Overview of Paediatric HIV Treatment and Prevention: From Then to Now Peter Mugyenyi, Joint Clinical Research Centre Kampala, Uganda
Outline The plight of HIV infected children (1980s and 1990s) Trends in new HIV infections and number of children treated Role of Global, Regional and National Efforts Sharing Uganda experience New Challenges and looking to the future
The plight of HIV infected children (1980s and 1990s) HIV access campaigns prioritized adults. High death rates of parents left up to 10 million orphans - many infected (UNAIDS) Initial access to ART reached only a tiny minority of adults and much fewer children Pharmaceutical companies did not invest much in paediatric ARV formulations
Equity and moral imperative Continuing suffering and horror when effective therapy was available (but unaffordable).
Significant Global Response Started late 2003: President Bush announces Presidents Emergency Program for AIDS relief (PEPFAR 2004: Global Fund to fight AIDS, Tuberculosis and Malaria
Early HIV treatment studies were mainly among adults The children responded optimally to ART clinically, immunologically and virologically Just like in resource rich settings Similarly in urban and rural settings To both 1 st and 2 nd line ART
Recently the face of HIV Infection has changed with ART Then Now
5,000 7,800 8,532 17,278 13,413 26,699 35,443 43,481 58,884 Numbers of Children on ART in Uganda (2006 2014) 70,000 60,000 32% 35% 32% 40% 35% 50,000 40,000 18% 20% 22% 25% 22% 30% 25% 20% 30,000 13% 15% 20,000 10% 10,000 5% 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 0% Number on ART % eligible on ART Source: MOH: Status of ART services in Uganda Dec 2014
(Thousands) Trends in AIDS-related deaths 250 Estimated number of AIDS-related deaths, in 0 4yr age group, 2001-2014 200 150 100 50 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: UNAIDS 2014 HIV and AIDS estimates, July 2015
New Infection trends Source: UNAIDS. On the fast track to an AIDS free generation. 2016
(Thousands) Trends in AIDS-related deaths Estimated number of AIDS-related deaths, by 5-year age groups, 2001-2014 Age 0-4 Age 5-9 Age 10-14 Age 15-19 Age 20-24 250 200 AIDS-related deaths are increasing in adolescents aged 10-19 years 150 100 50 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: UNAIDS 2014 HIV and AIDS estimates, July 2015
Disparities Between Adults And Children Percentage of ART Coverage Among Eligible Adults, Children and All Ages in the 22 Global Plan Priority Countries (2012) Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting. Note: Some numbers do not add up due to rounding. The coverage estimate is based on the estimated unrounded number of children receiving and eligible for ART.
Strategy to end AIDS epidemic: how are children doing?
Special issues and targets for ending Paediatric HIV Need for systematically addressing constraints peculiar to adolescents and children
7000 6000 5000 Implementation of Test and Treat: 74% increase in number of children newly initiated on ART Fig: Number of Children newly initiated on ART Implementation of Test and Treat 4000 3000 2000 1000 0 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 5-14 yr 1158 1957 1167 983 2200 3306 4105 2719 2-4 yr 601 694 793 574 822 1048 1362 1125 <2 yr 819 979 1096 803 910 859 917 892 Source: MOH Uganda, May 2015
Viral Suppression in Test and Treat Era in Uganda Proportion of children initiated on ART during the test and treat implementation who are viral suppressed by age Age ( years) Number received viral load test Number with suppressed viral load % with suppressed viral load < 2 43 35 81% 2-4 168 128 76% 5-9 246 211 86% 10-14 336 289 86% Overall 793 663 84% Source: MOH Uganda, May 2015
Access To Virologic HIV Testing (Early Infant Diagnosis) 2012 *Lesotho data represents 2011 coverage data Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting, and UNAIDS modeling2012 HIV and AIDS estimates.
Results of early infant HIV testing in Kampala PMTCT exposure Test status Number Percent Yes No Negative 436 84.3 Positive 81 15.7 Total 517 100 Negative 174 72.8 Positive 65 27.2 Total 239 100 Uganda MOH 2006
Major issues to address Rate of Mother to Child transmission of HIV (6,100 infants are newly infected in 2015) remains unacceptably high, Number of children accessing timely EID services remains too low Retention on ART and viral suppression especially for under 5s (<70%) - low Uganda MOH
Critical requirements to end Paediatric AIDS 99% 99% 99% Pregnant Mothers EID for all children of HIV infected mums ART drugs appropriate to age
Finding the children: potential opportunities to offer HIV testing Sources: Fergusson et al, 2007; Hesseling et al. 2009; Ferrand et al. 2010; Cohen et al. 2010
New challenge: Adolescents New Infection trends: drop in adolescents not as sharp as for younger children Estimated number of new HIV infections among children aged 0 14, adolescents aged 15 19 and young people aged 20 24, Global, 2001 2014 600,000 Children aged 0-14 Adolescents aged 15-19 Young people aged 20-24 500,000 400,000 300,000 200,000 100,000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: UNAIDS 2014 HIV and AIDS estimates, July 2015
Adolescent specific interventions needed Adolescent friendly services Psychosocial support Peer counseling Sexual and reproductive health Skills training Community support Transition to adult clinics Photos: JCRC Stigmaless band; Adolescent peer support meetings
Ending Paediatric AIDS epidemic achievable by identifying and addressing gaps Extend both ante-natal and EID coverage to all Maximize testing opportunities (e.g vaccination, clinics etc.) to cover children who missed out on EID Strengthen diagnostic, treatment and VL monitoring. Communication with policy makers and program partners to secure renewed commitment to 90-90-90
Acknowledgements 1. UNAIDS 2. JCRC research database 3. Uganda MOH AIDS control program 4. Dr Victor Musiime; Joint Clinical research Centre/Makerere University
Thank you!