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 ResponseStarted 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 1st and 2nd line ART

Recently the face of HIV Infection has changed with

ART

Then Now

Numbers of Children on ART in Uganda

(2006 – 2014)

Source: MOH: Status of ART services in Uganda – Dec 2014

5,00

0

7,80

0

8,53

2

13,4

13

17,2

78 26

,69

9

35,4

43

43

,48

1 58,8

84

13%

18%20%

32%

22%

25%

35%

22%

32%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2006 2007 2008 2009 2010 2011 2012 2013 2014

Number on ART % eligible on ART

Trends in AIDS-related deaths

0

50

100

150

200

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

(Th

ou

san

ds)

Estimated number of AIDS-related deaths, in 0 – 4yr age group, 2001-2014

Source: UNAIDS 2014 HIV and AIDS estimates, July 2015

New Infection trends

Source: UNAIDS. On the fast track to an AIDS free generation. 2016

Trends in AIDS-related deaths

0

50

100

150

200

250

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

(Th

ou

san

ds)

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

Source: UNAIDS 2014 HIV and AIDS estimates, July 2015

AIDS-related deaths are increasing in adolescents aged 10-19 years

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

Implementation of Test and Treat: 74% increase in number of children

newly initiated on ART

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

0

1000

2000

3000

4000

5000

6000

7000

Fig: Number of Children newly initiated on ART

Source: MOH – Uganda, May 2015

Implementation of Test and Treat

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 dataSource: 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

Negative 436 84.3

Positive 81 15.7

Total 517 100

No

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%

Pregnant Mothers

99%

EID for all children of

HIV infected mums

99%

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

0

100,000

200,000

300,000

400,000

500,000

600,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Estimated number of new HIV infections among children aged 0–14, adolescents aged 15–19 and young people aged 20–24, Global, 2001–2014

Children aged 0-14 Adolescents aged 15-19 Young people aged 20-24

Source: UNAIDS 2014 HIV and AIDS estimates, July 2015

New Infection trends: drop in adolescents not as sharp as for younger children

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.gvaccination, 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!