Why do African children lack HIV treatment?

On the African continent, many children are left behind when it comes to HIV treatment: If untreated, around fifty percent of children living with HIV die before they reach their second birthday - this is the bleak outlook of a new UNAIDS report published in July.

Pediatric HIV shortfalls: UN report calls for action

The UN agency and its partners warn that progress towards ending AIDS among children in the age group of up to 14 years, adolescents and young women has stalled dramatically, adding that none of the targets for 2020 were met. The total number of children presently on treatment declined in numbers for the first time.

An estimated 620,000 children living with HIV in the 21 African countries that the report focused on were not receiving any antiretroviral therapy. Only six of these countries provided antiretroviral therapy to children living with HIV in 2020, according to the authors of the report. These countries are Kenya, Eswatini, Lesotho, Malawi, Namibia and Zimbabwe.

The global pediatric HIV shortfalls are a huge challenge, says Peter Ghys, Director of UNAIDS Strategic Information Department. With treatment numbers higher among adults than among children, why is this vulnerable group not on par with grown-ups?

High coverage in Eswatini

Complex dynamics underlay the declining rates for children on treatment during 2020. "Some of these complexities include the fact that children on treatment leave the 0-14 age group evey year. That results in a [statistical] reduction of the number of children in treatment," Ghys said in an interview with DW.

The reductions in treatment numbers among children also occurred in some countries because of the COVID-19 pandemic. Ghys said that different countries' public health systems were differently equipped to address the pandemic, with some systems simply being more evolved than others. Countries with overstretched public health systems appear to have made more mistakes such as neglecting HIV therapies in children.

One of the countries with a high coverage of treatment among children is Eswatini. "Of course, it is a small country. It has great ability to bring its national programs to the entire population, and also has a high coverage of treatment for children and also for adults," Ghys explained.

On the other end of the spectrum, the list of countries with a low coverage rate of treatment today include Angola, Chad, DRC, Burundi. Ghys says that the reason for the failed targets in these countries consist of a mix between aspects pertaining to the public health system and political priorities - in addition to the individual nations' ability to reach the entire population.

'Slip in the system'

"In addition, it has become clear that in recent years some children are not tested when they are newly born, or are tested but somehow there is a slip in the system and the children that are positive are not put on treatment," Ghys highlighted in a DW interview.

To remedy some of these lost opportunities early in children's lives, he emphasizes that there has been a great deal of focus on alternative testing strategies more recently: "One of those is called family testing where all the members in the family where the person is living with HIV are identified, offered testing and treatment."

The UN report states further that six countries (Nigeria, Mozambique, South Africa, Tanzania, Democratic Republic of the Congo and Zambia) accounted for nearly two thirds of children acquiring HIV in 2020, with Nigeria accounting for almost one in five cases.

South Africa: remaining stigma

In South Africa, stigma and discrimination still remain a major barrier to HIV response efforts, which also affects children, says Thembisile Xulu, Director of the South African National Aids Council (SANAC), in a DW interview.

About 11 percent of South African children in the relevant age group (0-14) have reportedly acquired HIV in 2020. Xulu agrees with UNAIDS Director Peter Ghys that other factors resulting in the treatment shortage include the impact of COVID-19.

"The hard lockdown in March last year resulted in a fear of contracting infections at health care facilties, and this affected negatively the routine access to health facilities by beneficiaries, including children," she told DW.

COVID lockdowns and more

There has also been a migration of caregivers from different parts of the country due to socio-economic impacts resulting from the COVID-19 pandemic, Xulu said. Typically, rural dwellers are increasingly moving to the urban centers in South Africa in search for work.

Xulu adds that there has also been a decline in overall public health during the pandemic, with lockdowns and other measures reinforcing unhealthy habits among adults; this, in turn, affects children who are dependent on adults to help with their healthcare needs, she stressed.

According to Xulu, South Africa is working on a number of interventions to get on track in terms of achieving better treatment goals. She says that innovative approaches are needed to ensure that adolescents remain committed to their treatment plans.

For example, pellets with a new formulation have been approved for use in the country - this formulation is easier to administer to children and should improve adherence to the daily regimen of antiretroviral therapy. Additional sites for dispensing and distributing medicine to chronically ill patients, including those with HIV-AIDS, are also being opened to increase access to medication.

In-depth evaluations in facilities and communities across South Africa are also being rolled out - in addition to key entry point testing and expanded community-based screening, testing, and referral.

More awareness and advocacy needed

As part of its efforts to combat HIV, SANAC says it also aims to integrate paired mother-baby appointment dates to enhance adherence to therapy plans and to make sure that mothers and their children can attend clinic appointments on the same day.

And although school schedules were severely interrupted in South Africa during various lockdowns, the school nutrition program in South Africa continues to provide food for vulnerable children.

Xulu hopes that strong awareness campaigns and better advocacy for children's rights lead to increased support, not just for children but also for their caregivers. But despite the fact that South Africa has the highest number of people with HIV-AIDS in any country, social stigma remains a major boon in achieving better results.