01 December 2020

World Aids Day: Interview With Dr. Chewe Luo

Dr. Chewe Luo, chief of the HIV/AIDS Section at UNICEF, is a pediatrician by training who has also done public health and epidemiology work at the doctorate level. Originally from Zambia, she worked as a pediatrician in the United Kingdom before returning to her native country in 1996. “HIV was really ravaging our pediatric care and our wards were overcrowded,” she said. “Children were coming in sick or not getting better, parents were really desperate as to what to do—and at that point I felt that while it was nice to be working as a pediatrician, here was a much bigger problem that we had to deal with head on” using policy interventions. It was then that she decided to look at broader child health and what was possible from a public policy perspective. 

For World AIDS Day, Dr. Luo spoke with Every Woman Every Child about the state of HIV advocacy work, the important role of technology, the effects of COVID-19, and what remains to be done. This interview has been lightly edited for clarity

What is the current state of HIV/AIDS advocacy? 

It’s important to recognize that the global community has agreed to end AIDS by 2030. When we talk about “ending AIDS,” we mean bringing down to the minimum both the number of children that are born with HIV and the number of adolescents getting infected. We have global goals for two interventions, which are prevention and treatment, and we think that if we bring the two together, no child should be dying of HIV. That’s the thrust of UNICEF’s work. 

We have made enormous strides in making sure that women who are pregnant and living with HIV and AIDS globally can access the treatment they need to prevent infection from being transmitted. Today, globally, 85 percent of the 1.4 million women living with HIV have access to lifesaving antiretroviral treatment for their own health and to prevent infection from being passed on. Without treatment, about 30 to 40 percent of mothers who have HIV and are breastfeeding will transmit to their child. When they do get treatment—especially if they get it both during pregnancy and continue to take it while breastfeeding—that number is less than 2 percent. Overall, we’ve actually reduced infection in babies by as much as 52 percent from 2010. So that’s progress. 

But the same is not true when we talk about treating children. Of the children that are getting infected, only about 54 percent of them have access to antiretroviral treatment, so UNICEF is concerned about the gap that we have between mothers and children. And when it comes to adolescents, we don’t even have good numbers of how many adolescents are accessing treatment or transitioning from being children into adolescent care. Mortality in adolescents is high. We need to look at transition points and make sure that adolescents are comfortable with the way services are being delivered to them.

What are the factors that lead to such a gap between access for mothers and access for young children?

Well, we know that if 85 percent of women with HIV have access, we’re missing 15 percent, which means they’re not coming to prenatal care, or they weren’t tested even if they came. These women are not coming to prenatal care, maybe because user fees are prohibitive, maybe because there is stigma and discrimination. For children, the situation is different. The WHO recommendation is to test all children around 6 to 8 weeks of age because the disease in children is very aggressive without treatment. Without treatment, 30 percent of children with HIV will have died by year one, 50 percent by year two, and 80 percent by year five. So early recognition of infection and treatment is what we’re aiming for. 

But the tools for making a diagnosis in a small child are very different from the tools for making a diagnosis in an older child. For the young child, we’re looking for the virus itself—we’re looking for viral particles in the diagnosis—and that technology is very complicated. It requires a sophisticated laboratory and trained personnel. For adults, there’s a rapid test that can be done by everybody, so access to testing is much easier for older children and adults than for younger children. 

UNICEF has been working with industry to come up with a simplified diagnostic platform that can be applied in facilities where we don’t have specialized technical people to do the test. I’m happy to tell you that the point-of-care diagnostic platforms are now available for use and it’s now up to the programs to upscale their use. We’re excited about that. That’s likely to be a game changer. 

What have been other barriers?

Tech has been a big barrier. And then another barrier is access to optimal drugs or medicines for children. It’s been a challenge to calibrate what the youngest children need and what the older children need. The pills for adults don’t work for children. The liquid formulations that are available in developed countries are not available to the same level in developing countries. Even if they are, very few mothers will have refrigerators for storage. So we’ve been working to make sure that we transform the liquid into pellets and sprinkles that you can put in the baby’s mouth while breastfeeding and the child will still get the drug. 

How has the COVID-19 pandemic affected the lives of women and children with HIV and AIDS?

COVID has caused disruptions in service for all kinds of reasons: fear, lockdowns, health professionals being deployed to deal with the COVID response. We just finalized some analysis with UNAIDS and WHO and now have some figures that are quite disturbing: up to 50 percent disruption in testing of children in some settings and that’s impacting new initiations of treatment in children that are getting infected through mother-to-child transmission. So that’s very concerning and we are looking at this and trying to work with the communities. 

We want to make sure that, first of all, we deal with the misinformation that is out there about coming to clinic. But we also want to look at the best way to deal with the issue of lockdown and people not being able to move freely. One thing we’re looking at is making sure that the prescribing of medication is bundled by three-month timepoints. So instead of asking somebody to come every month for medication for their child, we bundle into three months to limit the contact. We have relied a lot on SMS platforms and telemedicine to make sure that are we linking up with mothers and we are aware of what’s going on, and also building on home visits and community networks to make sure we have local solutions and continuity of care. 

What more still needs to be done? 

I’ve told you about the new tools that we have. We work with industry and push them hard to develop the tools we want for children. It’s been a good journey with them, but one of the frustrations is that even when we do have tools that have been proven to be effective and help advance the cause of children, sometimes licensing and registration adoption at the country level takes a long time. So we work closely with countries to make sure that guidelines and systems are in place to absorb new technologies and new medications for children. 

The second thing is that we really want HIV response for children to be a family-centered approach. Imagine that mothers are going into clinic and they are also living with HIV and able to get their medication, but their chart doesn’t even talk about how many children they have at home that have probably not been tested and linked into care. We want to make sure that as pregnant mothers with HIV access care, we’re reaching out to their household to make sure every child is tested and linked into care too. A family-centered approach to testing is important to pick up on all the children that are sitting at home and not receiving treatment. All these things require policy change, guideline change, and that’s the work that UNCIEF does on the ground.