A look at policy: comparison of domestic and global efforts to fight against HIV/AIDS affecting children

In 1981, the first HIV/AIDS case was reported.1 Patients seen with HIV/AIDS cases rapidly began to multiply as the widespread outbreak of the HIV/AIDS infection caught the entire international community off guard. Costing millions of lives and billions of dollars worldwide, the epidemic signaled an immediate public health emergency response and has continued to be a priority of nations for more than 40 years. In 2017, it was reported that approximately 36.9 million people throughout the world were living with HIV/AIDS. Of that 36.9 million, 1.8 million were children (<18 years old).2 The focus of this paper will be on HIV/AIDS and its impact on children worldwide. Children have been particularly exposed throughout the lifespan of the epidemic. Despite scientific advances to further understand the HIV virus, development of prevention methods, and implementation of treatment efforts, youth are still largely affected by the infection. The early 2000's displayed promise for combating the disease, illustrated through significant decreases in rates of transmission, but since then, progress has plateaued. Only half of the 1.8 million children living with HIV/AIDS have access to treatment. This number does not include the millions of children that are affected due to family members diagnosed with HIV/AIDS and/or the impact of HIV/AIDS on their local communities.

2 TABLE OF CONTENTS BACKGROUND 3 DEFINITIONS 4 IMPACT OF HIV/AIDS ON CHILDREN 7 VULNERABLE POPULATIONS 9 HHS INVOLVEMENT 12 WHAT WORKS 15 POTENTIAL ISSUES 22 FUTURE DIRECTIONS 24 WORKS CITED 27 3 Background In 1981, the first HIV/AIDS case was reported.1 Patients seen with HIV/AIDS cases rapidly began to multiply as the widespread outbreak of the HIV/AIDS infection caught the entire international community off guard. Costing millions of lives and billions of dollars worldwide, the epidemic signaled an immediate public health emergency response and has continued to be a priority of nations for more than 40 years. In 2017, it was reported that approximately 36.9 million people throughout the world were living with HIV/AIDS. Of that 36.9 million, 1.8 million were children (<18 years old).2 The focus of this paper will be on HIV/AIDS and its impact on children worldwide. Children have been particularly exposed throughout the lifespan of the epidemic. Despite scientific advances to further understand the HIV virus, development of prevention methods, and implementation of treatment efforts, youth are still largely affected by the infection. The early 2000’s displayed promise for combating the disease, illustrated through significant decreases in rates of transmission, but since then, progress has plateaued. Only half of the 1.8 million children living with HIV/AIDS have access to treatment. This number does not include the millions of children that are affected due to family members diagnosed with HIV/AIDS and/or the impact of HIV/AIDS on their local communities. Due to these realities, when the United States Department of Health and Human Services (HHS) began writing their Strategic Plan for the FY2018-2022, they prioritized the goal of further addressing and managing the HIV/AIDS epidemic. Strategic Objective 2.2 of the Strategic Plan includes a discussion of strategies for combating the virus. The objective states, 1 2 (George K. Siberry, 2014) (Global Statistics, 2018) 4 “Prevent, treat, and control communicable disease and chronic conditions”.3 The relevance and severity of the disease is further explained, “More than 1.1 million people in the United States are infected with HIV; estimated lifetime treatment costs are more than $400,000 per person living with HIV”.4 Strategies emphasized the importance of further reducing rates of transmission by increasing screening, treatment, care and support services through engagement activities to improve HIV viral suppression, while also implementing HIV prevention, treatment, intervention programs in support of the President’s Emergency Plan for AIDS Relief (PEPFAR).5 This paper will include a variety of sources with the purpose of exploring the ways that HHS is addressing the multi-disciplinary needs of children affected by HIV/AIDS and compare their efforts, both domestic and global, to fight the pandemic. Material from government databases in the form of health journals and recently released data, as well as key messages from subject matter experts, will be analyzed. Definitions Several terms vital to the discussion surrounding the HIV/AIDS epidemic must first be defined. • Adolescent: Falls under the definition of a child but is specifically a group of children 10-19 years6. 3 HHS Strategic Plan HHS Strategic Plan 5 HHS Strategic Plan 6 (George K. Siberry, 2014) 4 5 • AIDS: The most advanced stage of HIV infection. According to the Centers for Disease Control and Prevention (CDC), a person must have a CD4 T-cell count less than 200 cells/mm³ or an AIDS-defining condition to be diagnosed with AIDS.7 • ART (Antiretroviral treatment): First introduced to the HIV/AIDS battle in 1995-1996 and proved to be the most effective way to treat the virus8. ART is a combination of certain HIV medications that prevent the HIV virus from multiplying in the body. In addition to treatment, ART has also been shown to be a sufficient method of prevention. • Child: A person that is younger than age 18 and not an emancipated minor9. • Epidemic: Denotes a sudden increase in the number of cases of a disease within a population occupying a particular area that is higher than normal.10 • HIV Virus: Stands for human immunodeficiency virus. There are two variants of the HIV virus, HIV-1 and HIV-2, which humans can be infected with. Both HIV-1 and HIV2 are transmitted through direct contact with HIV-infected body fluids, including: blood, breast milk, semen, and vaginal fluids.11 • HIV-1: The more common variant of the virus worldwide. • HIV-2: Primarily endemic to West Africa and usually takes longer for symptoms to develop. In this paper, the term HIV will be used for addressing both variants of the virus. 7 (AIDSinfo Glossary of HIV/AIDS-Related Terms: 9th Edition , 2018) ART Successes and Challenges 9 (Definitions of Child Abuse and Neglect in Federal Law, n.d.) 10 (Principles of Epidemiology in Public Health Practice, Third Edition An Introduction to Applied Epidemiology and Biostatistics, 2012) 11 (AIDSinfo Glossary of HIV/AIDS-Related Terms: 9th Edition , 2018) 8 6 • Mother-to-child transmission (MTCT): The leading cause of HIV/AIDS infections in children.12 Transmissions can occur during pregnancy while the baby is in the uterus (intrauterine), during delivery of the baby (intrapartum), or after delivery (postnatal) during breast feeding. Pregnant women that are infected with HIV and not receiving treatment are at a 25% to 30% risk of transmitting the HIV-infection to their infants. Transmission rates can increase to up to 50% if prolonged breastfeeding occurs13. • Orphan: Defined as a child that has lost their parents due to the death or disappearance of them, the abandonment or desertion by them, or separation or loss.14 Many HIVaffected children face socioeconomic challenges, often due to lack of parental care and support. • OVC: orphans and vulnerable children. • Pandemic: Defined as an epidemic that has spread over multiple countries and continents, generally affecting a large number of people. The HIV/AIDS infection fits both definitions of an epidemic and pandemic; therefore, these terms will be used interchangeably throughout the discussion. • U.S. President’s Emergency Plan for AIDS Relief (PEPFAR): The international outbreak of HIV/AIDS was addressed by several government and nongovernment organizations, all with the same goal of eradicating the pandemic. One of the largest stakeholders in the fight against HIV/AIDS is PEPFAR15. Launched in 2003 by the U.S. government in response to the HIV/AIDS pandemic, PEPFAR is the largest investment 12 (George K. Siberry, 2014) (George K. Siberry, 2014) 14 (Glossary: Orphan, n.d.) 15 (What is PEPFAR?, 2018) 13 7 of resources and funding by any nation to address a single disease in history.16 Through PEPFAR’s support, more than 2.4 million babies have been born free of HIV to pregnant women infected with HIV and their mothers have been kept healthy to be able to care for them.17 • Viral Load- The amount of HIV in the body at one time18. ART works to decrease the viral load of HIV, allowing the body’s immune system to repair itself and increase capability to fight off secondary infections and diseases.19 • Vulnerable children: Vulnerable children can be more susceptible to deprivation (food, education, and parental care), exploitation, abuse, neglect, violence, and infection with HIV20. This is due to the face that the impacts of HIV/AIDS on children is multidisciplinary, affecting social, economic, educational, mental and physical health factors that make up a child’s wellbeing. Children are often at risk for extreme vulnerability, meaning that they are at more risk than their peers21. Impact of HIV/AIDS on Children Despite progress that has been made in the past two decades to fight the HIV/AIDS epidemic, children worldwide are still being impacted. There are a variety of risk factors and effects that often accompany or exacerbate an HIV diagnosis. Some of these include but are not limited to: poverty, lack of education, medical health issues, social stigma, and mental health challenges. Physically, the HIV infection acts by attacking CD4 T-cells (Helper T-cells) in the 16 (What is PEPFAR?, 2018) (What is PEPFAR?, 2018) 18 HIV Treatment Basics 19 HIV Treatment Basics 20 (Shilpa Khanna Arora, 2015) 21 (Shilpa Khanna Arora, 2015) 17 8 body, which are a part of the immune system, as they play a role in fighting off infection and disease. With a decreased count of CD4 T-cells, the body is more susceptible to contract serious infections resulting in chronic illnesses, such as organ failure and kidney diseases22. The immunosuppression caused by the HIV virus is the cause of further illness and for those that are left untreated, a common result of death. Because effective testing and treatment options are now available, most children with access to appropriate resources survive to adulthood but often face additional complications and barriers23. Children affected by HIV/AIDS experience barriers to their education and development. This is especially the case in countries with a high prevalence of HIV/AIDS (>5%)24. The lack of education that correlates with the HIV infection is due to a multitude of factors25. If a child has contracted the HIV virus, their resulting decrease in physical health could prevent them from being well enough to attend school. For those that are not infected with HIV but have lost a parent or currently have a parent diagnosed with HIV, a particular vulnerability is also observed26. The effects of losing a parent or taking on the responsibility to care for a family member makes it difficult for students to continue their education and reach their developmental potential. In addition, the education of an HIV-affected child is impacted by other factors such as poverty and emotional health. An article published by Health Affairs concluded that HIV-affected children who were also poor were in a significantly more vulnerable situation than those who were not in poverty27. The 22 (How Does HIV Affect Children and Adolescents?, 2016) (How Does HIV Affect Children and Adolescents?, 2016) 24 (Beverly J. Nyberg, 2012) 25 (Beverly J. Nyberg, 2012) 26 (Beverly J. Nyberg, 2012) 27 (Malcolm Bryant, 2012) 23 9 treatment options necessary to care for children and their families that are affected by HIV/AIDS are often times not feasible due to a lack of stable income for many families, resulting in overall health and well-being complications for kids. Being informed about a new diagnosis of HIV for an individual or individual’s child is “emotionally devastating”28. It is not easy to cope with the idea of a loved one being told that they have HIV. Many HIV-affected children are faced with this reality, or the actuality of being diagnosed themselves. Labels are often placed on those that are diagnosed or affected by HIV/AIDS, resulting in stigmatization and additional emotional distress among children. Often times, OVC programming singles out certain children for services, labeling them as “AIDS orphans”29. This has caused unintentional stigmatization of certain groups, and heightened psychosocial distress30. Vulnerable Populations Within the realm of children that are impacted by HIV/AIDS, there are certain populations that express particular vulnerability and are more likely to be exposed to the risk factors and affects that were described above. Specific subpopulations – OVC residents of sub-Saharan Africa, young men who have sex with men (MSM) – are at a heightened risk of negative health outcomes. Orphans and vulnerable children (OVC) are one of the most at risk populations affected by HIV/AIDS infection. There are more than 16 million children living without one or both of their 28 (George K. Siberry, 2014) (Beverly J. Nyberg, 2012) 30 (Beverly J. Nyberg, 2012) 29 10 parents due to AIDS31. Another 1 million children who have a parent who is HIV infected are also considered vulnerable32. Children in these situations become more susceptible to malnutrition, illness, lack of access to services, neglect, abuse, and mistreatment33. A child’s developmental potential suffers, and effects may be chronic or constant34. Due to their vulnerability, these children require specific attention and care when it comes to responding to their needs. Illness and death of parents frequently result in an increase of household poverty, with decreased capacity and ability to care for the basic needs of children. The lack of resources and care available to this population is something to be addressed by both domestic and global efforts. Another population disproportionately affected by HIV/AIDS are communities that reside in sub-Saharan Africa. In this region, 1 in every 6 children will die before reaching the age of 5 years. Sub-Saharan Africa has a high prevalence of HIV (>5%), and of the nearly 2 million children living with HIV worldwide, two-thirds live in this region35. Additionally, nearly 12 million children living in sub-Saharan Africa have lost one or two parents to HIV/AIDS36. Implementation of treatment and services have been imperfect in these regions. Fragile health systems that struggle to provide the most basic treatment are not able to grapple with the logistics and expansion of proper action to combat HIV/AIDS.37 Delicate systems lacking funding and resources, paired with the high prevalence of HIV/AIDS in sub-Saharan Africa does not make it easy to treat children and prevent the further spread of the infection. 31 (Beverly J. Nyberg, 2012) (Malcolm Bryant, 2012) 33 (Beverly J. Nyberg, 2012) 34 (Beverly J. Nyberg, 2012) 35 (Lancet, 2009) 36 (Beverly J. Nyberg, 2012) 37 (Benjamin H. Chi, 2012) 32 11 Turning internally and looking at the United States, the rates of HIV infection in children (<13 years) have decreased from 2012-2017.38 These numbers are highlighted in the table below. Though the data represented in the table look promising, there are regions across the country that encompass several populations of older children who have been identified as higher risk groups. The group with most risk is young adolescent men who sleep with men39. This population is found in a geographically consolidated region and faced with challenges of social stigma and lack of education. In addition, intravenous drug users and adolescents who have unprotected anal or vaginal sexual intercourse, those who have sexually transmitted infections, and sexually active youth living in areas of increased HIV prevalence (defined by the CDC as a community with an HIV seroprevalence of at least 1%) are at a higher risk of contracting the HIV infection40. Other populations at higher risk of infection in the U.S. include children and 38 Table of HIV Infected Children (George K. Siberry, 2014) 40 (George K. Siberry, 2014) 39 12 adolescents that are affected by poverty, mental illness, and substance abuse. These risk factors place children in a susceptible environment where the HIV virus is more easily contracted. HHS Involvement The United States Department of Health and Human Services (HHS) has implemented a multipronged strategy to combat the outbreak of HIV/AIDS in the United States. Since the early 2000’s the rate of new HIV/AIDS infections has declined overall in the United States, but in recent years progress has somewhat stalled.41 As a response to these stagnant rates, President Donald J. Trump, in coordination with CDC Director Redfield and NIAID Director Fauci, recently announced the goal of the Administration to launch a new plan, Ending the HIV Epidemic: A Plan for America, intended to end the HIV/AIDS epidemic in the United States by 2030. A team of multiple divisions within HHS has been established to join forces and achieve the government’s plans. These divisions include: Centers for Disease Control (CDC), U.S. Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), Indian Health Service (HIS), and Substance Abuse and Mental Health Services Administration (SAMHSA). CDC focuses their attention on prevention and intervention, believing that a combination of those methods is key to achieving a sustainable impact. The Department has continued to develop and modernize strategies for effective methods to reduce new HIV infections. Their current priorities that are in place until 2020 include: testing and diagnosis, HIV care and treatment, access to condoms, PrEP availability and distribution, and support for risk reduction42. All strategies presented by CDC share a main goal of creating resources that are accessible, 41 42 (Max Roser, 2018) (HIV Prevention in the United States: New Opportunities, New Expectations) 13 affordable, and simple to navigate for communities.43 CDC and other federal programs have taken part in groundbreaking research, resulting in a prevention medication known as PrEP that has the ability to reduce the risk of acquiring the HIV virus through sexual transmission by 90%. The aim of CDC is to establish a widespread distribution of it, first to communities that present a higher risk of HIV/AIDS. Having this medication available to eligible populations would reduce the risk of HIV transmissions in women and further reduce downstream mother-to-childtransmission of HIV/AIDS in infants throughout the United States. The National Institutes of Health has also funded countless research initiatives to provide useful information so that government entities can provide the best possible care and resources44. Federal support is offered through the HIV Health Improvement Affinity Group (HHIAG) to state-level efforts such as Medicaid, as well as CMS that funds the Children’s Health Insurance Program (CHIP) to enroll children that are living with HIV.45 This allows children to access treatment and necessary services without the worries of costly copays that would otherwise inhibit them from being properly treated. Under HRSA, there are more than 90 programs that serve HIV/AIDS-affected populations, supporting more than 100 million people worldwide.46 Specifically, HRSA administers the Ryan White HIV/AIDS Program, that has proven to be incredibly effective for participants, with more than 86% of patients enrolled now virally suppressed.47 The program is divided into five different parts and Part D provides funds for local, community-based organizations that provide 43 (HIV Prevention in the United States: New Opportunities, New Expectations) (HIV Prevention Activities, 2017) 45 (HIV Prevention, Care, and Treatment, 2017) 46 HIV/AIDS Event- June 26th 47 HIV/AIDS Event- June 26th 44 14 care to children and women living with HIV.48 Part D program costs are spread among several categories including medical service costs, providing primary medical care that is familycentered to women and children, as well as support services such as case management and outreach to families.49 The success of this program is due to the ability of the foundation to recognize and address the general well-being of patients in addition to their medical health. Realizing that HIV/AIDS negatively impacts multiple determinants of a child’s health gives programs a purpose to provide meaningful treatment and support. Other programs throughout the country are looking to adopt similar models because of the positive results the Ryan White program has achieved.50 In addition to addressing HIV/AIDS domestically, the United States government has responded to global needs as well. In 2003, George W. Bush introduced PEPFAR, administered through the Office of Global Affairs (OGA). As the biggest response in history to a public health emergency, PEPFAR has focused much of its efforts on reducing the impact of HIV/AIDS on MTCT (mother-to-child transmission)51. PEPFAR’s passion for this issue can be understood by their driving statement, "Children are our future. PEPFAR is committed to supporting these children with the clinical and social services they need to survive, thrive, and become healthy and productive adults." They have joined efforts with the World Health Organization (WHO) and the United Nations Program for HIV/AIDS (UNAIDS) as well as local community partners in middle and low income countries in hopes of uniting to battle the disease together52. More than 10% of the PEPFAR budget is designated to serving children affected by HIV/AIDS. Since 48 (About the Ryan White HIV/AIDS Program, 2019) (About the Ryan White HIV/AIDS Program, 2019) 50 HIV/AIDS Event – June 26th 51 (Benjamin H. Chi, 2012) 52 (Benjamin H. Chi, 2012) 49 15 2003, $1.6 billion has been given to groups that provide services for children, directly affecting the lives of around four million children53. PEPFAR has been able to recognize the multidisciplinary care model that is necessary to properly treat HIV-affected children. Working side-by-side with the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Children’s Fund, and USAID, the organization has tried to focus efforts on the core needs of children54 These factors are known as the “6 + 1 needs” and include: food and nutrition, shelter and care, legal protection, health care, psychosocial support, education, and economic strengthening of families’ and households’ capacity.55 The United States has put in a great deal of work through PEPFAR to address these needs on a global scale, but studies have not been able to draw enough data and conclusions that their efforts and resources are making any significant impact56. These gaps in care and lack of measurable results are likely due to resources and programs being spread too thin for any substantial change to occur. Additionally, organizations like PEPFAR report having a difficult time collecting data and measuring the progress of implemented programs and their participants. Additional data are needed to better understand this issue and more purposefully address the progress that has been made and areas requiring further attention. What Works Dr. Anthony S. Fauci, the Director of the National Institute of Allergy and Infectious Diseases and National Institutes of Health and one of the world’s top experts on HIV/AIDS, explained that at the beginning of the HIV/AIDS epidemic, 50% of the patients that were 53 (Malcolm Bryant, 2012) (Malcolm Bryant, 2012) 55 (Malcolm Bryant, 2012) 56 (Malcolm Bryant, 2012) 54 16 diagnosed with HIV/AIDS were typically dead within one year.57 Today, if a patient is diligent about taking their prescribed ART, they can live more than fifty years. Fauci believes one of the critical aspects of eliminating the HIV/AIDS infection is the widespread distribution of ART, especially to the hotspot populations that have a higher prevalence of HIV/AIDS and therefore present a higher risk of children contracting the virus.58 “Without antiretroviral treatment, 50 percent of children living with HIV/AIDS would die before their second birthday, and 80 percent would die before their fifth birthday. Only half of children living with HIV/AIDS are accessing life-saving treatment”.59 In the United States, studies have shown that routine use of ART during pregnancy results in less than 1% to 2% in mother-to-child transmission (MTCT)60. Another study based in Zambia, conducted before the widespread availability of ART, concluded that administering the treatment to pregnant women could have the potential of reducing 88% of perinatal and postnatal infections and 92% of maternal deaths61. As previously mentioned, because of the way that ART works to decrease the overall viral load of HIV in the body, ART can treat while also preventing others from becoming infected. “Treatment as prevention” was pivotal when first discovered because it now allows those diagnosed with HIV/AIDS to be treated in a way that also prevents others that come into contact with them from contracting the virus, including MTCT. 57 HIV/AIDS Event- June 26th HIV/AIDS Event- June 26th 59 (Children, n.d.) 60 (George K. Siberry, 2014) 61 (Benjamin H. Chi, 2012) 58 17 Reducing MTCT would result in a significant decrease in the number of children infected with HIV and has been a priority worldwide since the beginning of the epidemic. HHS recommends that all women get tested for HIV/AIDS when they find out that they are pregnant62. Early diagnosis during pregnancy allows for treatment to be administered and the chance of transmitting the virus to the infant to be reduced. Each state has different laws and requirements in place regarding the testing of an expecting mother for HIV/AIDS. The map on the left illustrates the variety of HIV testing laws that are in place throughout the country. A large handful of the states have “no relevant laws” pertaining to the requirement for perinatal 62 (George K. Siberry, 2014) 18 HIV/AIDS testing.63 If pregnant women do get tested and the results prove to be HIV positive, ART treatment is given to the mother to reduce the risk of transmitting the infection to her baby and decrease the viral load in her body. It is also strongly recommended that HIV-positive women do not breast feed their baby. In particularly vulnerable populations, often middle and low income countries, formula feeding is not a viable option due to financial instability and access to clean water sources. In these cases, studies have shown that the ART treatment does a sufficient job of preventing transmission and that breastfeeding can be allowed in these circumstances64. Early testing and prevention of MTCT programs allow for earlier identification of vulnerable children, and provides an opportunity to link mothers and families to proper care and support networks65. Dr. Fauci and other experts in the field emphasize the three most critical aspects of fighting the HIV/AIDS epidemic: treatment, prevention, and care with intervention. Testing individuals for HIV/AIDS fits into all three of the critical categories, yet there are no clear standards for what age that testing should start. The CDC recommends that in addition to pregnant women, adolescents should be tested for HIV beginning at age 13 years66. The American Academy of Pediatrics encourages that patient populations with HIV prevalence of 0.1% or higher, 16 to 18 year old adolescents should be tested at least once67. The American Academy of Family Physicians (AAFP) believe that is a waste of resources and time to screen adolescent children who do present with high risk.68 Testing early for HIV allows medical care 63 (Perinatal HIV Testing Laws, n.d.) (George K. Siberry, 2014) 65 (Beverly J. Nyberg, 2012) 66 (George K. Siberry, 2014) 67 (George K. Siberry, 2014) 68 (AAFP, Routine HIV Screening 2013) 64 19 providers and case workers to educate patients and their families about HIV and point out behaviors or practices that can elevate or decrease their risk of contracting HIV infection.69 Additionally, linking the task of testing to that of intervention and care for HIV infection is critical in educating families and communities about risk factors and the multiple impacts of HIV/AIDS. Often, these opportunities open the door for family-centered services. An article written for the Journal of the International AIDS Society inserts a quote by Carol Levine, the founder of The Orphan Project: Families and Children in the HIV Epidemic, stating, “AIDS threatens the intimacy and acceptance that ideally undergird family relationships, while at the same time making them all the more powerful and necessary”70. One of the most effective and necessary ways to reduce the impact of the HIV infection on children worldwide is through strengthening the family unit, focusing on the child’s well-being71. These methods include emphasizing the importance of primary care visits which allows clinicians to assess the health of the child as well as social support needs that mothers and families may identify. Meeting with physicians also allows healthcare providers to collaboratively plan treatment with the patient and family, helping to create a relationship that is therapeutic for the family, while promoting successful adherence to treatment and HIV control.72 In parts of the world where access to healthcare services are limited because of location, finances, or lack of medical expertise, treatment and outreach programs are harder to keep track of but still entirely necessary. Programs that are focused on the well-being of the family and attempt to combat the impoverishing effects of AIDS have proven to be beneficial73. These may 69 (Beverly J. Nyberg, 2012) (Richter, 2010) 71 (Beverly J. Nyberg, 2012) 72 (George K. Siberry, 2014) 73 (Beverly J. Nyberg, 2012) 70 20 include services demonstrating money management skills and have been shown to “empower families to better care for children within their households and reduce their vulnerability”74. Additionally, international efforts focusing on educating communities about family planning have proven to be effective and benefit children75. This is particularly critical in regions that lack access to necessary HIV/AIDS treatment and facilities, which are often regions that have a higher prevalence (>5%) of HIV/AIDS. Evidence shows that “Prevention of unintended pregnancies is a highly cost-effective tool for decreasing the pediatric HIV burden and for reducing maternal deaths, both related and unrelated to HIV disease”76. Decreasing the overall number of children contracting HIV through MTCT will only ease the burden on future generations, saving lives, saving money, and improving the quality of life. The idea of family-centered services introduces the topic of community level engagement, focusing on sustainable practices77. International organizations such as PEPFAR, primarily works with local community groups: religious, traditional, civil, etc… to provide care78. PEPFAR has recognized that in order to make a significant impact on the HIV/AIDS epidemic, a sustainable workforce is required, and a systematic social service workforce is most powerful79. It has been identified that in order to make significant gains towards the goal of elimination, there needs to be an increased demand for ART prophylaxis, which means a demand for health care infrastructure, human resource development, and monitoring and evaluation. Midlevel providers need to be utilized for counseling and support services to community members 74 (Beverly J. Nyberg, 2012) (Benjamin H. Chi, 2012) 76 (Benjamin H. Chi, 2012) 77 (Beverly J. Nyberg, 2012), Chi et al. 78 (Beverly J. Nyberg, 2012) 79 (Beverly J. Nyberg, 2012) 75 22 Potential Issues Though there have been significant strides and successes in the history of fighting the HIV/AIDS epidemic, the battle has spanned more than forty years, and the infection has yet to be eradicated. Research is needed for continual exploration of the virus and its effects on populations worldwide. Continually readdressing the needs of those that are affected provides opportunities for best possible care and resources to be provided to those affected. Additionally, collecting baseline data that can be analyzed by programs providing aid (PEPFAR) allows for assessment of the impact of current programs and how they can be improved.82 Further research presents the opportunity for programs to focus on the most vulnerable and impacted populations and regions, prioritizing solutions that promote sustainability and results that can be passed down to generations.83 Development and implementation of programs is necessary especially when addressing the population of HIV-affected adolescents transitioning from youth to adult healthcare so that this population is not left behind. As new factors surrounding HIV/AIDS continue to emerge, it will be critical to address youth and young adults when thinking about future directions. Currently, HIV/AIDS infections within the United States are isolated both geographically and demographically. Due to this, the CDC’s recently proposed program Ending the HIV Epidemic: A Plan for America is focusing its efforts inward, giving the country’s HIV/AIDS hotspots necessary attention and resources. The population that will be targeted throughout this initiative primarily includes men who sleep with men, particularly those of African American 82 83 (Malcolm Bryant, 2012) (Malcolm Bryant, 2012) (Beverly J. Nyberg, 2012) 24 be to strengthen domestic programs. This may result in a decrease of funding and resources for PEPFAR and other international aid organizations. Cutting allocations devoted to international HIV/AIDS work might have unexpected consequences in regions where HIV/AIDS prevalence is high and also where most children worldwide are affected. Whether or not the cuts in international funds are being transferred to domestic efforts is difficult to determine. The new plan, with goals to be reached by 2030, will most likely result in quick results and decreases in the rates of transmission within the target communities of the 48 regions within the United States. Whether shifting the focus away from children will worsen outcomes for this population is still unknown but considering the results could influence future decisions of policy makers. Future Directions HIV/AIDS unfortunately impacts every aspect of a child’s life, and giving attention to social determinants of health is equally as important as treating medical needs. Social determinants of health refer to the conditions where people work, live, learn, and play. Multidisciplinary programs that address both medical needs and social determinants of health have the potential to improve efficiency and effectiveness of our responses. For example, it has been shown that school absenteeism and educational outcomes improve when substantial school fees support are given85. Additionally, “female adolescents receiving support from child-centered clubs experienced benefits in confidence and healthy attitudes”86. These positive results can be explained by the increase of confidence and decrease of financial burden by these HIV-affected children. 85 86 (Malcolm Bryant, 2012) (Malcolm Bryant, 2012) 25 Additionally, new policies and programs that shift efforts towards the root of the problem, focusing on prevention strategies rather than just treatment of those already with HIV/AIDS, could be an approach to further decreasing rates of transmission in infants and children. This is because prevention strategies are often times much more financially feasible for populations and easier to implement in areas that are difficult to access rather than treatment options. By further reducing the rate of transmission of HIV, the eventual eradication of the disease will be achieved. Education of children and mothers throughout communities worldwide is crucial for these sustainable results. This means taking the time to explain the transmission process, risk factors, and safe practices surrounding HIV/AIDS to children and their families. Knowledge of the issue and the feeling of empowerment has the potential to reduce transmission percentages. Education and intervention practices are most beneficial when implemented at the local level. This allows a sense of trust, credibility, and comfort for those that are treated, especially in regions where social stigma and societal roles are a barrier to receiving accurate information and proper resources. The HIV/AIDS epidemic is always evolving, much like the actual HIV virus. This requires policy makers to stay nimble, constantly researching and attempting to stay ahead of the virus. Policies, efforts, and distribution of funds will be most effective when based on evidence and data collected both domestically and globally. It is important to keep in mind the particular vulnerable populations that are affected by HIV/AIDS. In this case, children are vulnerable and require multidisciplinary care to meet their complex needs. Shifting focus away from this population presents potential risk for the future of the fight against HIV/AIDS. Policy makers and officials that keep a broad perspective and present a holistic, sustainable approach, have the potential to make a positive impact in reducing the rates of HIV/AIDS worldwide. The United 26 States is in a unique position, with access to the resources and technology that have the power to end the HIV/AIDS epidemic. Careful decision making of program funding and implementation of resources will determine whether or not HIV/AIDS can finally be eradicated. 27 Works Cited About the Ryan White HIV/AIDS Program. (2019, Feburary). Retrieved from Health Resources & Services Administration: https://hab.hrsa.gov/about-ryan-white-hivaids-program/about-ryanwhite-hivaids-program AIDSinfo Glossary of HIV/AIDS-Related Terms: 9th Edition . (2018). Retrieved from AIDSinfo: https://aidsinfo.nih.gov/contentfiles/glossaryhivrelatedterms_english.pdf Benjamin H. Chi, M. R.-N. (2012). Progress, Challenges, and New Opportunities for the Prevention of Mother-to-Child Transmission of HIV Under the US President's Emergency Plan for AIDS Relief. J Acquir Immune Defic Syndr, 78-87. Beverly J. Nyberg, D. D.-T. (2012). Saving Lives for a Lifetime: Supporting Orphans and Vulnerable Children Impacted by HIV/AIDS. J Acquir Deficiency Syndr, 127-135. Children. (n.d.). Retrieved from The United States President's Emergency Plan for AIDS Relief: https://www.pepfar.gov/priorities/children/index.htm Definitions of Child Abuse and Neglect in Federal Law. (n.d.). Retrieved from Child Welfare Information Gateway: https://www.childwelfare.gov/topics/can/defining/federal/ George K. Siberry, M. M. (2014). Preventing and Managing HIV Infection in Infants, Children, and Adolescents in the United States. Pediatrics in Review, 268-286. Global Statistics. (2018, November 20). Retrieved from HIV.gov: https://www.hiv.gov/hivbasics/overview/data-and-trends/global-statistics Glossary: Orphan. (n.d.). Retrieved from U.S. Citizenship and Immigration Services: https://www.uscis.gov/tools/glossary/orphan HIV Prevention Activities. (2017, May 20). Retrieved from HIV.gov: https://www.hiv.gov/federalresponse/federal-activities-agencies/hiv-prevention-activities HIV Prevention in the United States: New Opportunities, New Expectations. (n.d.). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hiv/pdf/policies/cdc-hivprevention-bluebook.pdf HIV Prevention, Care, and Treatment. (2017, Februrary 13). Retrieved from HHS.gov: https://www.hhs.gov/ohaidp/initiatives/hiv-prevention-care-and-treatment/index.html HIV Treatment: The Basics. (2019, January 15). Retrieved from AIDSinfo: https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/51/hiv-treatment--the-basics How Does HIV Affect Children and Adolescents? (2016, December 1). Retrieved from National Institutes of Health: https://www.nichd.nih.gov/health/topics/hiv/conditioninfo/children Lancet, T. (2009). A New Agenda for Children Affected by HIV/AIDS. The Lancet, 517. 28 Lucia Palmisano, S. V. (2010, September 20). A Brief History of Anitretroviral Therapy of HIV Infection: Success and Challenges. Retrieved from http://old.iss.it/publ/anna/2011/1/47144.pdf Malcolm Bryant, J. B. (2012). PEPFAR's Support for Orphans And Vulnerable Children: Some Beneficial Effects, But Too Little Data, And Programs Spread Thin. Health Affairs, 1508-1518. Max Roser, H. R. (2018, April). HIV/AIDS. Retrieved from Our World in Data: https://ourworldindata.org/hiv-aids Perinatal HIV Testing Laws. (n.d.). Retrieved from Centers for Disease Control: https://www.cdc.gov/hiv/images/policies/law/states/cdc-hiv-perinatal-testing-map.PNG Principles of Epidemiology in Public Health Practice, Third Edition An Introduction to Applied Epidemiology and Biostatistics. (2012, May 18). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html Richter, L. (2010). An Introduction to Family-Centred Services For Children Affected by HIV and AIDS. Journal of The International AIDS Society, S1. Shilpa Khanna Arora, D. S. (2015). Defining and Measuring Vulnerability in Young People. Indian Journal of Community Medicine, 193-197. What is 'Ending the HIV Epidemic: A Plan for America'? (2019, July 8). Retrieved from HIV.gov: https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview What is PEPFAR? (2018, November 28). Retrieved from HIV.gov: https://www.hiv.gov/federalresponse/pepfar-global-aids/pepfar