research recommends the scale-up of PrEP as one of nine key interventions to combat HIV in young people.
Another recommendation is the implementation of “cash + care” programmes. The authors noted that these cash grants work “by offering cash as an incentive to clinic or school attendance, or treatment uptake and adherence” and “can greatly reduce HIV risk among adolescents and improve retention in care”. “Cash + care seems especially useful for adolescents living in poverty, as well as for adolescent girls.” The report says this intervention has had a positive impact in South Africa through the child support and foster care grants.
According to 2013 research, girls were half as likely to be having transactional sex or become involved with older partners if they received a child-focused grant or attended a free school. Yet, globally, every day 700 more adolescents between the ages of 10 and 19 are infected with HIV. This equates to one child every two minutes, according to UNICEF, which called for “urgent” scale-up of treatment and prevention programmes for this group.
While new HIV infections among younger children will be cut in half by 2030, a reduction of only 29% is expected in adolescents. Said Fore: “We can’t win the fight against HIV if we don’t accelerate progress in preventing transmission to the next generation.”
Young people must take the lead in the fight against the HIV/Aids epidemic. According to a report in The Sunday Independent, this was the message of the deputy president and SA National Aids Council chair David Mabuza who said the voices of young people had been missing in the conversations about the epidemic. “It’s only young people who can stand up and fight this and I am happy that finally you have realised the need to stand up. No one is going to liberate you from this challenge except yourself,” said Mabuza.
The report says South Africa, home to over 7m people living with HIV and about 4m on antiretroviral (ARV) treatment, has made major strides in the past decade, running the biggest ARV roll-out in the world. Mabuza hailed the progress made but warned that the “road ahead remains long but not difficult”.
He lamented how the disease targeted the most vulnerable in society. “It is a parasite that targets the poor and the vulnerable. It thrives in conditions where women cannot negotiate condom use from a position of power. It depends on superstition, ignorance and stigma to kill hope, to kill people and to kill aspirations. It is merciless in its targeting of innocent children and young girls.”
Meanwhile, the report says, Médecins Sans Frontières (MSF) shone a spotlight on the lack of appropriate paediatric HIV drugs. MSF slammed pharmaceutical companies for “dragging their feet” in this regard. “Pharmaceutical corporations simply don’t consider children with HIV a priority, forcing us to use older, sub-optimal treatments for the youngest people in our care that make it harder for them to stick to their treatment.
“Worse, increasing resistance to existing HIV medicines in sub-Saharan African countries means that the older treatments may not work in infants and children, who are in urgent need of better treatment options,” said MSF Malawi medical co-ordinator Dr David Maman.
Health organisations say although the country has made great strides, not only in its attitude to the pandemic and the accessibility of treatment, more challenges continue to tip the scale in an unfavourable direction. National chair of the Treatment Action Campaign Sibongile Tshabalala said in a Cape Argus report: “As much as we are able to access treatment, we still have around seven million people who are HIV positive and we only have just over a half of those people, around four million, who are on treatment.
“At least the situation has changed from what it was before. We have people living longer, the denialism isn’t there either and when we talk about stigma and discrimination, it is no longer that prevalent. People are more accepting of those living with HIV and who are on treatment. We see more people who see the disease as another chronic illness. But, we still have challenges. The issue of stock-outs in facilities, where a person living with HIV will go to a clinic or hospital and not access treatment in a manner in which they are supposed to.
“Especially when it comes to the second-line regimen given to patients who are resistant to the first line of treatment, you find that in most facilities in provinces, there is no second-line regimen. And you find that patients are put on first-line regimens because there is nowhere else to find it.”
Tshabalala said in the report that the state of healthcare facilities was also of great concern. “The issues we find plaguing a lot of our healthcare facilities is the maladministration and corruption, the lack of political will, where you find that services don’t reach the people they are meant for, and that has been the outcry to the minister to deal with corruption and increase human resources,” she added.
“And now, we are talking about the National Health Insurance, and the big question is: how can we implement it when we have all these problems we have? And when you look at our health facilities, they are in crisis.
“We are going to lose the battle against bringing down high infection rates because, as much as we have good policies in the country, implementing them is something else.
“The minister introduced the ‘test and treat’ campaign, as part of other preventative campaigns. You find that a person who is on treatment is able to keep their viral load low and chances of infecting others is low, but when we have situations like stock-outs, the opposite happens.”
Just over 1m Capetonians have tested for HIV in the past year, setting a new record, the City of Cape Town said on the eve the 30th anniversary of World Aids Day. The Times reports that JP Smith, the mayoral committee member for social services, attributed the success of the HIV screening programme to the public health sector’s efforts and its NGO partners.
Between September 2017 and October, 1,065,386 people were tested at city clinics, he said, and the number was expected to increase when the city introduces self-screening in the near future. The population of Cape Town is just under 4m.
Even though HIV/Aids is now regarded as a chronic condition rather than a death sentence, Smith is quoted in the report as saying the journey started with testing and knowing your status. Data suggests that most HIV-positive Capetonians already know their status, but Smith said some had never started lifesaving antiretroviral treatment, while others had stopped taking their medication.
“Ideally, everyone who is HIV-positive should be on ART for their own health benefit, but also to protect others, such as their sexual partners, from acquiring HIV," he said. "We urge all those who are HIV positive to take steps to get onto treatment, or to get back onto treatment.”
The report says to improve access to treatment and speed up collection of medication, the city had introduced ART Clubs for stable patients, and was piloting a new appointment system.
In Russia, stigma around homosexuality and drug use means it and some former Soviet Union countries risk developing out-of-control HIV epidemics. The Guardian reports that experts were commenting on data that showed a record number of new cases last year.
Most new cases in the former Soviet Union in 2017 were from heterosexual sex as the disease spreads beyond high-risk groups, according to the World Health Organisation (WHO) and the European Centre for Disease Prevention and Control. The increased rate of new diagnoses in the region since 2012 runs against a global decline and Masoud Dara, HIV specialist at the WHO, said it could be “an early indication of overspill in the general population”.
“HIV starts off (in) key populations – meaning drug users, commercial sex workers and men having sex with men – but after that it (increases) exponentially … if there is no more intervention,” Dara said.
In Russia, official data shows there were more than 104,000 new HIV diagnoses in 2017, taking total cases to more than 1.2m. But the report quotes experts as saying this is probably an understatement. “We don’t have enough medication, we don’t treat every patient,” said Nikolay Lunchenkov, a doctor at the Moscow regional Aids centre. “We are increasing the number of people who receive antiretroviral therapy, but it’s still not enough.”
The number of HIV treatment courses bought by the Russian government rose 37% to about 360,000 last year according to the NGO Treatment Preparedness Coalition. But, the report says, methadone, which research has shown helps to prevent injecting drug users passing on HIV, is banned in Russia.
“We also don’t have enough data about men who have sex with other men, because of high levels of stigma,” said Lunchenkov, who is openly gay. The number of Russian men who were infected with HIV through having sex with another man more than doubled to 695 between 2008 and 2015, according to official data.
The report says discrimination against LGBTI people means those at risk of HIV/Aids are afraid to seek out testing and treatment, experts say. Russia was ranked Europe’s second least LGBT-friendly nation in 2016 by ILGA-Europe, a network of European LGBT groups. And a requirement introduced in 2012 for some international NGOs working in Russia to register as “foreign agents” led to a decrease in organisations working with groups vulnerable to HIV, said Oli Stevens, a HIV researcher based in Britain. “The message was very clear, MSM (men having sex with men) are not us, they are the other, they are not part of society we’re trying to build,” said Stevens.
In the rest of the former Soviet Union new cases of infected drug users have fallen 45% to 6,218 a year in a decade, while new cases of heterosexual transmission increased 59% to almost 18,000.
The report says activists blame widespread discrimination against LGBTI people for an eight-fold rise in transmission among men having sex with men, to more than 1,000 cases annually. “State-sponsored homophobia and transphobia (have become) a crucial issue,” said Yuri Yoursky of the Eurasian Coalition on Male Health, which supports men with HIV/Aids in the region.
Meanwhile, in Namibia’s war against HIV, a data-driven on-the-ground approach has helped it become one of the most successful countries in tackling its spread. BBC News reports that red-uniformed health workers are field officers, who report to a troop commander, who in turn is under a division commander. Rather than guns, their weapons are a small plastic table and a cooler bag filled with ice packs and HIV tests.
Leontine Iipinge and Maria Johannes have walked more than 3km (2 miles) from their base in the Oshana region to visit 79-year old Harvey Davis and his wife, Ruth Nasidengo. The initials TCE, meaning Total Control of Epidemic, stand out in bold letters on their shirts. It is a programme run by a national NGO, Development Aid from People to People (Dapp Namibia). The field workers are two of more than 200 TCE health workers serving a population of nearly 182,000.
The report says Nasidengo, a mother of twins, has been living with HIV for over a decade and has been a client of TCE for two years. But this visit is about her husband as he is about to get his first home HIV test. The ice packs in the cooler maintain the correct temperature for the rapid tests. With his 11-month-old daughter, Dora, sitting on his lap Davis watches as Iipinge unpacks and disinfects her instruments and pricks his finger. "I'm not worried," he quips, "but it sure looks like Dora is."
The report says as the 15 minutes tick by before the result is known, Iipinge explains how testing the partners of people with HIV helps contain the spread of the virus. Back at their base in Oshakati town, they compile data of all people known to be HIV-positive and then set about tracing their sexual partners to establish their HIV status. The rapid test looks for HIV antibodies in the blood and the results are indicated by stripes appearing in the window of the device.
As Davis and his daughter watch, a single stripe appears showing that he is HIV-negative (two stripes indicates a positive result). But he is still referred to a hospital as he needs to be given drugs that reduce the risk of contracting the virus from someone who is HIV-positive by 90%.
The report says TCE field officers have worked in this area for 14 years. They have built community trust and respect but not everyone can be easily persuaded to take an HIV test.
The next stop for Iipinge and Johannes is about 12km away and they are heading to the home of Lucas Angula in the Evululuko township. He found out that he was HIV-positive just last month, but it had taken his wife, Matilda Ipandula, 10 years to convince him to take the test: “We would always fight and argue whenever I brought up the issue of HIV testing with my husband," she says. "He refused to listen and that's why I asked our neighbour to get involved. It was difficult but it had to be done."
The report says the neighbour, Emirita Kuutondokwa, now forms part of Angula's trio, a support group made up of someone who is HIV-positive and two others. He says their encouragement has helped him deal with his diagnosis and take the drugs that help contain the spread of the virus.
The report says support is a key ingredient to the success in containing the spread of HIV here. Close to Angula's house, a small knot of people have gathered under a Marula fruit tree. They are singing a song, in the Oshiwambo language, about how they are the lucky ones. This is what is known as a Community Adherence Club – a group of 12 people who are all HIV-positive. They take turns to collect medication from the clinic 20km away. This frees the remaining 11 to get on with other things and avoids clogging up the clinic.
After seeing to her clients, the division commander, Johannes, joins the group to shake off the tension of the day as they dance around the tree. "When you get into this, it's first about the job and the salary but as you stay it becomes about the people and the passion," she is quoted in the report as saying. "I've had field officers here who have only stayed for five months because they feel what they get as a salary does not compensate the time they spend at work but the ones that stay, they have passion to be with the people, to work with the people, to improve the lives of the people."
The report says newly released data by the US President's Emergency Plan for Aids Relief (PEPFAR) shows it is this community-centred approach that has helped Namibia exceed some of the 90-90-90 targets set by UNAIDS in 2014.
The figures measure: the percentage of people who are thought to be HIV-positive who know their status; the percentage of people who know their status who are taking antiretroviral drugs; and the percentage of people who are taking the drugs who have an undetectable level of HIV – for Namibia, the figures are 86%, 96% and 91% respectively.
Its neighbour, South Africa, the country with the highest number of HIV infections in the world, scores 90-68-78. But Health Minister Dr Bernard Haufiku says now is not the time for complacency. "There is a real possibility that we will be able to reach our target by the date set by UNAIDS (2020), we just have to give it a little bit of a push because we are almost there, just a few percentage left. We need to focus, especially on the prevention campaigns in the field, targeting young people that have not been tested."
The report says Namibia used to have one of the highest HIV-prevalence rates in the world, but in the past 15 years, the number of new HIV infections has halved. But the high infection rate among young women aged 15-24 continues to worry health officials here. The health minister adds that on the 30th anniversary of World Aids Day, he will be encouraging young men to get tested and treated.
In Namibia, the report says it seems to be the older generation, men like Davis and Angula, who are setting the example.
[link url="https://www.dailymaverick.co.za/article/2018-11-30-world-set-to-miss-2030-target-of-ending-aids-among-children-and-adolescents/"]Daily Maverick report[/link]
[link url="https://data.unicef.org/resources/children-hiv-and-aids-2030/"]UNICEF report[/link]
[link url="http://thesundayindependent.newspaperdirect.com/epaper/viewer.aspx"]The Sunday Independent[/link]
[link url="http://capeargus.newspaperdirect.com/epaper/Interstitial.aspx"]Cape Argus report (subscription needed)[/link]
[link url="https://www.timeslive.co.za/news/south-africa/2018-11-30-cape-town-chalks-up-million-hiv-tests-in-a-year/"]The Times report[/link]
[link url="https://www.theguardian.com/world/2018/nov/29/stigma-means-russia-risks-hiv-epidemic-as-cases-rise"]The Guardian report[/link]
[link url="https://www.bbc.com/news/world-africa-46397877"]BBC News report[/link]
[link url="https://phia.icap.columbia.edu/"]PEPFAR material[/link]