PMTCT

Ibu Mawar (not her real name) learned she was living with HIV after receiving a test during an antenatal care visit.

 “I was surprised, of course, when they told me. But I didn’t really doubt or deny the result,” she remembered from the Sorong City Health Office in West Papua. She immediately started treatment to prevent transmission to her son. “Even though I’m positive,” she said, “our child is not.”

In principle, since 2009 every pregnant woman receiving antenatal care in Indonesia should receive an HIV test. And every woman found to be living with HIV should receive medicines to prevent transmission to their babies just as Ms Mawar did.

But this isn’t yet the reality.

In 2022 more than one-third (37%) of all pregnant women in Indonesia did not get screened for HIV and just 18% of mothers living with HIV had access to antiretroviral therapy. There were an estimated 2800 new HIV infections among children that year.

But now stakeholders in Indonesia are mobilising. Not only will they scale-up prevention of mother-to-child HIV transmission services, but they will work toward eliminating vertical HIV transmission while assuring the health and wellbeing of women and children living with HIV. At the centre of this approach is the engagement of women, who comprise roughly one-third of the adult population living with HIV.

In June 2023 Indonesia established the National Alliance to End AIDS in Children. This partnership between government, civil society and international organizations seeks to provide access to health services and support for women and children living with HIV. It has committed to three main priorities. The first is advocacy for the needs of adolescent girls and children living with HIV. Second is promotion and dissemination of information on Prevention of Mother-to-Child Transmission (PMTCT), Early Infant Diagnosis, treatment literacy and comprehensive sexual education. And third is the empowerment of communities regarding issues pertaining to children living with HIV.

The Alliance’s first major initiative was an Elimination of Mother-to-child Transmission symposium—the first ever in Indonesia. Partners have embraced the World Health Organization (WHO) triple target of eliminating mother-to-child transmission of HIV, syphilis and hepatitis B by 2030. A series of sessions were delivered in-person and online. A total of 115 participants from the government, communities, academia, healthcare and media joined the EMTCT Symposium in Jakarta.

Dr. Laila Mahmudah, Head of the Neo Maternal Division at the Ministry of Health, underlined the importance of accelerating EMTCT efforts across the range of issues. She noted that currently 66% of pregnant women received hepatitis B early detection services while just 25% of pregnant women are tested for syphilis.

Multisectoral stakeholders and participants discussed strategies with participants from Malaysia and Thailand, which have both received EMTCT validation for HIV. Dr Anita Suleiman, Director of Disease Control of the Ministry of Health of Malaysia, pointed to the importance of effective leadership and health system governance for country-wide implementation.

“One of the lessons from countries that achieved EMTCT is that it is possible to end AIDS and vertical transmissions, especially in low-prevalence regions like Indonesia, through robust governance and good-quality performance. Indonesia can also achieve EMTCT by 2030, and I hope this symposium leverages the coordination efforts towards the elimination of HIV, syphilis and hepatitis B,” said Dr Shafflq Essajee, Senior Advisor, HIV, UNICEF New York.

However, it was emphasised that political commitment must be bolstered by community-led strategies to reach and retain mothers living with HIV. Community mobilization and community health workers are critical approaches. Ikatan Perempuan Positif Indonesia (IPPI), the national network of women living with HIV, also endorsed the Thai approach of providing free formula for mothers living with HIV in low-resource districts.

Ayu Oktariani, IPPI National Coordinator and a member of the National Alliance to End AIDS in Children reiterated her organization’s commitment to implementing the community-led strategies in support of EMTCT in the coming years.

“This Symposium means more than words I can explain,” said Ayu Raka from the Akar Cinta Kasih Foundation, a community organisation in Bali. “When I return to Bali, I will advocate for EMTCT with local multisectoral stakeholders and communities in my region. I am confident we can make a healthier society and improve health for all mothers and babies.”

UNAIDS Country Director for Indonesia, Krittayawan Boonto, promised the continuous backing of UNAIDS.

“We will continue to support not only mothers, but also fathers, in protecting babies from new HIV infections. I wish for Indonesia to become the fifth country in Asia Pacific to achieve EMTCT. But we can only do it with the leadership of communities,” she ended.

GENEVA, 13 July 2023—A new report released today by UNAIDS shows that there is a clear path that ends AIDS. This path will also help prepare for and tackle future pandemics and advance progress towards achieving the Sustainable Development Goals. The report, ‘The Path that Ends AIDS’, contains data and case studies which highlight that ending AIDS is a political and financial choice, and that the countries and leaders who are already following the path are achieving extraordinary results.

Botswana, Eswatini, Rwanda, the United Republic of Tanzania, and Zimbabwe have already achieved the “95-95-95” targets. That means 95% of the people who are living with HIV knowing their HIV status, 95% of the people who know that they are living with HIV being on lifesaving antiretroviral treatment, and 95% of people who are on treatment being virally suppressed. A further 16 other countries, eight of them in sub-Saharan Africa, the region which accounts for 65% of all people living with HIV, are also close to doing so.

“The end of AIDS is an opportunity for a uniquely powerful legacy for today’s leaders,” said Winnie Byanyima, Executive Director of UNAIDS. “They could be remembered by future generations as those who put a stop to the world’s deadliest pandemic. They could save millions of lives and protect the health of everyone. They could show what leadership can do.”

The report highlights that HIV responses succeed when they are anchored in strong political leadership. This means following the data, science, and evidence; tackling the inequalities holding back progress; enabling communities and civil society organizations in their vital role in the response; and ensuring sufficient and sustainable funding.

Progress has been strongest in the countries and regions that have the most financial investments, such as in eastern and southern Africa where new HIV infections have been reduced by 57% since 2010.

Thanks to support for and investment in ending AIDS among children, 82% of pregnant and breastfeeding women living with HIV globally were accessing antiretroviral treatment in 2022, up from 46% in 2010. This has led to a 58% reduction in new HIV infections among children from 2010 to 2022, the lowest number since the 1980’s.

Progress in the HIV response has been strengthened by ensuring that legal and policy frameworks do not undermine human rights, but enable and protect them. Several countries removed harmful laws in 2022 and 2023, including five (Antigua and Barbuda, the Cook Islands, Barbados, Saint Kitts and Nevis, and Singapore) that have decriminalized same-sex sexual relations.

The number of people on antiretroviral treatment worldwide rose almost fourfold, from 7.7 million in 2010 to 29.8 million in 2022.

However, the report also sets out that ending AIDS will not come automatically. AIDS claimed a life every minute in 2022. Around 9.2 million people still miss out on treatment, including 660 000 children living with HIV.

Women and girls are still disproportionately affected, particularly in sub-Saharan Africa. Globally, 4,000 young women and girls became infected with HIV every week in 2022. Only 42% of districts with HIV incidence over 0.3% in sub-Saharan Africa are currently covered with dedicated HIV prevention programmes for adolescent girls and young women.

Almost one quarter (23%) of new HIV infections were in Asia and the Pacific where new infections are rising alarmingly in some countries. Steep increases in new infections are continuing in eastern Europe and central Asia (a rise of 49% since 2010) and in the Middle East and North Africa (a rise of 61% since 2010). These trends are due primarily to a lack of HIV prevention services for marginalized and key populations and the barriers posed by punitive laws and social discrimination.

Funding for HIV also declined in 2022 from both international and domestic sources, falling back to the same level as in 2013. Funding amounted to US$ 20.8 billion in 2022, far short of the US$ 29.3 billion needed by 2025.

There is an opportunity now to end AIDS by increasing political will by investing in a sustainable response to HIV through financing what matters most: evidence-based HIV prevention and treatment, health systems integration, non- discriminatory laws, gender equality, and empowered community networks.

“We are hopeful, but it is not the relaxed optimism that might come if all was heading as it should be. It is, instead, a hope rooted in seeing the opportunity for success, an opportunity that is dependent on action,” said Ms Byanyima. “The facts and figures shared in this report do not show that as a world we are already on the path, they show that we can be. The way is clear.”

In 2022, an estimated:

• 39.0 million people globally were living with HIV
• 29.8 million people were accessing antiretroviral therapy
• 1.3 million people became newly infected with HIV
• 630 000 people died from AIDS-related illnesses

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

DAR ES SALAAM, 1 February 2023—Ministers and representatives from twelve African countries have committed themselves, and laid out their plans, to end AIDS in children by 2030. International partners have set out how they would support countries in delivering on those plans, which were issued at the first ministerial meeting of the Global Alliance to end AIDS in children.

The meeting hosted by the United Republic of Tanzania, marks a step up in action to ensure that all children with HIV have access to life saving treatment and that mothers living with HIV have babies free from HIV. The Alliance will work to drive progress over the next seven years, to ensure that the 2030 target is met.

Currently, around the world, a child dies from AIDS related causes every five minutes.

Only half (52%) of children living with HIV are on life-saving treatment, far behind adults of whom three quarters (76%) are receiving antiretrovirals.

In 2021,160 000 children newly acquired HIV. Children accounted for 15% of all AIDS-related deaths, despite the fact that only 4% of the total number of people living with HIV are children.

In partnership with networks of people living with HIV and community leaders, ministers laid out their action plans to help find and provide testing to more pregnant women and link them to care. The plans also involve finding and caring for infants and children living with HIV.

The Dar-es-Salaam Declaration on ending AIDS in children was endorsed unanimously.

Vice-President of the United Republic of Tanzania, Philip Mpango said, “Tanzania has showed its political engagement, now we need to commit moving forward as a collective whole. All of us in our capacities must have a role to play to end AIDS in children. The Global Alliance is the right direction, and we must not remain complacent. 2030 is at our doorstep.”

The First Lady of Namibia Monica Geingos agreed. “This gathering of leaders is uniting in a solemn vow – and a clear plan of action – to end AIDS in children once and for all,” she said. “There is no higher priority than this.”

Twelve countries with high HIV burdens have joined the alliance in the first phase: Angola, Cameroon, Côte d'Ivoire, the Democratic Republic of the Congo (DRC), Kenya, Mozambique, Nigeria, South Africa, the United Republic of Tanzania, Uganda, Zambia, and Zimbabwe.

The work will centre on four pillars across:

1. Early testing and optimal treatment and care for infants, children, and adolescents;
2. Closing the treatment gap for pregnant and breastfeeding women living with HIV, to eliminate vertical transmission;
3. Preventing new HIV infections among pregnant and breastfeeding adolescent girls and women; and
4. Addressing rights, gender equality and the social and structural barriers that hinder access to services.

UNICEF welcomed the leaders’ commitments and pledged their support. "Every child has the right to a healthy and hopeful future, but for more than half of children living with HIV, that future is threatened," said UNICEF Associate Director Anurita Bains. "We cannot let children continue to be left behind in the global response to HIV and AIDS. Governments and partners can count on UNICEF to be there every step of the way. This includes work to integrate HIV services into primary health care and strengthen the capacity of local health systems."

“This meeting has given me hope,” said Winnie Byanyima, Executive Director of UNAIDS. “An inequality that breaks my heart is that against children living with HIV, and leaders today have set out their commitment to the determined action needed to put it right. As the leaders noted, with the science that we have today, no baby needs to be born with HIV or get infected during breastfeeding, and no child living with HIV needs to be without treatment. The leaders were clear: they will close the treatment gap for children to save children’s lives.”

WHO set out its commitment to health for all, leaving no children in need of HIV treatment behind. “More than 40 years since AIDS first emerged, we have come a long way in preventing infections among children and increasing access to treatment, but progress has stalled,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “The Global Alliance to End AIDS in Children is a much-needed initiative to reinvigorate progress. WHO is committed to supporting countries with the technical leadership and policy implementation to realise our shared vision of ending AIDS in children by 2030.”

Peter Sands, Executive Director of The Global Fund, said, “In 2023, no child should be born with HIV, and no child should die from an AIDS-related illness. Let’s seize this opportunity to work in partnership to make sure the action plans endorsed today are translated into concrete steps and implemented at scale. Together, led by communities most affected by HIV, we know we can achieve remarkable results.”

PEPFAR's John Nkengasong, U.S. Global AIDS Coordinator, said he remains confident. "Closing the gap for children will require laser focus and a steadfast commitment to hold ourselves, governments, and all partners accountable for results. In partnership with the Global Alliance, PEPFAR commits to elevate the HIV/AIDS children's agenda to the highest political level within and across countries to mobilize the necessary support needed to address rights, gender equality and the social and structural barriers that hinder access to prevention and treatment services for children and their families."

EGPAF President and CEO, Chip Lyons, said that the plans shared, if implemented, would mean children were no longer left behind. “Often, services for children are set aside when budgets are tight or other challenges stand in the way. Today, African leaders endorsed detailed plans to end AIDS in children – now is the time for us all to commit to speaking up for children so that they are both prioritized and included in the HIV response.”

Delegates emphasized the importance of a grounds-up approach with local, national and regional stakeholders taking ownership of the initiative, and engagement of a broad set of partners. The alliance has engaged support from Africa REACH and other diverse partners and welcomes all countries to join.

“We have helped shape the Global Alliance and have ensured that human rights, community engagement and gender equality are pillars of the Alliance,” said Lilian Mworeko, Executive Director of the International Community of Women living with HIV in Eastern Africa on behalf of ICW, Y+ Global and GNP+. “We believe a women-led response is key to ending AIDS in children.”

Progress is possible. Sixteen countries and territories have already been certified for validation of eliminating vertical transmission of HIV and/or syphilis; while HIV and other infections can pass from a mother to child during pregnancy or while breastfeeding, such transmission can be interrupted with prompt HIV treatment for pregnant women living with HIV or pre-exposure prophylaxis (PrEP) for mothers at risk of HIV infection.

Last year Botswana was the first African country with high HIV prevalence to be validated as being on the path to eliminating vertical transmission of HIV, which means the country had fewer than 500 new HIV infections among babies per 100 000 births. The vertical transmission rate in the country was 2% versus 10% a decade ago.

UNAIDS, networks of people living with HIV, UNICEF and WHO together with technical partners, PEPFAR and The Global Fund unveiled the Global Alliance to end AIDS in children in July 2022 at the AIDS conference in Montreal, Canada. Now, at its first ministerial meeting, African leaders have set out how the Alliance will deliver on the promise to end AIDS in children by 2030.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

In December 2021, Botswana became the first high HIV burden country to be certified by the WHO Global Validation Advisory Committee (GVAC) as having achieved a critical milestone along the path to eliminating vertical HIV transmission. As striking as what Botswana has achieved, however, is how it went about documenting this achievement—using the certification process as an avenue to empower women living with HIV and reinforce their fundamental rights.¹

Botswana is the first high HIV burden country to be certified for achieving the required indicators for the Silver Tier on the “Path to Elimination of HIV” criteria that were introduced in 2017. The Silver Tier requires an HIV case rate of fewer than 500 per 100 000 live births, a vertical HIV transmission rate of under 5% and the provision of antenatal care and antiretroviral treatment to more than 90% of pregnant women.

UNAIDS data show that over 95% of pregnant women in Botswana were receiving antiretroviral therapy in 2021, up from 77% in 2010. Vertical transmission rates were only 2.2%, down from 9.0% a decade earlier. According to a woman living with HIV in Kgalagadi South, “I have three children...I breastfed all three, and all of them were given medication for prevention of HIV.”

Botswana placed women living with HIV at the centre of the process of documenting the country’s prevention success. With the support of UNAIDS, the International Community of Women living with HIV oriented networks of women living with HIV to administer the human rights assessment tool to their networks in 10 of Botswana’s districts.² These networks led the process, and the Government of Botswana provided logistical support to ensure the engagement of women living with HIV within a safe space. Women living with HIV, who are represented on the National Validation Committee, also reviewed a draft of the national validation report.

GVAC validated that Botswana’s programmes and services to eliminate vertical HIV transmission are consistent with international, regional and national standards on human rights, gender equality and community engagement. As one woman living with HIV in Kweneng West remarked, “the nurses and health-care officers give the option for all to test-and-treat. It is always a clear choice, and not a forced one.”

95% OF PREGNANT WOMEN IN BOTSWANA WERE RECEIVING ANTIRETROVIRAL THERAPY IN 2021

The Botswana Ministry of Health, with the engagement of women living with HIV and the support of the Joint Programme, convened a workshop in May 2022 to foster partner and stakeholder involvement for ensuring that rights-based approaches are used to maintain the country’s Silver Tier certification—and its possible progression to the Gold Tier.

¹ As of December 2021, 15 countries and territories—Anguilla, Antigua and Barbuda, Armenia (HIV only), Belarus, Ber- muda, Cayman Islands, Cuba, Dominica, Malaysia, the Maldives, the Republic of Moldova (syphilis only), Montserrat, Sri Lanka, St Kitts and Nevis and Thailand—have been certified for eliminating vertical HIV and syphilis transmission. Countries apply using standardized criteria for the assessment of programme performance, data and laboratory sys- tems, and they ensure the integration of human rights, gender equality and community engagement under a process overseen by the United Nations Children’s Fund (UNICEF), UNFPA, WHO and UNAIDS.

² These included the Botswana Network of People Living with HIV (BONEPWA+), Bomme Isago (a local partner of the International Community of Women living with HIV) and the Botswana Network on Ethics, Law and HIV/AIDS (BONELA).

The path to elimination of vertical transmission of HIV

• PATH TO ELIMINATION VALIDATION
  • BRONZE: 90% antenatal care coverage (at least one visit), 90% HIV testing coverage among pregnant women, 90% antiretroviral treatment coverage among pregnant women living with HIV Case rate of new paediatric HIV infections due to MTCT^a of ≤750 cases per 100 000 live births MTCT rate <5%
  • SILVER: 90% antenatal care coverage (at least one visit), 90% HIV testing coverage among pregnant women, 90% antiretroviral treatment coverage among pregnant women living with HIV Case rate of new paediatric HIV infections due to MTCT of ≤500 cases per 100 000 live births MTCT rate <5%
  • GOLD: 95% antenatal care coverage (at least one visit), 95% HIV testing coverage among pregnant women, 95% antiretroviral treatment coverage among pregnant women living with HIV Case rate of new paediatric HIV infections due to MTCT of ≤250 cases per 100 000 live births MTCT rate <5%
• FULL VALIDATION: 95% antenatal care coverage (at least one visit), 95% HIV testing coverage among pregnant women, 95% antiretroviral treatment coverage among pregnant women living with HIV Case rate of new paediatric HIV infections due to MTCT of ≤50/100 000 cases per 100 000 live births MTCT rate <5%

Source: Adapted from: Global guidance on criteria and processes for validation: elimination of mother-to-child transmission of HIV, syphilis and hepatitis B virus. Geneva: WHO; 2021 (https://www.who.int/publications/i/item/9789240039360).

^a MTCT = mother-to-child transmission of HIV.

MONTREAL, 30 July 2022—More than two decades ago at the 13^th International AIDS Conference (IAS) in Durban, Nkosi Johnson from South Africa stood up as the first child to speak publicly about HIV.

”Hello, my name is Nkosi Johnson, I am 11 years old and I have full-blown AIDS,” he said in front of a packed auditorium.

“I get very sad when I think of all the other children and babies that are sick with AIDS. ​I just wish that the government could start giving HIV treatment to pregnant HIV+ mothers to help stop the virus being passed on to their babies.”

Since Nkosi’s call for help in 2000, remarkable progress has been made. In a decade, coverage of HIV treatment to prevent vertical transmission for pregnant women living with HIV has increased to 85% from 45% and there has been a 53% reduction in new child HIV infections.

Last year, Botswana became the first high-burden country to be certified by the World Health Organization (WHO) for achieving an important milestone on the path to eliminating vertical transmission of HIV from mother to child.

But it’s still not enough.

Global targets towards reaching an AIDS-free generation have been missed year after year. In 2020, there were 1.7 million children living with HIV globally, almost half (46%) of whom were not receiving life-saving HIV treatment. In the same year there were 150 000 new HIV infections among children.

On the sidelines of this year’s IAS conference in Montreal, UNAIDS, networks of people living with HIV, UNICEF and WHO, together with technical partners, PEPFAR and The Global Fund are launching a new Global Alliance to End AIDS in children by 2030. The Alliance will be co-created with the broad participation of stakeholders, national governments, implementing agencies, regional and country-based organizations, faith-based and community partners including women, children and youth living with HIV. The aim is to measure and coordinate progress towards the bold targets of the Sustainable Development Goals (SDGs) and mobilize leadership, funding and action to end AIDS in children by 2030 by tracking work globally, regionally, nationally and at community levels.

“It is unacceptable that children are lagging far behind adults in accessing HIV treatment and that progress on eliminating vertical transmission has stalled in recent years,” said Winnie Byanyima, Executive Director of UNAIDS.

“The committee of co-sponsoring organizations of UNAIDS has approved the Global Alliance to End AIDS in children by 2030, co-led by UNAIDS, WHO and UNICEF as a Global Strategic Initiative. We are united in our commitment to reach this goal,” she added.

Most of these new infections could have been prevented if adolescent girls and women had universal access to HIV testing, prevention and treatment services and the support they need to stay in prevention care or on HIV treatment throughout pregnancy and breastfeeding. In addition, stigma, discrimination, punitive laws and policies, violence and entrenched societal and gender inequalities hinder access to care for women, adolescents and children.

Renewed political commitment and leadership is needed to eliminate vertical transmission and end AIDS in children once and for all. The launch of a new Global AIDS Strategy in 2021 and the Political Declaration on HIV and AIDS provide an opportunity to redirect global attention and redouble efforts to end AIDS in children

Most of the 150 000 new HIV infections among children in 2020 could have been prevented. A strong start would be to better engage women and girls at significant risk of acquiring HIV infection in integrated antenatal care and HIV services, including HIV prevention and testing, delivered at the local level, and to ensure that those who are HIV-positive receive treatment before pregnancy. Nearly 65 000 child infections occurred in 2020 because women already living with HIV were not diagnosed during pregnancy and did not start treatment.

More than 35 000 additional child infections occurred because women acquired HIV during pregnancy or breastfeeding, which led to a spike in their viral load and a high risk of vertical transmission. Women at substantial risk of HIV infection require tailored combination HIV prevention, including pre-exposure prophylaxis, more comprehensive counselling, repeat HIV testing and the provision of self-testing kits for partners.

More than 38 000 additional child infections occurred when mothers who started antiretroviral therapy did not continue treatment during pregnancy and breastfeeding, and nearly 14 000 occurred among women who were on treatment but not virally suppressed. Improving the quality of treatment and care—including the use of optimized treatment regimens and peer-assisted retention efforts (such as mentor mothers)—can help close these gaps.