Start Free Stay Free AIDS Free - 2019 Report

Executive Summary

The Start Free Stay Free AIDS Free report reveals a mixed story. The global targets set for 2018 have been missed by a wide margin in some subregions and countries. Some countries, however, have shown impressive progress and achieved success across all the target areas. These country examples demonstrate that success is possible and highlight the need for a paradigm shift in action across all focus countries to reach the targets by 2020.

Fewer children newly infected with HIV and improved health for mothers living with HIV stand out as achievements of the global AIDS response in recent years.

Within in the 23 focus countries, programmes for elimination of mother-to-child transmission of HIV have averted an estimated 1.5 million [982 000–2.4 million] new HIV infections in children aged 0–14 years since 2010. This has been done by dramatically increasing the proportion of pregnant women living with HIV receiving antiretroviral medicines from 43% [32–54%] in 2010 to 85% [63% to >95%] in 2018. This was a significant achievement, but the 2018 target of 95% coverage was missed in all but 5 focus countries (Botswana, Malawi, Mozambique, Namibia, Zambia). Furthermore, in 2018 51% of pregnant women living with HIV were receiving antiretroviral medicines before conception, compared with only 7% in 2010.

The progress underscores the potential to end AIDS as a public health threat among children in the near future, but much work still lies ahead. The number of new HIV infections among adolescent girls and young women, many of whom become mothers, remains too high. Access to antiretroviral therapy for pregnant women living with HIV to improve their own health and that of their babies has stagnated recently, for several reasons:

• A sixth of pregnant women living with HIV in the focus countries are not diagnosed or offered antiretroviral therapy during pregnancy.
• Retention on antiretroviral therapy for pregnant and breastfeeding women is too low, with 20% of women in sub-Saharan Africa who start antiretroviral therapy dropping out of care before delivering their babies.
• About 140 000 women acquired HIV infection while pregnant or breastfeeding in 2018 in the 21 sub-Saharan African focus countries. Many of these women are not diagnosed or treated, emphasizing the myriad missed opportunities for testing, retesting, prevention, treatment and care.

As a result, an estimated 130 000 [87 000–210 000] children acquired HIV in utero, at birth or while breastfeeding in 2018 in the 23 focus countries. This is substantially fewer than the approximately 240 000 [160 000–380 000] children newly infected in 2010, but it is well short of the 2018 target of fewer than 40 000 children per year. Countries such as Botswana, Malawi and Namibia have seen over 70% declines in the number of new child infections in the same time period.

Although new HIV infections are falling among adolescent girls and young women aged 10–24 years, the number of new HIV infections in this age group is still three times higher 7 (310 0000 [190 000–460 000]) than the 2020 target of below 100 000, and the rate of decline is intolerably slow. More than 6000 adolescent girls and young women acquired HIV each week in 2018. One of the reasons for this is low coverage of voluntary medical male circumcision (only 11 million performed since 2015). Approximately 13 million more medical circumcisions need to be performed from the end of 2018 to the end of 2020 to meet the target. However, there were about 4.1 million voluntary medical male circumcisions performed for HIV prevention in 14 high-priority countries in eastern and southern Africa in 2018.

Knowledge of HIV and condom use among young people aged 15–24 years, especially among young women, are low. Overcoming the social and structural barriers to deliver universal access to integrated sexual and reproductive health and rights and combination HIV prevention services that empower adolescent girls and young women to make informed choices about contraception and HIV prevention is essential.

Children living with HIV are being left behind in HIV treatment scale-up and are not being diagnosed and treated early enough to prevent HIV-related morbidity and mortality. For optimal outcomes, children living with HIV must access diagnosis and effective treatment and achieve viral load suppression as soon as possible after infection. In 2018 only 63% [47–78%] of the 1.1 million infants exposed to HIV were tested by the age of two months in the focus countries, although countries such as Malawi and South Africa tested more than 85% of infants exposed to HIV within the first two months after birth. Furthermore, only 56% [38–76%] of the estimated 1.5 million [1.1 million–1.9 million] children aged 0–14 years living with HIV in 2018 were receiving lifesaving antiretroviral medicines. Children living with HIV are less likely to be receiving treatment compared with adults living with HIV (63% [48–76%]), and this disparity is widening, especially in countries in western and central Africa. Strong efforts in Eswatini, Namibia, Zambia and Zimbabwe have led to paediatric treatment levels of over 75%.

In 2018 only 55 countries reported disaggregated numbers of adolescents on treatment through the Global AIDS Monitoring tool. Among eight focus countries reporting treatment coverage data by age group (Botswana, Cameroon, Eswatini, Indonesia, Namibia, Nigeria, United Republic of Tanzania, Zimbabwe), four reported over 75% antiretroviral therapy coverage in people aged 10–14 years, while none of the eight countries reported coverage over 40% in people aged 15–19 years. Among the four countries with available data from population-based HIV impact assessment surveys, treatment coverage for respondents aged 15–24 years was 32% in Zambia, 34% in the United Republic of Tanzania, 42% in Malawi and 54% in Eswatini.

As a result, the AIDS epidemic is claiming the lives of too many children aged 0–14 years. Children in this age group comprised 5% of the people living with HIV in the focus countries but accounted for 15% of the people dying from AIDS-related causes in 2018. AIDS-related deaths have declined by only 16% among older adolescents aged 15–19 years, but they have declined by 35% among people aged 20 years and over.