Africa’s gains against paediatric HIV are real, fragile and at risk

I have worked in the HIV sector for 15 years. I have sat in clinics listening as women living with HIV describe their fears during pregnancy about their babies’ futures. I have also been in policy rooms, hearing ministers of health express concern about tightening budgets and uncertain donor funding. These experiences underscore a shared reality: the gains we have made for children are real – but fragile.

Ending paediatric HIV on the continent is still entirely possible. But it will only happen through increased and unwavering national leadership, supported by aligned global partners.

Extraordinary progress — and extraordinary risk

Africa has been home to some of the most important innovations in the global HIV response. Malawi pioneered Option B+, starting pregnant and breastfeeding women on lifelong antiretroviral therapy as early as possible – a model later adopted worldwide. Across the region, nurse-led initiation of treatment, community health workers, and integrated maternal and child health services have dramatically expanded access to care.

These innovations have saved millions of lives. Since 2010, new HIV infections among children aged up to 14 have fallen by more than 60%. This progress proves what is possible when evidence, leadership and delivery align.

But today, those gains are at risk. National health budgets are under pressure. Global inflation has strained supply chains. Funder priorities are shifting. In many countries, clinics are understaffed, outreach programmes are scaled back, and progress has begun to plateau.

This is not a moment to retreat. It is a moment to lead.

A pivotal transition

For decades, Africa’s HIV response has relied heavily on external funding and global priorities. That support has been lifesaving and remains essential. But as funding landscapes evolve, countries can no longer depend on others to set the agenda.

African governments and the African Union now have an opportunity to define a new era of health leadership – one rooted in domestic priorities, powered by national resources, and accountable to local communities. Ending paediatric HIV is the right place to begin.

Private philanthropy and global funders also have a critical role to play in this transition. Philanthropic capital has long been catalytic in advancing innovation and filling gaps where public systems could not yet reach. At this moment, its greatest value may lie not in launching new pilots, but in reinforcing nationally led strategies – supporting execution, integration, and sustainability as countries assume greater ownership of their HIV responses.

What leadership looks like now

Ending paediatric HIV is one of the few areas in global health where elimination is scientifically achievable. We know when transmission occurs – during pregnancy, childbirth and breastfeeding. We know how to prevent it. With political will and consistent application of proven approaches, no child should be born with HIV.

To accelerate progress, AU member states can take three critical steps over the next 12 to 24 months.

First, governments should use pregnancy and breastfeeding as a strategic window of opportunity. Women living with HIV have frequent contact with the health system during this period, creating a powerful timeframe for ensuring uninterrupted treatment and strengthening domestic systems that can sustain care over time.

Second, countries must reprioritise national budgets toward health and implement commitments already on paper. Frameworks such as the Abuja Declaration and the AU’s Roadmap to 2030 & Beyond outline what is needed. What has been missing is consistent execution. Financing and implementing these plans would strengthen HIV programmes while advancing broader health system resilience.

Third, children must be placed at the centre of health agendas, not treated as an afterthought. Paediatric HIV services require integration with maternal health, nutrition, tuberculosis care and primary health systems. When children are prioritised, health systems become stronger for everyone.

A legacy within reach

African leaders have an opportunity to make history by demonstrating that the continent’s health future will be defined by its own leadership, priorities and solutions. Ending HIV in children is a victory within reach.

The tools are here. The evidence is clear. The moment demands action. The children are waiting. DM

Rhoda Igweta is director of public policy and advocacy at the Elizabeth Glaser Pediatric Aids Foundation.