AIDS 2022: Sharing evidence and determination to reach viral suppression among children and adolescents living with HIV
The voice of a Community Case Worker (CCW) smiles as she relates how she “feels like a doctor” when she makes home visits to support children living with HIV. The video from Pact’s ACHIEVE project in Tanzania highlights the value of CCWs as they link vulnerable households to Care and Treatment Centers to keep children living with HIV (CLHIV) adhering to their treatment.
In line with the AIDS 2022 theme of “re-engage and follow the science,” Pact’s satellite session focused on evidence for how to fill the gaps in viral suppression among children and adolescents living with HIV (C/ALHIV). With PEPFAR and USAID partners plus Oxford and University of Cape Town researchers, Pact panelists shared data supporting the important role of OVC programs in HIV epidemic control.
Key to these efforts are community response, youth-friendly services, economically secure households – especially adolescent mothers – and community workers that advocate for children.
Pact’s President & CEO, Caroline Anstey, and VP for Global Health, Gloria Sangiwa, opened the session, which came in the middle of the conference in Montreal from July 29 - August 2. Together, they set the stage by offering a testament to what has been achieved in the fight against HIV, including adult viral load suppression and growing trust within local communities. The continuing challenge is for adolescents and children to reach the 95-95-95 goals and viral suppression. Through its work with local communities for more than 50 years, Pact knows that progress comes from the local level.
The ACHIEVE project – led by Pact and funded by PEPFAR/USAID – moderated the session, which included Gretchen Bachman, Senior OVC Advisor for PEPFAR, George Siberry, Senior Treatment Advisor for USAID, and Lucie Cluver and Elona Toska of Oxford and Cape Town Universities.
The panel of experts focused on how to build a sustainable HIV response in C/ALHIV, via community case management, service delivery and system strengthening to benefit families. Gretchen Bachman stressed that the last mile of the HIV response will be the most challenging, and cited Pact’s work with local partners under the ACHIEVE project in Rwanda as an example of a sustainable response for children.
Pact has so many great programs that at the PEPFAR Equity Satellite session, they’re showing a video of the Pact Tanzania program. PEPFAR’s partnership with Pact has been long and fruitful, and we look forward to a continued partnership.
Dr. Siberry emphasized that viral suppression gaps will not be closed with only testing and drugs. Sustaining positive outcomes such as those coming from ACHIEVE programming will require economically secure families with resilient youth. PEPFAR endorsed Pact’s Economic Strengthening package for adolescent girls and young women (AGYW) in 2022, due to project data showing results from tools and curricula used to facilitate wage employment and entrepreneurship. Differentiated service delivery is as important for social welfare efforts as for treatment services.
Lucie Cluver, who during the conference received the International AIDS Society prize for excellence in research related to the needs of children and adolescents, presented new evidence linking OVC programming to adolescent viral suppression. After outlining the drivers of adolescent non-adherence – poverty, inequitable relationships, violence, stigma – Dr. Cluver highlighted solutions. Accessible clinics increase adherence, including funds for transport, empathetic providers in facilities, peer supporters and community health workers. Government economic support such as basic social welfare grants reduce food insecurity and contribute to viral suppression. Safe schools, parenting support and cash transfers combine to support children, adolescent girls and their families.
Key factors in viral suppression: economic strengthening + parenting skills + youth-friendly health services + peer and mental support + comprehensive sexuality education.
Elona Toska added that respectful care for adolescent girls is a crucial area for further investment. AGYW must find compassionate health care providers when they visit health facilities – particularly adolescent mothers living with HIV.
Pact staff from programming in Africa concluded the satellite session. Nosipho Gwebu Storer of the Insika Ya Kusasa project in Eswatini presented on the successful community-based model for supporting viral suppression in CLHIV. Despite Eswatini being only one of a few countries to reach the 95-95-95 UNAIDS targets, gaps remain in CLHIV viral suppression. Insika has nearly closed the gap, by finding and supporting CLHIV. After four years, the project has reached 99% adherence among C/ALHIV enrolled in treatment, with 93% of those eligible for viral load testing achieving viral suppression. The key has been a package of care that links communities and clinics, through home visitors and formal linkage assistants at facilities.
Two ACHIEVE Country Program Directors, Peter Mawora from South Sudan and Moise Mutabazi form Rwanda, confirmed in their presentations the importance of community and government engagement for success and sustainability. These ACHIEVE country projects also show the value of clinic coordinators working with CCW. Viral suppression comes from the support of these local actors accompanying C/ALHIV to facilities and from adherence support from phone calls and SMS reminders. In South Sudan, viral suppression among C/ALHIV increased to 84% in 2022 from 63% in 2020, despite the disruptions of the Covid-19 pandemic.
The Pact team brought back new perspectives and important messages from the conference. We were reminded that UNAIDS estimates that every week around 4,900 young women aged 15-24 acquire HIV. We learned about injectable pre-exposure prophylaxis (PrEP) and the promise of differentiated use of PrEP to make it more accessible. Pact’s experience with human-centered design can help educate communities on PrEP rollout and implementation. Mental health support has become even more important over the past two years, particularly for ALHIV. Pact’s DREAMS programming could contribute with support packages for adolescent parents and mothers and key populations. Youth-friendly services and respectful care are key.
The conference also validated aspects of Pact’s planned learning agenda for global health, including documenting the cost and value of OVC case management. We can contribute to the evidence base by exploring how to simplify service delivery while responding to the most difficult cases.
The team also noticed an emphasis on the maternal cascade: HIV-positive mothers, HIV-exposed infants and early infant diagnosis. Programs often focus on HIV-positive infants but also need to have support packages for mother-baby pairs with HIV-negative infants, including early child development, nurturing care framework – better linking prevention of mother-to-child transmission and OVC platforms.
Community-led monitoring also proved to be a timely topic, with presenters underscoring the importance of participant feedback, including of adolescent girls and OVC households. Community-led design and innovation will be ever more important to get to communities leading the response by supporting convening processes that bring change. This will involve expanding partnerships with cultural leaders, faith-based providers and the private sector.
In 2022, youth aged 15-30 continue to be the most vulnerable to HIV. Given the importance of economic strengthening and resilience, PEPFAR has expressed interest in DREAMS programming as a youth movement and a pathway to wage employment. Epidemics start and end with the community. Our determination to support them through evidence-based, data-driven solutions to end AIDS remains steadfast.