“The report makes it clear, without the shadow of a doubt, that the world is off track when it comes to ending Aids among children and adolescents by 2030,” said UNICEF’s executive director Henrietta Fore about the international commitment to end the epidemic as a public health threat in just over a decade.

In 2018, more than half of the children and adolescents living with HIV globally are in Eastern and Southern Africa. The report noted that, by 2030, despite comparatively faster declines in prevalence, these two regions “will still be home to the majority of those aged 0-19 years living with HIV”.

While infection rates have dropped around the world “this downward trajectory is too slow, particularly among adolescents”, according to a UNICEF statement.

According to the organisation, the major “shortfalls” in fighting HIV in young people are the failures in preventing infection and in addressing the “structural and behavioural drivers of the epidemic”.

“Many children and adolescents do not know whether they have HIV or not, and among those who have been found HIV-positive and put on treatment, very few adhere to that treatment,” it noted.

Dr Lee Fairlie, director of Child and Adolescent Health at the Wits Reproductive Health and HIV Institute, said treating HIV in adolescence is particularly challenging and is the one life-stage where “adherence does deteriorate”.

“There are lots of complexities — children’s busy lifestyles with school and sport — and sometimes trying to fit antiretrovirals in is a challenge,” she said.

According to Fairlie, sometimes young people, especially those who are unemployed or face socioeconomic issues at home, struggle to physically get to clinics.

In children who acquired HIV perinatally, or just before, during or after birth, relatives sometimes choose to delay disclosing their HIV status to them until adolescence, which “has a direct impact on adherence”.

“And often, if they are feeling well, taking medication is a reminder of their illness,” she said. “In the end there are many different reasons why adolescents may not take their treatment.”

While South Africa is doing relatively well in terms of treating children and preventing HIV around birth, said Fairlie, the UNICEF report noted that, today, there are three million children and adolescents living with HIV around the world, which will drop to 1.9 million by 2030. To meet the global targets the figure needs to drop to at most 1.4 million.

UNICEF’s Fore said that prevention of mother-to-child infection programmes are “paying off but haven’t gone far enough, while programmes to treat the virus and prevent it from spreading among older children are nowhere near what they should be”.

The slowest decline in the number of children living with HIV is expected to be in Central and West Africa.

According to Doctors’ Without Borders, countries in West and Central Africa face a “major overall funding gap”. The resources needed to end Aids in the region by 2030 were 81% greater than was available in 2017, yet this is where 30% of the world’s Aids-related deaths occur, said the organisation.

To its credit South Africa has the largest HIV treatment programme in the world.

But on Tuesday Deputy Director-General at the Department of Health Dr Yogan Pillay told Health-e News that only 3,011 young people are receiving one of the most effective prevention interventions, termed pre-exposure prophylaxis or PrEP.

The report recommends the scale-up of PrEP as one of nine key interventions to combat HIV in young people.

Another recommendation is the implementation of “cash + care” programmes. The authors noted that these cash grants work “by offering cash as an incentive to clinic or school attendance, or treatment uptake and adherence” and “can greatly reduce HIV risk among adolescents and improve retention in care”.

“Cash + care seems especially useful for adolescents living in poverty, as well as for adolescent girls.”

This intervention has had a positive impact in South Africa through the child support and foster care grants.

According to 2013 research, girls were half as likely to be having transactional sex or become involved with older partners if they received a child-focused grant or attended a free school.

Yet, globally, every day 700 more adolescents between the ages of 10 and 19 are infected with HIV. This equates to one child every two minutes, according to UNICEF, which called for “urgent” scale-up of treatment and prevention programmes for this group.

While new HIV infections among younger children will be cut in half by 2030, a reduction of only 29% is expected in adolescents.

Said Fore: “We can’t win the fight against HIV if we don’t accelerate progress in preventing transmission to the next generation.” DM