Pediatric AIDS in the Elimination Agenda

In 2011, Ambassador Eric Goosby of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and Michel Sidibe, Executive Director of Joint United Nations Programme on HIV and AIDS (UNAIDS), formally announced a plan for eliminating new HIV infections in children and keeping their mothers alive [1]. The elimination of pediatric HIV agenda, or the Global Plan, calls for decreasing new pediatric infections by 90% and halving maternal deaths from HIV and AIDS by 2015 [1]. This newest call to action strengthens previous global commitments to reduce the number of vertical HIV infections with concomitant decreases in mortality from HIV and AIDS and mortality in children under age 5 [2]. While high-level rhetoric is necessary to mobilize resources, the strategy to end mother-to-child transmission of HIV (eMTCT) has thus far focused primarily on the expansion of prevention of motherto-child transmission (PMTCT) [1–3] with little attention focused on infected children or those missed by current programming. This strategy places at risk a whole generation of children who despite our best efforts are missed by current PMTCT programming and continue to become infected with HIV. Eliminating MTCT is a worthy aspiration, and while the 2015 goal is ambitious, we are closing the gap. Expanding the focus on pediatric HIV is a collective effort and many experts in the field are aligned on what they know to be the existing barriers and potential solutions to ensuring equity in access to care and treatment for children infected and affected by HIV. The evolution of the WHO treatment guidelines is a case in point. The 2010 WHO PMTCT guidelines called for earlier initiation and extended periods of prophylaxis in pregnant and breastfeeding women to ensure protection throughout the duration of potential HIV exposure. Consensus has since emerged that earlier introduction of antiretroviral therapy (ART) in pregnant women is safer than imagined and results in lowered viral load and decreased vertical transmission [4]. The 2013 WHO guidelines will move us closer to a ‘‘test and treat’’ paradigm by expanding recommendations for lifelong ART for all pregnant and lactating women [5], which is routine practice in developed countries where vertical transmission is now seen as a rare but tragic curiosity [6].