Paediatric HIV: We are not done yet!

On 9th July 2020, Martina Penazzato presented at the plenary session on Pediatric HIV at the 23rd International AIDS Conference. We met with her and asked for her thoughts on what Penta can do to continue the fight against paediatric HIV, particularly in light of the COVID-19 public health emergency.

Martina Penazzato is the paediatric HIV lead for the HIV, Hepatitis and STI Programme at the World Health Organization (WHO) Headquarters in Geneva, Switzerland. She is an infectious disease specialist and has spent more than 15 years contributing to clinical research and developing global policies on paediatric HIV. She obtained her MD and PhD at the University of Padua and a Master’s in Public Health in Developing Countries at the London School of Hygiene & Tropical Medicine.  
Prior to joining WHO, she worked in Uganda and collaborated with Penta, where she further developed her research interest focused on the optimization of diagnosis and treatment of infants and children living with HIV. Martina has provided technical assistance to several countries, particularly in the African region, as well as contributed to the guidelines development processes in the areas of HIV, tuberculosis and child health. For the past six years, she has led the WHO’s work in HIV paediatric treatment and care,  and contributed to a number of global initiatives to improve access to HIV services for children living with HIV. Martina is a co-founder of the Global Accelerator for Paediatric Formulations and a key contributor to the work that WHO is undertaking to accelerate access to better medicines for children.

Paediatric HIV: why are we not done yet?

In the last few decades the global community has made great strides in the fight against HIV in babies and children. The majority of pregnant women who are diagnosed with HIV can now start antiretroviral therapy (ART). This extensive use of ART during pregnancy has been crucial for the prevention of the HIV transmission from mother to child. Despite these remarkable advancements, children continue to have a higher mortality rate compared to adults. Every day, approximately 400 children acquire HIV globally and around 260 children die because of AIDS. We know that disease progression in children is fast, particularly in the first months of life. We have effective and innovative technologies to diagnose HIV soon after birth, however only two thirds of infants born to mothers living with HIV receive an HIV test by 2 months of age. Only half of the 1.8 million children living with HIV receive life-saving ART and even when they receive it, our ability to suppress the virus in their blood is poorer than in adults.

If that was not enough to dash our hopes that AIDS will soon be a disease of the past for children, COVID-19 has disrupted the situation even further. This pandemic has exposed the fragility of our healthcare systems and prevented patients to seek appropriate care due to fear, which has been amplified by the lack of reliable information. We have heard of mothers and children who are unable to access healthcare services due to the public health measures in place, or because they can’t find transport to reach the facility and are scared they may acquire COVID-19. We are also hearing of out of stock paediatric formulations at a time when many countries were finally undertaking a major shift to optimal treatment regimens.

Epidemiological modeling predicts that the COVID-19 pandemic will impact the number of new paediatric HIV infections, causing an increase of up to approximately 86%. This is reverting the progress made so far, taking us back to a similar situation that we were in 2014.

What can we do to ensure COVID-19 and other global health emergencies don’t stop our progress in this field?

We need to act now. We need to start to strengthen our work in countries adapting our interventions to the epidemic context and the local characteristics but also promote and spread innovation widely. We must make the most of what we already know works; such as testing children born to HIV-infected parents. We have new diagnostic tools that can be used at the point of care, which effectively reduce the time required for diagnosis and treatment initiation.

It is extremely important to continue and strengthen research to develop better treatments for infants, children and adolescents. 2021 can finally be our year of change, as dolutegravir, a safe and well-tolerated drug, available in a child-friendly formulation, is now approved from 3 kg and 4 weeks of life and generic formulations are on their way. The contribution of the Penta-sponsored ODYSSEY trial was key in obtaining the FDA approval for this drug, which now allows for full implementation of WHO guidelines for all  children living with HIV. The level of collaboration we have witnessed to make this possible is unprecedent and should set a new standard for the way research networks, innovators, generic manufacturers and other stakeholders work together in this field.

We also need to invest in a more comprehensive package including supporting the mental and psychological development of children and adolescents as they grow up with HIV. We cannot be satisfied with children just surviving and reaching virological suppression. If we don’t give them the chance to improve their quality of life and reach their full potential, our job is not done.

Further, we need to support and increase the capacity of those who are leading outstanding research on the ground, and we need to promote stronger collaborations with those holding expertise and know-how, in order to bring innovation into the field.

As researchers, what can we learn from this COVID-19 emergency?

I believe that to achieve impact, the way we deliver interventions is as important as the interventions themselves. It is extremely important to push operational research, that helps us find new and effective ways to deliver our research. A remarkable experience of this kind is the Zvandiri operational research in Zimbabwe, which has demonstrated that, if you provide HIV services with the support of peers, you can improve adherence to treatment and impact health outcomes.

The COVID-19 pandemic has offered us an opportunity to re-think the way in which we implement research. Digital platforms are one way we can provide children and adolescents with the support and information they need and can be a starting point to change and improve the way in which we will deliver treatment and care services.

We also need to innovate! Innovation is key to improving diagnosis and care for our children and adolescents, but it requires a collaborative effort and the necessary resources to make it possible.

New collaborations are being developed to do just this. In Europe, conect4children is a new clinical trial network aiming to facilitate the development of new drugs and therapies for the paediatric population. This network, with central involvement from Penta, remains in the development and testing phase, but the possibilities for accelerating the clinical development process poses an exciting prospect.

The Global Accelerator for Pediatric Formulations is another example of how an innovative collaboration across sectors can aspire to deliver better paediatric products quicker and cheaper in low and middle-income countries. Led by WHO, this network includes Penta and others such as Clinton Health Access Initiative, Medicine Patent Pool, Elizabeth Glaser Pediatric AIDS Foundation. Together, this collaboration aims to accelerate the availability of optimized formulations for infectious diseases, such as HIV, tuberculosis and viral hepatitis, by prioritizing products, streamlining the generation of clinical evidence, incentivizing manufacturers, accelerating product development and introduction, and coordinating procurement.

We cannot forget to mention EPIICAL, one of the largest collaborative research efforts in paediatric HIV, paving the way for testing novel therapeutic strategies to help find a cure for HIV, which are now being tested in the HVRRICANE study.

We can work towards an AIDS-free generation, but we must do this together.

 

July 9, 2020

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