Pediatric AIDS: Progress But Then a Plateau | AIDS 2024

Despite substantial progress in reducing vertical transmission from mothers to children, efforts to curtail the HIV/AIDS among children and adolescents are plateauing in some respects and falling short of the goals set by the Joint United Nations Programme on HIV/AIDS (UNAIDS) , according to a leading investigator of HIV/AIDS treatment of children.

Anna Turkova, M.D.

Speaking for 40 minutes at the opening plenary session of the International AIDS Society’s AIDS 2024 meeting this morning in Munich, Germany, Anna Turkova, M.D., spoke optimistically about the potential for long-acting injectable antiretrovirals to alter the course of the pediatric AIDS worldwide while also emphasizing the effectiveness nonpharmaceutical interventions that provide social support.

“Antiretrovirals alone can’t treat HIV. To keep children and adolescents alive and enable them to reach their life potential, families and young people need support in many areas,” said Turkova, and then mentioned food, nutrition, education and dealing with stigma. Turkova singled out SEARCH Youth, a youth-focused program tested in Kenya and Uganda, as a “beautiful example” of an intervention that didn’t depend on antiretrovirals that was effective in increasing virologic suppression.

Turkova, a research clinician at the clinical trials united at University College London, is the lead investigator on several large, global trials assessing new treatments for HIV and AIDS treatment. She led the ODYSSEY trial, conducted in South Africa, Uganda and Zimbabwe that established dolutegravir-based antiretroviral was superior to other regimens in children and infants.

Perhaps setting the tone for the three-day conference, Turkova balanced kudos for the achievements in the global effort to combat pediatric AIDS with data and observations chronicling recent shortcomings and flagging efforts.

In 2023, there were 1.4 million children in the world living with HIV and an additional 1 million older adolescents, ages,15-19, infected with the virus. Most live in the global south, she said, and 60% in eastern southern Africa. Turkova noted the striking similarity between the map showing where children living with HIV reside and the global poverty map.

That’s the statistical and geographic backdrop to what Turkova described as the “remarkable progress” made in stopping vertical transmission of HIV from infected mothers to children, which involves both the mothers and the children taking antiretroviral medication. The number of new infections has been halved over the past decade and the number of AIDS-related deaths among children has dropped by more than that.

Programs to stop vertical transmission of syphilis and hepatitis B are also meeting with some success. “We are now firmly on the path of triple elimination of vertical transmission of HIV, syphilis and hepatitis B,” said Turkova. “Prevention of three infections allows us to leverage cross-cutting opportunities for investments across may areas and make a substantial impact on health outcomes in children.”

Turkova said that Cuba, in 2015, was the first country to eliminate HIV vertical transmission and now 18 have validated that they have done so. She credited the validation process with requiring government to commit to policies and prioritize women’s health.

But Turkova did not take a victory lap. Progress in halting vertical transmission has slowed, she said; in 2023, the vertical transmission rate was 10% worldwide, she said. Some regions (eastern Europe, central Asia) have made strides but others haven’t. Turkova noted that in North Africa and the Middle East, where the prevalence of HIV is low and use of antiretroviral medication low, the vertical transmission rate is 1 in 3 infant exposed infants acquiring HIV.

Globally, just under half of all new infections of infants are due to infected mother not being treated with antiretroviral therapy when they were pregnant or breastfeeding and one-quarter occur women who have been newly infected, Turkova said. Approximately 43% occur of new infections of infants occur during breast feeding.

“These data call for better programs—for mothers to be tested, diagnosed and receive ART [antiretroviral therapy] during pregnancy and throughout breastfeeding,” Turkova said.

Children and adolescents are lagging behind adults when it comes to two of the three of UNAIDS’ 95-95-95 goals, test and virological suppression, according to data cited by Turkova.

Among adults living with HIV, 87% have been tested and identified as being infected with the virus. The UNAIDS goal is 95%, thus the 95-95-95 label for the goals. Among children, that proportion is just 66%.

There is also a gap between treated adults achieving virological suppression (94%) and children (84%).

Early infant diagnosis (EID) programs have been started to identify children who haven’t been tested for HIV. Health officials have Eastern Europe, Central Asia and eastern southern Africa embraced EID. According to Turkova, the coverage in those regions is 80%.

But Turkova discussed the programs limitations. For example, they are not likely to identify infants living with the virus if their mothers are not engaged with the healthcare system. Turkova said programs that deal with HIV at the community level will also help with testing. She also said that stigma and ignorance about HIV are also factors in testing shortfalls. “If we want to find undiagnosed children, we all need to take action to improve knowledge of HIV in general population," she said.

Turkova discussed various oral regimens for treating HIV in children, noting that resistance to dolutegravir is emerging. Groups are collaborating to make generic alternatives to dolutegravir available in low-and middle-income countries. Generic versions of the TAF/XTC regimen — which consists of tenofovir alafenamide and either emtricitabine or lamivudine — is not available. Turkova said the absence of a generic version poses equity issues that calls for urgent action.

She emphasized that choice is important in treatment and that access to long-acting injectable antivirals as an alternative to oral drugs is essential. Turkova said the long-acting injectable could revolutionize prevention of vertical transmission, used as preexposure prophylaxis for women during pregnancy and breastfeeding and as postnatal prophylaxis for infants. The long-acting injectables include cabotegravir, which is marketed under the name Apretude, and lenacapavir, which is marketed under the name Sunlenca.

“But we need now a clear plan for rapid, equitable and affordable access to long-acting injectables, and for this we need to combine our efforts,” Turkova said. “We need strong community advocacy. From the pharmaceutical companies we need voluntary license —and not only for prevention but also for treatment. We need technology transfer to generic companies. We need targeted donor investment, accelerating generic development. And from researchers we need adult studies to include to include adolescents and pregnant women.”