Where is the political demand to eliminate pediatric HIV/AIDS?

Advancements in children’s health such as universal childhood immunization have been “astonishing,” but progress has stalled — and new ways of thinking need to be adopted to kick-start them back into gear. That’s according to Chip Lyons, who recently stepped down as president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation, or EGPAF, after 15 years with the organization, following a long career in children’s health, including at UNICEF and the Gates Foundation. In that time, he’s seen huge innovations in the prevention and treatment of HIV/AIDS in children, but it hasn’t always been accompanied by scale or political will. He pointed to one massive technological shift — the HIV testing turnaround time for newborns, which could be 45 to 50 days in some places. “There is a world of hurt that happens to an HIV-exposed child in 45 or 50 days,” he said in a recent Devex Pro briefing. But when technology was developed to detect the virus in under 24 hours, “it was a breakthrough,” Lyons said. However, it has yet to take off at scale in many developing countries. Another example is the development of a more weight-appropriate antiretroviral treatment for children called pediatric dolutegravir. “That literally is life-changing and lifesaving, and those are the kinds of technical progress steps that have happened over the last number of years that we all feel very good about,” Lyons said, “but unless and until it gets to scale and unless and until it’s really deployed in countries that have low-coverage testing knowledge of their HIV status … unless and until those pieces move, then we’re going to be stuck, as we have been for the last number of years, in the number of pediatric infections every year.” “Where is the demand to take pediatric testing and treatment to scale? Where’s that going to come from? It … should be countries that are in the lead in demanding that, and it should be donors that recognize the tremendous opportunity of historic success in HIV and AIDS in effectively eliminating new pediatric infections,” he added, noting that the creation of that political demand among government leaders in countries with high HIV/AIDS rates “is absolutely central.” Lyons pointed out that in 2010, there were roughly 390,000 new pediatric HIV infections globally, most of them in sub-Saharan Africa. World leaders pledged to reduce that number to 50,000, but now “we’re stuck” at around 120,000 new infections per year. “Where’s the political demand to address that and get back on the right track towards the 2030 [U.N. Sustainable Development] Goals? And I’ve asked myself a hard question, is 120,000 new pediatric infections — and what the implications are in terms of mortality — is that just not a big enough number? Are we so inured to suffering?” “I think part of the role of an EGPAF and others is to keep this as visible as possible, to emphasize how much can be done, even as we speak today with so much uncertainty,” he added. But beyond visibility and political will, the entire ecosystem needs a rethink, Lyons argued. That’s what EGPAF did, combining forces with Population Services International last year under a new umbrella group called HealthX Partners that controls a combined budget of nearly half a billion dollars. Both PSI and EGPAF will continue to operate independently, retaining their names, brands, and missions — but they will be subsidiaries to HealthX Partners. While technical and programmatic staff will remain at PSI and EGPAF, ultimately, the two organizations will share back-office functions at the HealthX Partners level, such as human resources, accounting, and finance. Lyons said this type of model fits the moment. “That is a rethink, partnering in different ways, a consolidation, almost certainly in global health among organizations,” he said. “Hopefully it also has piqued the interest of donors, because I know at times individual organizations say, ‘There are too many of you and too many inefficiencies’ and so on. Well, come on, at least the other side of that coin is donors that want control. Donors want accountability. I mean, the financing of silos, in part, comes from donors. And so I think we all have a role to play to have this rethink.” That rethink has certainly been sped up by the Trump administration and its controversial freeze on most U.S. foreign aid, which has thrown the sector into a tailspin of uncertainty. Lyons said he doesn’t know yet what the freeze will ultimately do — “it’s been two weeks for goodness sakes” — but he’s blunt that while these last few weeks have been “painful, confusing, and worrying,” they could spark overdue change. “What I’m confident saying is the status quo doesn’t cut it anymore and it didn't take executive orders for a lot of people to [realize that],” he said. “I think we just can’t rely on that which has worked before.” Among the changes he said need to happen is a greater push to involve the private sector. “Creative financing, multilateral development banks, World Bank, other regional financial institutions, private sector financing players — that’s where I think there’s a lot of opportunity,” he said, urging health organizations to make these players feel “encouraged, invited, provoked, enticed.” Going back to the U.S. Congress and “earning their trust” is also critical. “We have to have a new understanding and collaboration with Congress, Republicans and Democrats, House and Senate, as part of the way forward. We need their leadership. We need their support.” He admitted the path won’t be easy. For instance, on the waivers that so many organizations are trying to secure so they can be exempt from the U.S. aid freeze, he said “there’s all sorts of confusion and uncertainty.” “That which you stopped, you need explicit approval, project by project, to start it up again. And in some cases, we’ve gotten those. I mean, this is a day-by-day thing,” he said. “But I do want to commend the folks that are trying to get the instructions and approvals to resume. People are working like crazy,” he added. “This was a disruption that no one could have imagined. Everyone is going full force to resume treatment and other services, but the real fallout is over a period of time. It’s not 72 hours later.”