I got a call from the resident doctor to come to exam room 6. As soon as I entered the room, I prepared myself. The little girl, 7- or maybe 8-years-old, didn’t look well; she was “floppy,” combative, and not entirely aware of where she was or what we were doing to her. She was HIV-positive, and my colleague needed to get an IV line in her arm to test the latest in experimental treatments for kids with HIV– and needed the four of us interns to help hold her still.
It was 1993 during my residency in pediatrics in Cleveland, Ohio. We were at one of the best children’s hospitals in the world; it didn’t matter. The young girl died a few months later.
With the advent of antiretroviral therapy (ART) a few years later, the whole world changed. The world of HIV medicine blossomed; new drugs and drug combinations literally exploded with amazing effect. HIV-positive mothers could give birth to HIV-negative babies, and HIV-positive children and their moms could get treatment.
Now, eliminating pediatric HIV is on the agenda. US Global AIDS Coordinator Ambassador Eric Goosby and Executive Director of UNAIDS Michel Sidibé announced the goal to eliminate pediatric HIV by 2015 last year.
We want our policymakers to think big and to provide the support and resources to make the impossible possible. But how are we actually going to get there? Do we have the required funding and innovative thinking devoted to the effort? What is really possible on the frontlines — and what is not?
Yesterday, the President’s Emergency Program for AIDS Relief (PEPFAR) outlined how the US will achieve its goals through its Blueprint: Creating an AIDS-free Generation (PDF).
The Blueprint is challenging and bold.
We applaud PEPFAR for the emphasis on the evidence base and on investing in implementation science and research. This is exactly the type of work that MSH can contribute to: figuring out the best way to find kids who may be HIV-exposed or infected and get them to the care they need.
Our best bet toward eliminating pediatric HIV? Ensure prevention of mother-to-child transmission (PMTCT).
While many amazing and dedicated clinicians and program folks have worked long and hard to make Option A and B for PMTCT work, the truth is that too many women and babies are still lost in the process. We need to beef up existing PMTCT programs using Option A or B, and where it’s not working, move to creative and innovative approaches such as the Option B+ model started in Malawi. With Option B+, if a mom gets diagnosed during pregnancy, she is offered ART for life — even without a CD4 count. Other countries are exploring Option B+, yet Malawi is currently the only country implementing it.
In addition to considering new methods for PMTCT, we need to come up with ways of finding the babies and children who are missed because they never have the opportunity to get diagnosed in antenatal care. Despite our best efforts, nearly half of all moms never make it into antenatal care. A proportion of those women are infected with HIV and, of course, their babies are born exposed or infected. We never know about these infected and affected children – until they get sick. In Malawi, for example, we found that we could reach women and children through immunization clinics, who otherwise had fallen off the PMTCT cascade, or were never tested in the first place. Testing all children who present sick to hospitals is another option. We need the political will and resources to seek and find those at-risk babies and moms.
Lastly, a strategic focus on key vulnerable populations—drug users, sex workers and men who have sex with men— is long overdue. We hope this will translate into real and effective programming on the ground.
Today, we’ve achieved the goal of elimination of mother to child transmission and hence pediatric HIV in places like New York City, London and Melbourne — too late for the little girl from Cleveland. But in Kigali, Nairobi, and Johannesburg and elsewhere in the Global South — we’ve got a long way to go. As we commemorate World AIDS Day, it is time to start thinking seriously about what it will take to eliminate pediatric HIV.
Scott Kellerman, MD, MPH, is MSH’s Global Technical Lead for HIV & AIDS.