Reauthorise PEPFAR to Prevent Death, Orphanhood, and Suffering for Millions of Children
Lucie Culver, Jeffrey W. Imani-Eaterry, Lorraine Sherr, Mary Mahy, Seth Flaxmen.
Published August 17, 2023, The Lancet
As researchers on HIV, AIDS, and paediatric health, nothing is more central to our work than preserving children’s lives. Considering the current challenge to the 5-year reauthorisation of the US President’s Emergency Plan for AIDS Relief (PEPFAR), we used 2023 UNAIDS estimates on the prevalence of children orphaned by AIDS, infant and young child HIV- infections, and incidence of adult and child AIDS deaths to estimate PEPFAR’s effect on child survival and health. We focused on sub-Saharan Africa: the region receiving more than 90% of PEPFAR funds and containing two-thirds of all people with HIV. We note that PEPFAR provides support through and in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria (to which PEPFAR is the largest donor), national governments, UNAIDS, and other UN agencies.
Figure: AIDS orphanhood, infant and young child HIV infections, and infant and young child AIDS deaths in sub-Saharan Africa
(A) Incidence of orphanhood caused by AIDS in sub-Saharan Africa (children aged <18 years who are newly orphaned per year). Regression model estimates were based on linear regression with no intercept term, 1-year lagged orphanhood prevalence, and new AIDS deaths for individuals aged 15–49 years, based on UNAIDS data. (B) Prevalence of orphanhood caused by AIDS in sub-Saharan Africa (living children
[aged <18 years] who were orphaned by the loss of at least one parent). Replication code is available at https://github.com/MLGlobalHealth/PEPFAR-letter. (C) New HIV infections due to vertical transmission (infants and young children aged <36 months) in Lesotho, 1990–2022, based on UNAIDS data. (D) Paediatric AIDS deaths in sub-Saharan Africa, based on UNAIDS data (infants and young children aged <36 months).
PEPFAR has substantially reversed the devastating effects of HIV and AIDS on children who are newly orphaned (figure A). Loss of a parent is associated with education loss, child abuse, and child sexual exploitation, with consequent elevated risks of HIV infection. Using UNAIDS data, we estimated the number of children who were newly orphaned by AIDS annually before and after PEPFAR by regressing orphanhood prevalence on previous-year orphanhood prevalence and adult (aged 15–49 years) AIDS deaths. Incidence of orphanhood in sub-Saharan Africa increased rapidly from 1990, reaching a peak of 1.6 million children newly orphaned by AIDS (aged <18 years) during 2004. In this year, PEPFAR began to prevent parental deaths via a massive roll-out of antiretroviral agents to 28 countries in sub-Saharan Africa. From 2005, the incidence of orphanhood due to AIDS has reduced annually to 382,000 in 2021.
UNAIDS data show that 10.3 million children orphaned by AIDS in sub-Saharan Africa remain in need of support (figure B). Globally, 13.9 million children are orphaned, living without one or both parents who have died of AIDS, alongside 7.5 million children orphaned due to COVID-19-associated excess deaths. 10% of PEPFAR’s bilateral funding is dedicated to care of orphaned and vulnerable children, including provision of nutritious food, school fees, small loans and savings clubs for caregivers, and psychosocial support. Failure to reauthorise PEPFAR would mean that this support will no longer be guaranteed.
The PEPFAR era has brought four-fold reductions in new HIV infections among infants and young children. PEPFAR reduces paediatric infections through programmes for prevention of parent-to- child transmission, and through antiretroviral agent roll-out, which suppresses viral load and therefore the transmission of HIV to partners and children. New HIV infections among infants and young children (aged <36 months) in sub-Saharan Africa escalated from 250,000 in 1990 to more than 465,000 per year between 1999 and 2002, then reduced to 110,000 by 2022. As an example, figure C shows incident HIV infections in infants and young children in Lesotho. We saw rapid reductions in paediatric infections in the PEPFAR era, despite increasing numbers of women with HIV: 4,600 children were infected per year in 2004, which reduced to fewer than 500 per year in 2022.
Since PEPFAR’s implementation, AIDS deaths in infants and young children have fallen by 80% (figure D). Using the UNAIDS data, we examined deaths among infants and young children from 1990 to 2022. PEPFAR prevents child deaths by preventing infections and providing antiretroviral agents to children born with HIV—without which 50% of infants will die before reaching 2 years of age. Figure D shows that deaths among infants and young children in sub-Saharan Africa more than doubled during the 1990s, reaching 240,000 per year in 2004. After PEPFAR implementation deaths reduced five-fold to 47,000 in 2022.
PEPFAR has supported 7.1 million children who are orphaned and vulnerable and their caregivers, and provides 700,000 children per year with antiretroviral medication and psychosocial and nutritional support to stay on treatment. PEPFAR’s direct effects extend further to the reduction of subsequent negative outcomes on children’s lives, such as avoidance of HIV- related developmental delays, family breakdown and separation, abuse and mental health distress, and reduction of poverty-driven sexual exploitation of children.
But the task is far from done. During COVID-19 lockdowns, PEPFAR innovated to provide continuity of HIV care and child abuse prevention, but the initiative now needs to develop preparedness for future pandemics. Only 56% of children aged younger than 14 years with HIV in sub-Saharan Africa have access to antiretroviral treatment. Prevention of parental and child deaths requires sustained provision of antiretroviral medication and prevention of parent-to-child transmission. PEPFAR is working, where feasible, to support sustainable shifts towards national government ownership of antiretroviral programmes, but evidence shows that successful transitions require planning and investments in national financial, technical, and logistical capacity. Abrupt halting of development aid can cause health system collapses. PEPFAR, the Global Fund to fight AIDS, Tuberculosis and Malaria, national governments, and donors such as the Bill & Melinda Gates Foundation are a crucial partnership for global health security.
In 2022, PEPFAR provided life-saving antiretroviral medication to 20 million people—most of them parents and children. Epidemiological models for children younger than 15 years predict that a 6-month interruption in supply would cause an additional 107 300 paediatric HIV infections and an additional 20 600 childhood AIDS deaths within a year.
Loss of PEPFAR would inevitably result in death, orphanhood, and suffering for millions of children.