Development and Impact of the Global Plan.

The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (Global Plan) was transformative, helping drive a 60% reduction in new HIV infections among children in 21 priority countries in sub-Saharan Africa from 2009 to 2015. It mobilized unprecedented political, technical, and community leadership at all levels to accelerate progress toward its ambitious targets. This progress is well documented, many specific elements of which are explained in greater detail across this JAIDS supplement. What is often less well or widely understood are the critical aspects of the Global Plan that shaped its structure and determined its impact; the factors and forces that coalesced to form a deep and diverse coalition of contributing partners committed to catalyzing change and action; and the critical lessons that the Global Plan leaves behind, a living legacy to inform and improve ongoing efforts to achieve its ultimate goals.

Integrating PMTCT Into Maternal, Newborn, and Child Health and Related Services: Experiences From the Global Plan Priority Countries.

The urgency to scale-up sustainable programs for the prevention of mother-to-child transmission of HIV (PMTCT) prompted priority countries of the Global Plan Toward the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan) to expand the delivery of PMTCT services through greater integration with sexual and reproductive health and child health services. Countries approached integration-what, where, and how services are provided-in diverse ways, with predominantly favorable results. Approaches to integrated services have increased access to a broader range of PMTCT interventions, and they also have proved to be largely acceptable to clients and providers. The integration of PMTCT interventions with maternal, newborn, and child health settings was supported by strategies to reconfigure service delivery to provide additional services, including shifting tasks to nurses (such as initiating antiretroviral therapy and providing long-term follow-up). This was complemented by supporting community outreach and integrating HIV and sexual and reproductive health services bidirectionally, including by providing family planning through antiretroviral therapy clinics and HIV testing in family planning clinics. A systematic and rigorous study of country experiences integrating HIV and maternal, newborn, and child health services, including maternal and pediatric TB services, cost analysis, could provide valuable lessons and demonstrate how such integration can improve systems for health care delivery.

Scale-up of Early Infant HIV Diagnosis and Improving Access to Pediatric HIV Care in Global Plan Countries: Past and Future Perspectives.

Investment to scale-up early infant diagnosis (EID) of HIV has increased substantially in the last decade. This investment includes physical infrastructure, equipment, human resources, and specimen transportation systems as well as specialized mechanisms to deliver laboratory results to clinics. The Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, as well as related international initiatives to prevent mother-to-child transmission of HIV and treat children living with HIV have been important drivers of this scale-up by mobilizing resources, creating advocacy, developing normative recommendations, and providing direct technical support to countries through the global community of international stakeholders. As a result, the number of early infant diagnosis tests performed annually has increased 10-fold between 2005 and 2015, and many thousands of infants are now receiving life-saving antiretroviral therapy because of this improved access. Despite these efforts and many success stories, timely infant diagnosis remains a challenge in many Global Plan countries. The most recent data (from the end of 2015) suggest a large variation in access. Some countries report that almost 90% of HIV-exposed infants are being tested; others report that the level of access has stagnated at 30%. Still, just over half of all exposed infants in Global Plan countries receive a test in the first 2 months of life. We discuss the key factors that are responsible for this scale-up of diagnostic capacity, highlight some of the challenges that have hampered progress, and describe priorities for the future that can help maintain momentum to achieve true universal access to HIV testing for children.

Pediatric Treatment Scale-Up: The Unfinished Agenda of the Global Plan.

Five million children have died of AIDS-related causes since the beginning of the epidemic. In 2011, the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan) created the political environment to catalyze both the resources and commitment to end pediatric AIDS. Implementation and scale-up have encountered substantial hurdles, however, which have resulted in slow progress. Reasons include a lack of emphasis on testing outside of prevention of mother-to-child transmission services, an overall lack of integration and coordination with other services, a lack of training among providers, low confidence in caring for children living with HIV, and a lack of appropriate formulations for pediatric antiretrovirals. During the Global Plan period, we have learned that simplification is essential to successful decentralization, integration, and task shifting of services; that innovations require careful planning; and that the family is an important unit for delivering HIV care and treatment services. The post-Global Plan phase presents a number of noteworthy challenges that all stakeholders, national programs, and communities must tackle to guarantee universal treatment for children living with HIV. Accelerated action is essential in ensuring that HIV diagnosis and linkage to treatment happen as quickly and effectively as possible. As fewer infants are infected because of effective prevention of mother-to-child transmission interventions and the population of children living with HIV will age into adolescence adapting service delivery models to the epidemic context, and engaging the community will be critical to finding new efficiencies and allowing us to realize a true HIV-free generation-and to end AIDS by 2030.

Where Public Health Meets Human Rights: Integrating Human Rights into the Validation of the Elimination of Mother-to-Child Transmission of HIV and Syphilis.

In 2014, the World Health Organization (WHO) initiated a process for validation of the elimination of mother-to-child transmission (EMTCT) of HIV and syphilis by countries. For the first time in such a process for the validation of disease elimination, WHO introduced norms and approaches that are grounded in human rights, gender equality, and community engagement. This human rights-based validation process can serve as a key opportunity to enhance accountability for human rights protection by evaluating EMTCT programs against human rights norms and standards, including in relation to gender equality and by ensuring the provision of discrimination-free quality services. The rights-based validation process also involves the assessment of participation of affected communities in EMTCT program development, implementation, and monitoring and evaluation. It brings awareness to the types of human rights abuses and inequalities faced by women living with, at risk of, or affected by HIV and syphilis, and commits governments to eliminate those barriers. This process demonstrates the importance and feasibility of integrating human rights, gender, and community into key public health interventions in a manner that improves health outcomes, legitimizes the participation of affected communities, and advances the human rights of women living with HIV.

Lessons learnt from promising practices in community engagement for the elimination of new HIV infections in children by 2015 and keeping their mothers alive: summary of a desk review.

INTRODUCTION: Through the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping their Mothers Alive, leaders have called for broader action to strengthen the involvement of communities. The Global Plan aspires to reduce new HIV infections among children by 90 percent, and to reduce AIDS-related maternal mortality by half. This article summarizes the results of a review commissioned by UNAIDS to help inform stakeholders on promising practices in community engagement to accelerate progress towards these ambitious goals. METHODS: This research involved extensive literature review and key informant interviews. Community engagement was defined to include participation, mobilization and empowerment while excluding activities that involve communities solely as service recipients. A promising practice was defined as one for which there is documented evidence of its effectiveness in achieving intended results and some indication of replicability, scale up and/or sustainability. RESULTS: Promising practices that increased the supply of preventing mother-to-child transmission (PMTCT) services included extending community cadres, strengthening linkages with community- and faith-based organizations and civic participation in programme monitoring. Practices to improve demand for PMTCT included community-led social and behaviour change communication, peer support and participative approaches to generate local solutions. Practices to create an enabling environment included community activism and government leadership for greater involvement of communities. Committed leadership at all levels, facility, community, district and national, is crucial to success. Genuine community engagement requires a rights-based, capacity-building approach and sustained financial and technical investment. Participative formative research is a first step in building community capacity and helps to ensure programme relevance. Building on existing structures, rather than working in parallel to them, improves programme efficiency, effectiveness and sustainability. Monitoring, innovation and information sharing are critical to scale up. CONCLUSIONS: Ten recommendations on community engagement are offered for ending vertical transmission and enhancing the health of mothers and families: (1) expand the frontline health workforce, (2) increase engagement with community- and faith-based organizations, (3) engage communities in programme monitoring and accountability, (4) promote community-driven social and behaviour change communication including grassroots campaigns and dialogues, (5) expand peer support, (6) empower communities to address programme barriers, (7) support community activism for political commitment, (8) share tools for community engagement, (9) develop better indicators for community involvement and (10) conduct cost analyses of various community engagement strategies. As programmes expand, care should be taken to support and not to undermine work that communities are already doing, but rather to actively identify and build on such efforts.

What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs.

BACKGROUND: The number of HIV-positive pregnant women receiving antiretroviral drugs (ARVs) to prevent mother-to-child transmission (MTCT) of HIV has increased rapidly. OBJECTIVE: To estimate the reduction in new child HIV infections resulting from prevention of MTCT (PMTCT) over the past decade. To project the potential impact of implementing the new WHO PMTCT guidelines between 2010 and 2015 and consider the efforts required to virtually eliminate MTCT, defined as <5% transmission of HIV from mother to child, or 90% reduction of infections among young children by 2015. METHODS: Data from 25 countries with the largest numbers of HIV-positive pregnant women were used to create five scenarios to evaluate different PMTCT interventions. A demographic model, Spectrum, was used to estimate new child HIV infections as a measure of the impact of interventions. RESULTS: Between 2000 and 2009 there was a 24% reduction in the estimated annual number of new child infections in the 25 countries, of which about one-third occurred in 2009 alone. If these countries implement the new WHO PMTCT recommendations between 2010 and 2015, and provide more effective ARV prophylaxis or treatment to 90% of HIV-positive pregnant women, 1 million new child infections could be averted by 2015. Reducing HIV incidence in reproductive age women, eliminating the current unmet need for family planning and limiting the duration of breastfeeding to 12 months (with ARV prophylaxis) could avert an additional 264 000 infections, resulting in a total reduction of 79% of annual new child infections between 2009 and 2015, approaching but still missing the goal of virtual elimination of MTCT. DISCUSSION: To achieve virtual elimination of new child infections PMTCT programmes must achieve high coverage of more effective ARV interventions and safer infant feeding practices. In addition, a comprehensive approach including meeting unmet family planning needs and reducing new HIV infections among reproductive age women will be required.

Sexual risk-taking and HIV testing among health workers in Zambia.

Health workers (N=692) in five Zambian hospitals were interviewed to assess HIV/AIDS risk-taking and status awareness. They comprised of physicians, nurses, clinical officers and paramedics. Only 33% had been tested for HIV and only 24% said their partner had been tested. 26 percent of sexually active respondents had multiple partners; thirty-seven percent of these had not used condoms. Only 60% of respondents believed condoms were effective in preventing HIV. Women were less likely to trust or use condoms even in high-risk relationships. The data suggest a need to develop HIV/AIDS programs for health workers, with emphasis towards gender-based obstacles hampering safer behaviors.