Year in and out, experts gather and highlight research around HIV prevention, treatment, and even cures that promise to have a very real effect on people living with HIV. But there remain notable gaps, not just in bridging the science but in reaching the most vulnerable, including children.
In 2015, the World Health Organisation issued global guidelines recommending treatment for all people with HIV as soon as possible after diagnosis. This ‘treat all’ approach applies to adults and children. It has led to substantial increases in the proportion of people with HIV on treatment and reductions in HIV-related deaths. But HIV treatment coverage in children lags behind adults in the ‘treat all’ era.
“Children are left behind in drug-related research, drug formulations, and donor investments for HIV activities and programmes, and the existing gaps in HIV service delivery for children and the adolescent population are inimical to ending the HIV epidemic by 2030 in Nigeria,” said Dr Avese Torbunde, the country manager for the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF).
The United Nations Children’s Fund (UNICEF) says in a report that about 30 percent of AIDS-related deaths in 2020 occurred in children. Alarmingly, only about 3.5 percent of the 1,629,427 Nigerians receiving antiretroviral treatment (ART) are children, revealing a big treatment gap.
The report added, “Nigeria has the highest number of children and adolescents aged zero to 19 years living with HIV in West and Central Africa, with an estimate of 190,000.”
Insufficient access to HIV treatment for children
The Country Manager for EGPAF, Dr Avese Torbunde, speaking at a media briefing in Abuja with the theme “Now is the Time: Fighting Paediatric HIV Through Strategic Partnership,” said the existing gaps in HIV service delivery for children and the adolescent population are inimical to ending the HIV epidemic by 2030 in Nigeria.
According to Dr Torbunde, although programmes for adults on HIV are doing very well, the country cannot say it has achieved success in its HIV interventions if children and adolescents living with HIV/AIDS continue to be left behind on drug treatment and testing, HIV research, and viral load suppression rates.
“We don’t hear about children when drug trials start. Children are talked about much later, when things have advanced. But it is still children who cannot wait. Science tells us that if a child was born with HIV today and you did nothing, half of them would have died before their second birthday.
“So, it is an emergency; it cannot wait, and yet these are the people being made to wait. Children should be part of the discussion right from the start of the discussion on anything regarding treatment, testing, viral load suppression, and HIV research.
“The number of children on treatment is about 34 percent, whereas the general population is close to 100%, indicating that we are not treating enough children in comparison to adults.
“In adults, you see a very high viral load suppression rate, but when you come to children, it is not so. We are also seeing children left behind in drug-related research, drug formulations, and donor investments for HIV activities and programmes.
“For instance, children were not included in the studies done on the long-acting injectable HIV medication, already used in Western countries. Since there is no data to say that children can use it, children will have to continue to take their ARV pills every day while adults can go on to long-acting injectable HIV.”
HIV diagnoses remain suboptimal in children
Dr Torbunde said rates of infant HIV diagnosis remain suboptimal, even as children may have been more likely to fall out of treatment than older people living with HIV, who have greater difficulties achieving viral suppression and keeping their virus under control.
“Programmes tend to focus on the larger population because children living with HIV are fewer. It is going to take a lot more effort to actually find them, unlike adults living with HIV. So, we have to design programmes that look for these children; otherwise, we are not going to find them.”
Although new HIV infections and AIDS-related deaths from HIV have reduced, Dr Torbunde stated that considering Nigeria’s population and birth rate, the pool of children with HIV is not reducing as much as it ought to, despite Nigeria’s interventions on reducing mother-to-child transmission of HIV.
Children are left out of HIV drug research and testing
Professor Rosemary Ugwu, a consultant paediatrician at the University of Port Harcourt Teaching Hospital (UPTH), stated that although the first reported case of HIV in Nigeria was in a 13-year-old sexually active person, until late 2000, there was no drug to treat children with HIV.
“Then, what we did was take the HIV medications for adults, crush them, and mix them with vitamin C and vitamin B syrups. Some children took it and started recovering. That gives us hope that syrups can actually work.”
These syrups come in large volumes, such that mothers need to come in with very big bags to carry them. So, if a mother is walking out of a pharmacy with a very big bag, people automatically suspect it is a case of HIV and stigmatise them.
At times, there are 3 to 4 drugs to be taken, almost 3 or 4 times a day. So what the mother does the whole day is pursue the child just to administer the syrups, and because these syrups are not palatable, many children spill them out, and as such, many children were not doing well.
However, Professor Ugwu said there are now HIV medications in tablet forms that children can use, but still more needs to be done to research newer ARV drugs and the formulation of ARV that works best for children.
Nigeria joins an alliance to end HIV in children
The National Coordinator of the National AIDS and STDs Control Programme, Dr Adebobola Basorun, represented at the meeting by Dr Peter Nwaokenneya, who put the prevalence of HIV in children at 0.2 percent of the national prevalence, assured that the country is prioritising strategies to improve HIV service delivery for children and adolescents.
According to him, “We have over 2000 health facilities across the country that provide HIV medication services, and as of December 2022, we have 1.9 million people with HIV; 1.6 million of them are on treatment, and over 50,000 of them are children.
“We are reviewing strategies for bridging the gap between the adult population and the child population. Among adults, we have made significant progress. But in paediatrics, we have not.”
He declared that Nigeria is also part of an alliance by 12 countries to end HIV in children because they realized the gap in HIV response between the adult and child populations in terms of the number of people identified and placed on treatment.
“It is only when you identify cases that you can then place them on treatment and achieve viral suppression, so the priority among all partners is to increase case identification among children, and a lot of interventions have been put in place towards achieving this. For us to do this, we also need to focus on the mothers.
“Also, we are increasing awareness in the community about this to help them understand the need for the children to be tested and those identified to be placed in treatment. There are still a lot of myths and misconceptions about HIV, hindering bringing out children to be tested. We don’t have problems putting those identified on treatment.”
Managing HIV in a family-centred way
Professor Ugwu, however, stated that managing treatment in a family-centred way will enhance early and adequate diagnosis of HIV, both for the pregnant woman and the children, treatment and adherence to HIV medications, and viral suppression and disclosure purposes.
“With family-centred care targeting especially the prevention of mother-to-child transmission, it will ensure that women of childbearing age are not infected, and even when they are infected, they will not have an unplanned pregnancy. It also expands to include maternal child health care and other programmes that impact on HIV, like tuberculosis and malnutrition. It also cuts out stigma.”
Dr Torbunde said the EGPAF vision is a world where no child is left behind and every child is free of AIDS, and it has been promoting innovations in ensuring that children, adolescents, and the community are not left behind in the fight against HIV/AIDS.
“For instance, in HIV self-testing, the person is given the kit, given an orientation on how to use it, and the person does the test at home and then shares the result with the healthcare worker. We used that strategy to improve case identification within families.
“The strategy is called family-index testing, and we use it to address some of the barriers that prevent them from bringing children to the facility, so they are tested in their homes, and in that way, we amplify case finding.
“Still around testing, there are other strategy innovations like mother-love parties, a community-based outreach where you bring together women who are pregnant and organise events for them and use the opportunity to test them so that those living with HIV can be identified and enrolled in the prevention of mother-to-child transmission of HIV programme.
“This is because data from Nigeria has shown that not all pregnant women go for antenatal services; even those that eventually come for antenatal services, many come very late, and many deliveries are not by skilled birth attendants.”
“Also, as a strategy innovation, we implemented, together with the African Network of Adolescents and Young Persons Development, using what is called social network testing. Within their network, they are able to identify young people, get them tested, and link them to treatment. Again, we bring in innovations to ensure open access for young people to HIV testing, sexual reproductive health services, and prevention health services.”
Mr Aaron Sunday, the National Coordinator of the Association of Positive Youths Living with HIV in Nigeria, said Nigeria should also demonstrate meaningful youth engagement in the implementation of HIV programmes by engaging in adolescent-centred designs and refraining from thinking for them but creating a space for them to be a critical contributor to their health.