INTRODUCTION:HIV continues to devastate the adolescent population in sub-Saharan Africa (SSA). The complex array of interpersonal, social, structural and system-level obstacles specific to adolescents have slowed progress in prevention and treatment of HIV in this population. The field of implementation science holds promise for addressing these challenges.DISCUSSION:There is growing consensus that enhanced interactions between researchers and users of scientific evidence are important and necessary to tackle enduring barriers to implementation. In 2017, the Fogarty International Center launched the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) to promote communication and catalyse collaboration among implementation scientists and implementers to enhance the cross-fertilization of insights as research advances and the implementation environment evolves. This network has identified key implementation science questions for adolescent HIV, assessed how members' research is addressing them, and is currently conducting a concept mapping exercise to more systematically identify implementation research priorities. In addition, AHSA pinpointed common challenges to addressing these questions and discussed their collective capacity to conduct implementation science using the shared learning approach of the network. Specifically, AHISA addresses challenges related to capacity building, developing mentorship, engaging stakeholders, and involving adolescents through support for training efforts and funding region-/country-specific networks that respond to local issues and increase implementation science capacity across SSA.CONCLUSIONS:Innovative platforms, like AHISA, that foster collaborations between implementation science researchers, policymakers and community participants to prioritizes research needs and identify and address implementation challenges can speed the translation of effective HIV interventions to benefit adolescent health.

The initial impression that pediatric SARS-CoV-2 infection is uncommon and generally mild has been replaced by a more nuanced understanding of infectious manifestations in children and adolescents across low-, middle-, and high-income countries and by demographic structure, with recognition of a widening disease spectrum. Critical knowledge gaps, especially in low- and middle-income countries remain, that have significant public policy and programme implications. Insufficient data dis-aggregated by age, geography and race/ethnicity are hindering efforts to fully assess prevalence of infection and disease in children and adolescents and their role in transmission. Potential biologic differences in susceptibility to infection and transmissibility between children and adults need to be assessed. Determination of mother-to-child SARS-CoV-2 transmission during pregnancy or peripartum requires appropriate samples obtained with proper timing, lacking in most studies. Finally, predictors of disease progression, morbidity and mortality in children need to be determined particularly as the pandemic moves to low- and middle-income countries, where poor nutritional and health conditions and other vulnerabilities are more frequent among children than in higher-income settings. Countries, UN agencies, public health communities, donors and academia need to coordinate the efforts and work collectively to close the data and knowledge gaps in all countries (high, middle and low income) for better evidence to guide policy and programme decision-making for children and COVID-19 (coronavirus) disease.

Background The closed-loop stimulation (CLS) pacemaker algorithm is a system that permanently monitors the contractile state of the myocardium and converts the intrinsic information into rate regulation. The role that the CLS algorithm plays in the prevention of syncope recurrences still remains unclear. The aim of our prospective, randomised, single-blind, crossover study was to evaluate the effect of dual-chamber CLS in the prevention of syncope recurrence in patients with refractory vasovagal syncope (VVS) and a cardioinhibitory response to head-up tilt test (HUT) during a 36 months follow-up. Method sand results We studied 50 patients (mean age 53±5.1; 33 male) with the indication for permanent dual-chamber cardiac pacing for HUT-induced vasovagal cardioinhibitory syncope. They were randomised after 1 month of stabilisation period to CLS algorithm features programmed OFF or ON for 18 months each, using a crossover design. The number of syncopal and presyncopal episodes during active treatment was lower than those registered during no treatment (n syncopal episodes: 2 vs 15; p=0.007; n presincopal episodes: 5 vs 30; p = 0.004). Lead parameters remained stable over time, and there were no lead-related complications. Conclusions Based on these 36 months follow-up data, it is concluded that dual-chamber CLS is an effective algorithm for preventing syncope recurrences in healthy patients with tilt-induced vasovagal cardioinhibitory syncope.

INTRODUCTION:Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother-to-child HIV transmission (PMTCT).METHODS:We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services.RESULTS AND DISCUSSION:From May to November 2019, we identified numerous promising, evidence-based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility-based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT.CONCLUSIONS:A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Research on child marriage from the first decade of the 2000s was largely, and we now know, often mistakenly, interpreted to suggest that child brides—girls who marry under the age of 18 years—faced a higher vulnerability to and higher rates of HIV acquisition than girls and women who married later [1–4]. In one of the starkest statements on the perceived connection, a paper stemming from a December 2003 global consultation stated that "married adolescent girls tend to have higher rates of HIV infection than their sexually active, unmarried peers" [5].

Climate change, violent conflicts, and HIV/AIDS are linked to multiple Sustainable Development Goals (SDGs) through complex pathways (Figure 1) that include food insecurity, population displacements and migration, disruptions of health and HIV services, and increased incidences of sexual based violence. This interlinkage has the potential to result in high newborn and under five mortality rates and increased burden of HIV, directly affecting SDG 3.2 and 3.3 with children and adolescents being primarily affected. In the past two years, five severe (classified by the UN as L3) emergencies were declared with over 50 million children caught up in major conflicts and other humanitarian crises 1. Nine of 21 countries deemed “high priority” for HIV by UNAIDS are fragile, conflict-affected, or affected by climate-related hazards. Today, more than 59 million people are displaced – 22 million more than a decade ago 2, while more than 70 million people in 45 countries are food insecure – 40% more than in 2015. There are more than 1.8 million people living with HIV in emergency settings, with children under the age of 15 years accounting for around 10% 3. Emergencies have increasingly become protracted (long term) with an average stay in refugee camps reaching 20 years 4 – implying that children could face more HIV risks throughout their adolescence in a refugee camp. The road towards the SDGs is further constrained by rapid population growth with an estimated one billion children likely to live in Africa by mid-century, of which 217 million will be under-five and over one third living in conflict-affected zones 5. Yet, most humanitarian plans and appeals have not been included in national development strategies, HIV interventions are largely underfunded despite high HIV vulnerability in emergency contexts 6, and most funding opportunities have been short term and focussed on immediate life-saving interventions. Similarly, the opportunities provided by investments in SDGs are not optimal in humanitarian settings. These include medium-long term funding by global financial instruments such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and novel service delivery models, including enabled community systems that have had remarkable impact on improving HIV service delivery and access in countries such as South Africa 7. These roadblocks, and a divide between humanitarian and development fields have tremendous implications for children and adolescents living with HIV in emergency contexts such that a clear way forward, building on the current global discourse on humanitarian-development nexus, remains critical. Most L3 emergencies have a potential to reverse gains in the global HIV response – including the legacy of the global plan on the elimination of new paediatric HIV infections. This five-year plan was developed in 2011 with the aim of reducing new paediatric HIV infections by 90% and AIDS-related maternal and paediatric mortality by 50% 11. Over the course of the Global Plan, more than 60% of annual new HIV infections were reduced, translating to 1.2 million new infections among children averted 8. However, among countries affected by emergencies such as Nigeria, the reduction in new infections remains as low as 40% 8. The effects of climate change are more profound in Africa and Asia, where there is a disproportionately high burden of HIV. Of the nine fragile countries with high HIV burden, five are in Central and West Africa, contributing 45% of the global number of new paediatric HIV infections with Nigeria alone accounting for more than 27% 9. As more fragile countries have graduated to middle income status, development assistance for HIV will likely reduce, as for instance, domestic contribution thresholds by eligible middle income countries for grants from the GFATM is 20% to 60% – a significant rise from 5% for developing economies 10. Without significant financial resources, these fragile states will not be able to sustain their HIV response. The humanitarian-development nexus provides an important framework that could bridge a divide between these two fields that are guided by two separate, but complementary global processes – Agenda 2030 for sustainable development 16 and Agenda for Humanity 17, endorsed during the World Humanitarian Summit in 2016. The nexus calls for joint analysis and planning; defining collective outcomes; and joined-up programming 18. Adapting this nexus in HIV responses during the emergencies could provide a way forward for addressing the roadblocks previously mentioned. The first step could be understanding the climate change or conflict risks that could impact HIV response through a joint analysis using current evidence and existing analytical frameworks. It is also important to note during the analysis that different types of emergencies such as acute or protracted, could have different needs requiring different programme designs. This risk analysis could form the basis of risk-informed joint planning, allowing synergies between HIV and humanitarian interventions. Joined-up programming could be facilitated with sustainable financing by optimizing development and humanitarian funding mechanisms 14, and ensuring systematic integration and transition of humanitarian interventions to national or local authorities. Linking early recovery, resilience building and health system strengthening will ensure a quick development pathway after an emergency. Empowering communities and their infrastructure is equally important for resilience and improved outcomes. There is mounting evidence of the importance of community health workers in the reduction in under-5 mortality rate 15 that could also benefit children and adolescents living with HIV. Some promising practices are also emerging such as GFATM's establishment of a special envelope for “challenging operating environments” 19 that aims to expand access to services in manmade or natural crises. New models of service delivery and innovations such as Point-of-Care diagnostics for dual HIV and syphilis testing 20, could also be adapted in emergencies. Collective outcomes should be defined from the onset of the emergencies, and a robust monitoring and evaluation system put in place to track progress towards SDGs. Sustaining peace resolutions, is critical for maintaining this progress. The renewed momentum in HIV workstreams spearheaded by the new post-Global Plan programming framework, Start Free, Stay Free, AIDS Free 12, provides an opportunity for moving forward with this agenda. Creating a humanitarian-development nexus is the centrepiece for the new way of working arising from the global humanitarian summit and a major theme in the Sendai framework for Disaster Risk Reduction 2015 to 2030 13. These are critical elements for achieving SDGs without leaving behind children and adolescents living with HIV in humanitarian crises. Authors declare no competing interests DC, CL and PI have not received grants or speakers fees from any commercial body in the preparation or submission of this manuscript DC conceptualized the article, established links between emergencies and HIV, and drafted the first draft. CL and PI reviewed the draft, elaborated links with SDGs and contributed to the writing of the manuscript

Global experts recognize the need to transform conventional models of healthcare to create adolescent responsive health systems. As countries near 80% coverage of voluntary medical male circumcision (VMMC) for those aged 15-49 years, prioritization of younger men becomes critical to VMMC sustainability. This special supplement reporting 9 studies focusing on adolescent VMMC programming and services comes at a critical time. Eight articles report how well adolescents are reached with the World Health Organization's minimum package for comprehensive human immunodeficiency virus (HIV) prevention in South Africa, Zimbabwe, and Tanzania, analyzing motivation, counseling, wound healing, parental involvement, female peer support, quality of in-service communication, and providers' perceptions, and one presents models for achieving high VMMC coverage by 2021. One important finding is that adolescent boys, especially the youngest, experience gaps in their comprehension of key elements in the World Health Organization's minimum package. Although parents, counselors, and providers are involved and supportive, they are inadequately prepared to counsel youth, partly owing to discomfort with adolescent sexuality. At the country level, deliberately prioritizing young adolescents (aged 10-14 years) is likely to achieve national coverage targets more quickly and cost-effectively than continuing to focus on older, harder-to-reach men. The studies in this supplement point to areas where VMMC programs are achieving successes and they reveal areas for improvement. Given that prioritizing adolescents will be the best means of achieving sustainable VMMC for HIV prevention for the foreseeable future, applying the lessons learned here will increase the effectiveness of VMMC programs.

For the past 30 years, HIV has united the international community in an unprecedented fashion. Grassroot groups have mobilized in both the north and the south; policy-makers and donors have worked with civil society, researchers and the private sector, and the epidemic response has inspired new thinking and medical innovation. The Millennium Development Goal (MDG) era was epitomized by the HIV response. For example, the remarkable progress on antiretroviral therapy has put the world closer to reaching the global target on reducing AIDS-related deaths. Since 2000, two million HIV infections have been averted in children as a result of pregnant women living with HIV being able to access antiretroviral medicines 1. This progress has motivated the global HIV community to commit to fast track the response to end AIDS by 2030, a target in the new development era 2. During this time, much of the advocacy for the importance of paediatric and adolescent HIV has been within the HIV/AIDS constituency itself, ensuring that children are not forgotten or discriminated against in the global HIV response 3. Advocacy has focused on prevention of mother to child transmission (PMTCT), meeting the specific needs and conditions of children living with HIV and advancing the complex interventions related to preventing infection in adolescents. Despite this, progress in ensuring access to antiretroviral treatment for children and adolescents has been slower than for pregnant women and adults 4, and we continue to witness the slow progress in preventing new infections in adolescents 5. The Agenda 2030 and associated Sustainable Development Goals (SDGs) now bring a fundamental change. Instead of having a Millennium Development Goal focused on combating the major infectious diseases of HIV, TB and malaria, HIV is subsumed within one of 169 targets and 17 goals that comprise the SDGs 6. This could be construed as a dilution of attention to HIV, or conversely a redressing of the balance, given the evolution of the global burden of disease and the plurality of major disease threats, especially the rise of non-communicable diseases (NCDs). The shift from exceptionalism to active integration of HIV across health, education, violence prevention, poverty and the lived environment is the new imperative. Should the SDGs be framed as a major “threat” to HIV funding, support and response capacity? The SDGs are here, and the HIV community, both epistemic and activist, needs to resituate itself within this new dominant development framework. UNAIDS and the International AIDS Society have spearheaded a conversation and strategic thinking on this reconfigured relationship, capitalizing on the growing sub-discipline that aims to articulate the “learning from AIDS” to inform and promote solutions to address other public health challenges. These are characterized by complex causal networks, “combination” structures, and the need for advanced investment and governance models which coordinate a spectrum of responding actors across systems and society as a whole 7. SDG Target 3.3 urges the global community to “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.” The indicator 3.3.1 is one of five for this target, tracking the “Number of new HIV infections per 1000 uninfected population, by sex, age and key populations.” The scale of intention has also shifted from “halt and reverse” HIV in relation to the previous MDG 6, to the more substantial “end the epidemic” by 2030. While the development scope has broadened, the level of HIV response required has actually intensified. The complexity of Agenda 2030 entails the need to prioritize and inevitably embark on a series of trade-offs at country level. The UN Development Group, led by UNDP, is undertaking a series of inter-agency missions to countries to help develop SDG roadmaps at national and where appropriate, sub-national level 8. Furthermore, a recent Global Review of the UNAIDS Operational Model recommended introduction of country resource envelopes to domesticate and enhance the joint UN response in priority high HIV burden countries, so called fast-track countries. This domestication and prioritization of SDGs aims to seek the most cost-effective combination of investments across the targets, bespoke to the situation and prioritizing interventions that at scale will deliver against multiple targets and goals simultaneously, the “accelerators” of sustainable development. Addressing the causes and consequences of HIV is arguably one of these accelerators. HIV/AIDS experience has major value in informing the SDG core approaches, over and above being a component response in its own right. UNAIDS argues that “…lessons learned from the multisectoral, multistakeholder AIDS response, including engagement of civil society are key to progress across the SDGs. The AIDS response has advanced such issues as the right to health, gender equality, health information systems, service delivery platforms, commodity access and security and social protection. The response has garnered substantial experience in addressing entrenched social norms, social exclusion and legal barriers that undermine health and development outcomes, and its investment approach is increasingly being adopted to accelerate gains across global health and development. The AIDS response can be a leader in leveraging strategic intersections with the SDGs, while disseminating lessons learned from three decades of unprecedented progress.” 9 The implication is that the HIV response has not only intrinsic value in its efforts to end AIDS by 2030 (as a component of target 3.3), but also has extrinsic value in leveraging other associated and potentially connected development objectives. This framing of the HIV “dividend” relates to both the synergies between HIV response and other objectives, as well as the understanding that the HIV response infrastructure, with its inbuilt experience and precedents, is a significant asset on which to build comprehensive health and social service provision. HIV responses are a driver of universal health coverage, for both integrated service delivery and through deliberate exposure and overcoming of barriers to accessing quality health services. All the while, the human rights of HIV-affected communities have permeated the advocacy, programme design, monitoring and impact assessment. Action on HIV has deliberately targeted “those left behind”, the core group of obligation in the 2030 Agenda. HIV-focused or invested institutions cannot be seen as the sole claimant of this positive scenario. A conversation is ongoing across a broad range of themes regarding their valued contribution, given the synergistic nature of the SDGs and the need to view targets and their associated themes as integral to a larger whole, interdependent on shared successes across targets. We stress, however, that the claim of HIV responses to a central SDG role is a strong one. For example in the field of global health, HIV has innovated through the building and use of evidence, and normalized this research evidence as fundamental to the validity and expansion of the response infrastructure. Understanding this value of the HIV response for children and adolescents within and for the development agenda is the purpose of commissioning this Special Issue, led by the Collaborative Initiative for Paediatric HIV Education and Research at the International AIDS Society. These papers identify a set of opportunities for addressing paediatric and adolescent HIV that are offered by the SDGs. They highlight the areas of common interest and specific connections with targets and indicators beyond HIV and health alone. They illustrate how HIV and AIDS responses have the latent potential to be a driver across the development arena. Extraordinary knowledge, skills and expertise have been built, new ways of working, of implementation and of embedding evidence-based practice. Over the past 30 years, the evolution and multiple reinvention of programming has been in response to positive and negative changes such as advances in prevention technology, new treatment regimens and the threat of viral resistance, all with their own intended and unintended consequences. So this is the new challenge, to evolve in a way that capitalizes on the opportunities of the SDGs and that ensures that children and adolescents both vulnerable to and affected by HIV are themselves not left behind. The papers in this Special Issue address this challenge from a range of perspectives. Several retain the core focus on SDG 3 (healthy lives and wellbeing) and examine new challenges and solutions in the SDG era. All seek synergies at various levels with other SDGs and targets. Cluver and colleagues demonstrate the impressive effects of combined service provision, as a proxy of SDG interaction, on HIV mortality in adolescents in South Africa. Longevity and survival is associated not only with ART but with food security, social protection and access to non-HIV health services 10. Chaudhury and colleagues delve deeper into questions of equity of access to treatments and care for children in Tanzania across age groups. Compared to paediatric cases, adolescence is associated with risk of late presentation, delayed treatment initiation and loss of continuity of care. Improving health and wellbeing for all, “at all ages” as required by Goal 3, entails particular attention to the adolescents living with HIV 11. Fatti and colleagues examine treatment adherence and outcomes (notably the degree of viral suppression) for adolescents living with HIV in South Africa, and their findings suggest that community-based support could be the crucial link between clinical support and progress toward several health, economic and equity-related SDG targets 12. Slogrove and colleagues assess treatment outcomes in adolescents living with perinatally acquired HIV across 25 countries. They conclude that at the macro-level and irrespective of ART access, measurable differences in mortality relate to the income status of the country, with poorest outcomes in the lower income countries, highlighting the relevance of promoting equality within and between nations 13. Kilburn and colleagues generate further evidence that poverty alleviation and reduction of HIV risks are highly connected. In South Africa, conditional cash transfers work in part through delaying sexual debut or reducing the number of sexual partners of adolescent girls and young women. Intimate partner violence is reduced and proves a critical mediator in reducing HIV risks 14. Grosso et al. draw the link between HIV-related risk behaviours in female sex workers in Lesotho that are directly influenced by experience of sexual abuse as children. The complex causal pathways between child sexual abuse, sex work and HIV risk are mapped out and demand our attention with regard to intervention design and impact mitigation, again with the life course and range of SDGs in full view 15. Leaving no one behind means full accountability of the state to those who are in need of quality and accessible HIV services. Gleeson and colleagues highlight the need for adolescents and young people to be meaningfully engaged as leaders of HIV within the SDG response 16. Hodes and colleagues examine what happens when this is enacted through participatory engagement. Adolescents in South Africa identified strong needs and linkages between SDGs 2 (end hunger), 3 (healthy lives and wellbeing) and 6 (clean water and sanitation) in material, not abstract policy terms 17. The SDGs demand policy coherence across development policy domains and innovative partnerships to advance them. Penazzato and colleagues describe how capacity-building and South-North collaborations have the potential to accelerate availability of optimized treatment options not only for infectious diseases including HIV, but also for tuberculosis and viral hepatitis, which affect children in low- and middle-income countries 18. Tinasti assesses the criminalization of drug use and punitive policy environments and their impact on adolescents’ health and HIV transmission risks 19. Similarly, Chamla and colleagues explore the connections between HIV and humanitarian setting engagement. With 9 of the 21 countries in Africa deemed by UNAIDS as being “high priority” for HIV, being fragile, conflict-affected, or impacted by climate-related hazards, to what extent is HIV and crisis prevention and recovery integrated? While clearly work in progress, the drug policy-HIV service synergies, and the humanitarian-development nexus provide important frameworks that could bridge divides between these all-too-often disparate areas of concern 20. We are privileged to have been guest editors for this Special Issue and emerge convinced that while HIV responses were advanced prior to the SDG agenda, ending AIDS will only be possible as one of its core components. The authors declare no competing interests. DW, LC and CW reviewed all articles in the special issue, and formulated, drafted and developed the editorial. All authors have read and approved the final version. We thank Marlene Bras, Biljana Samopjan Radovic, Douglas Fraser, Marissa Vicari and Martina Penazzato, as well as all the authors and peer reviewers for the articles in this Special Issue.

The global HIV response is leaving children and adolescents behind. Because of a paucity of studies on treatment and care models for these age groups, there are gaps in our understanding of how best to implement services to improve their health outcomes. Without this evidence, policymakers are left to extrapolate from adult studies, which may not be appropriate, and can lead to inefficiencies in service delivery, hampered uptake, and ineffective mechanisms to support optimal outcomes. Implementation science research seeks to investigate how interventions known to be efficacious in study settings are, or are not, routinely implemented within real-world programmes. Effective implementation science research must be a collaborative effort between government, funding agencies, investigators, and implementers, each playing a key role. Successful implementation science research in children and adolescents requires clearer policies about age of consent for services and research that conform to ethical standards but allow for rational modifications. Implementation research in these age groups also necessitates age-appropriate consultation and engagement of children, adolescents, and their caregivers. Finally, resource, systems, technology, and training must be prioritized to improve the availability and quality of age-/sex-disaggregated data. Implementation science has a clear role to play in facilitating understanding of how the multiple complex barriers to HIV services for children and adolescents prevent effective interventions from reaching more children and adolescents living with HIV, and is well positioned to redress gaps in the HIV response for these age groups. This is truer now more than ever, with urgent and ambitious 2020 global targets on the horizon and insufficient progress in these age groups to date.

Inspired by unprecedented improvements in human health and development in recent decades, our world has embarked on a quest that only a generation ago would have been considered unreachable—achieving sustainable health and development for all. Improving the health and wellbeing of the world's people is at the core of the Sustainable Development Goals (SDGs), reflected in targets that call for ending the epidemics of AIDS, tuberculosis, and malaria; achieving enormous improvements in maternal and child health; and tackling the growing burden of non-communicable diseases (NCDs). Attaining universal health coverage is the means by which these ambitious health targets are to be achieved. Although on their face, the SDGs reflect an unprecedented level of global solidarity and resolve, the trends that increasingly define our world in 2018 are inconsistent with both the sentiments that underlie the SDGs and the ethos that generated such striking health and development gains in recent years. Democracy is in retreat, and in many countries the space for civil society is declining and the human rights environment deteriorating. Official development assistance for health has stalled, as an inward-looking nationalism has in many places supplanted recognition of the need for global collaboration to address shared challenges. The loss of momentum on global health ignores the urgent need to strengthen health systems to address the steady growth of NCDs, which now account for seven of ten deaths worldwide. Recent trends in the HIV response are especially concerning. Although the number of new HIV infections and AIDS-related deaths have markedly decreased since the epidemic peaked, little progress has been made in reducing new infections in the past decade. Without further reductions in HIV incidence, a resurgence of the epidemic is inevitable, as the largest ever generation of young people age into adolescence and adulthood. Yet where vigilance and renewed efforts are needed, there are disturbing indications that the world's commitment is waning. Allowing the HIV epidemic to rebound would be catastrophic for the communities most affected by HIV and for the broader field of global health. If the world cannot follow through on HIV, which prompted such an extraordinary global mobilisation, hopes for achieving the ambitious health aims outlined in the SDGs will inevitably dim. At this moment of uncertainty for the future of the HIV response and for global health generally, the International AIDS Society and The Lancet convened an international Commission of global experts and stakeholders to assess the future of the HIV response in the context of a more integrated approach to health. A central finding of the Commission is that the HIV epidemic is not on track to end and that existing tools are insufficient. Although antiretroviral therapy (ART) has transformed the HIV response by averting deaths, improving quality of life, and preventing new HIV infections, HIV treatment alone will not end the epidemic. The UNAIDS 90-90-90 approach must be accompanied by a similarly robust commitment to scaled-up primary HIV prevention and to the development of a preventive vaccine and a functional cure for HIV. Ironically, the diminishing energy on HIV is occurring at the moment when lessons learned during the HIV response could serve as pathfinders in the quest for sustainable health for all. Key messages•The HIV pandemic is not on track to end, and the prevailing discourse on ending AIDS has bred a dangerous complacency and may have hastened the weakening of global resolve to combat HIV•Existing HIV tools and strategies are insufficient, and although dramatic gains can be made through maximizing existing prevention and treatment strategies, the HIV pandemic is likely to remain a major global challenge for the foreseeable future•Tens of millions of people will require sustained access to antiretroviral therapy for decades to come, vigilance will be needed to prevent a resurgence of the epidemic as the largest-ever generation of young people age into adolescence and young adulthood, and intensified efforts are required to address HIV among populations and settings that are being left behind•Allowing the pandemic to rebound after achieving such remarkable progress would not only increase the human and financial costs of HIV, but it would potentially demoralise the global health field and diminish support for similarly ambitious global health undertakings•A rejuvenated global effort on HIV is essential; to renew and strengthen the global HIV response, the world's impressive commitment to the scaling up of HIV treatment services must be matched by a similarly robust commitment to expanded access to HIV prevention•The HIV response must make common cause with the broader global health field to herald a new era of global solidarity for health, and specific action is urgently needed to respond to the rapidly rising health toll associated with non-communicable diseases, including taking health into account in the development of public policies of all kinds. HIV services should, where feasible, be integrated with broader health services, in co-located sites where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes; greater integration of HIV and global health must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice•The new era of global health solidarity should focus on the development of robust, flexible, people-centred health systems to end communicable diseases, develop effective measures to address the steady rise of non-communicable diseases, achieve universal health coverage, provide coordinated services tailored to the needs of health service users, and effectively address the social and structural determinants of health •The HIV pandemic is not on track to end, and the prevailing discourse on ending AIDS has bred a dangerous complacency and may have hastened the weakening of global resolve to combat HIV•Existing HIV tools and strategies are insufficient, and although dramatic gains can be made through maximizing existing prevention and treatment strategies, the HIV pandemic is likely to remain a major global challenge for the foreseeable future•Tens of millions of people will require sustained access to antiretroviral therapy for decades to come, vigilance will be needed to prevent a resurgence of the epidemic as the largest-ever generation of young people age into adolescence and young adulthood, and intensified efforts are required to address HIV among populations and settings that are being left behind•Allowing the pandemic to rebound after achieving such remarkable progress would not only increase the human and financial costs of HIV, but it would potentially demoralise the global health field and diminish support for similarly ambitious global health undertakings•A rejuvenated global effort on HIV is essential; to renew and strengthen the global HIV response, the world's impressive commitment to the scaling up of HIV treatment services must be matched by a similarly robust commitment to expanded access to HIV prevention•The HIV response must make common cause with the broader global health field to herald a new era of global solidarity for health, and specific action is urgently needed to respond to the rapidly rising health toll associated with non-communicable diseases, including taking health into account in the development of public policies of all kinds. HIV services should, where feasible, be integrated with broader health services, in co-located sites where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes; greater integration of HIV and global health must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice•The new era of global health solidarity should focus on the development of robust, flexible, people-centred health systems to end communicable diseases, develop effective measures to address the steady rise of non-communicable diseases, achieve universal health coverage, provide coordinated services tailored to the needs of health service users, and effectively address the social and structural determinants of health From its inception, the HIV response was a unique undertaking, apart from the broader health system. Although elements of a disease-specific approach will and should be retained, the future of the HIV response will also depend on finding opportunities for integrating HIV services more closely within health systems. Wholesale abandonment of vertical HIV funding would involve considerable risks, as the laser-like focus on a single disease accounts in large measure for the HIV response's successes. Unique attributes that have defined the HIV response (including its multisectoral and inclusive approach, engagement of civil society, emphasis on equity and human rights, galvanisation of scientific innovation, and foundation of global collaboration and problem solving) must be preserved and mainstreamed across global health practice. Whether to integrate HIV within broader health systems is not an either–or choice, and optimal paths will differ between settings, populations, and services. To be effective, more integrated approaches must yield improvements both to HIV-related and non-HIV-related health outcomes. In most cases, approaches to integration will and should be incremental, allowing learning by doing. To assess the health and financial benefits of such win-win scenarios, the Commission engaged modellers to examine different scenarios for incremental integration of HIV-related and non-HIV-related services. These include: models in South Africa and Kenya for screening of HIV alongside screening for diabetes, hypertension, and other NCDs; integration of HIV in reproductive health services in Nigeria; integrated management of HIV and sexually transmitted infections in India; and integration of harm reduction and overdose services and ART for people who use drugs in Russia. In each of these scenarios, integrated approaches generated concrete improvements in HIV and broader health outcomes. With one exception (antiretroviral pre-exposure prophylaxis [PrEP] in India), integrated models were consistently found to be cost-effective. The HIV community must make common cause with the global health field— to make universal health coverage a reality, to substantially increase the share of resources devoted to health, and to build worldwide recognition of health as key to progress across the breadth of the SDGs. The global health field must take a leading role in resisting the turn towards authoritarianism, xenophobia, and austerity with respect to essential public health investments. In a time of fragmentation and uncertainty, the global health field can aid in reminding all of us of our common humanity. Health systems must be designed to meet the needs of the people they serve, including having the capacity to address multiple health problems simultaneously. No one can be left behind in our efforts to achieve sustainable health. Recognising health as an investment, major new resources (from national governments, the international community, and the private sector, involving innovative financing mechanisms) must be mobilised to support stronger, sustainable, and people-centred health systems. The SDGs sharply elevate global health and development aspirations, contemplating a world that is far more prosperous, secure, healthy, and equitable, where human rights and dignity are universally respected, and where human development unfolds in a manner that preserves the natural environment. Yet, the 3 years that have passed since the SDGs were agreed have dimmed prospects for achieving many of these visionary aims. By contrast with the international solidarity, shared commitment, and increased investments that characterised the era of the Millennium Development Goals (MDGs), much of the world has, since 2015, turned inward and toward authoritarianism, repression, a diminished role for civil society, a policy of austerity for public investments, and suspicion of international cooperation. As a result of civil conflicts that have yet to elicit an appropriate international response, more people than ever have been forced from their homes and countries. At a time when the fruits of scientific advances are so evident, denial in many quarters of the role of humankind in the degradation of our environment threatens the very health and wellbeing of our planet and our civilisations. Among the reasons why the world opted for such an ambitious agenda for the SDGs was the success of the HIV response. As a result of a worldwide mobilisation, the incidence of HIV infections peaked and began to decrease in all parts of the world, and AIDS-related mortality decreased from 1·9 million in 2005 to 1·0 million in 2016.1AIDSInfoJoint United Nations Programme on HIV/AIDS.http://aidsinfo.unaids.orgDate accessed: June 14, 2018Google Scholar The HIV response has not been an unalloyed story of achievement, as the world's capacity to respond effectively to the epidemic has been undermined by 15 years of relative inaction in the epidemic's early stages, an approach to epidemic management that has undervalued primary prevention, and the enduring stigma associated with HIV. The broader global health community, facing both historic opportunities and profound challenges, could potentially benefit from lessons learned from the successes and failures of the global HIV response. With its multisectoral and inclusive approach, mobilisation of political commitment, engagement of civil society at every level, emphasis on equity and human rights, galvanisation of scientific innovation, and foundation of global collaboration and problem solving, the HIV response has properly been cited as a model for the future of global health.2Piot P Quinn TC Response to the AIDS pandemic—a global health model.N Engl J Med. 2013; 368: 2210-2218Crossref PubMed Scopus (85) Google Scholar The global health challenge remains immense, with millions of people in low-income and middle-income countries (LMICs) dying each year from causes that have either been largely eradicated or are decreasing in prevalence in high-income countries (figure 1).3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (662) Google Scholar Whether the world is prepared to meet these challenges is unclear. Although the incidence of communicable, maternal, neonatal, and nutritional diseases have decreased worldwide since 1980,3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (662) Google Scholar the most recent projections indicate that financial resources available for health programmes in LMICs are likely to fall far short of amounts needed to reach the health targets set forth in the SDGs.4Global Burden of Disease Health Financing Collaborator NetworkFuture and potential spending on health 2015–40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries.Lancet. 2017; 389: 2005-2030Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Persistent weaknesses of health systems undermine prospects for progress in addressing the full panoply of health challenges. At the very moment when HIV could serve as a pathfinder for global health, there are signs that global commitment to build on the gains achieved against HIV thus far is waning. From 2013 to 2016, international HIV assistance was reduced by roughly 20%, from almost US$10 billion to US$8·1 billion.5UNEnding AIDS. Progress towards the 90–90–90 targets. Joint United Nations Programme on HIV/AIDS, Geneva2017Google Scholar Relinquishing the fight against HIV before it is over would have disastrous consequences, both for people affected by HIV and for the broader global health community. Unless further investments are made to accelerate expansion of HIV prevention and treatment programmes, the HIV epidemic is likely to rebound and grow far more serious in the coming years, especially as the world's largest-ever cohort of young people age into adolescence and young adulthood.6Piot P Abdool Karim SS Hecht R et al.the UNAIDS–Lancet CommissionDefeating AIDS—advancing global health.Lancet. 2015; 386: 171-218Summary Full Text Full Text PDF PubMed Google Scholar Notwithstanding the enormous progress that has been made in the HIV response, HIV remains "the epidemic of our time".7Corey L Gray GE Preventing acquisition of HIV is the only path to an AIDS-free generation.Proc Natl Acad Sci USA. 2017; 114: 3798-3800Crossref PubMed Scopus (4) Google Scholar In 2015–16, an estimated 36·7–38·8 million people were living with HIV worldwide, including 1·9–2·5 million newly infected in 2015.1AIDSInfoJoint United Nations Programme on HIV/AIDS.http://aidsinfo.unaids.orgDate accessed: June 14, 2018Google Scholar, 8GBD 2015 HIV CollaboratorsEstimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015.Lancet HIV. 2016; 3: e361-e387Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar More than 35 million people have died of AIDS-related causes; 1·0 million of these deaths were in 2016.9WHOGlobal Health Observatory (GHO) data.http://www.who.int/gho/hiv/en/Date accessed: June 14, 2018Google Scholar A refusal to follow through to achieve long-term control of the epidemic would merely repeat a longstanding pattern in global health, when failure to sustain a surge in global interest in combating particular health threats allows these epidemics to return in force. The history of malaria elimination efforts is a case in point, as the failure to sustain malaria-related control programmes, funding, and research investments led to an abandonment of the global malaria elimination campaign in 1969 and subsequent increases in the global malaria burden.10Nájera JA González-Silva M Alonso PL Some lessons for the future from the Global Malaria Eradication Programme (1955-1969).PLoS Med. 2011; 8: e1000412Crossref PubMed Scopus (0) Google Scholar At a moment when the means to improve human health are greater than ever, allowing a resurgence of HIV through neglect and apathy could deal a blow from which the broader cause of global health could need decades to recover. The relationship between the HIV response and the broader global health field is multilayered and bidirectional. Even as the HIV response offers important lessons from which global health can learn, it is also clear that controlling the HIV epidemic will depend in large measure on the broader global health and development fields. However, the exceptionalist approach to the HIV epidemic, in which the HIV response has often unfolded as a vertical undertaking, distinct from other health programmes, has achieved historic results and should not be jettisoned lightly. Both the HIV response and the broader global health field share a commitment to the development of health systems that are capable of addressing several health challenges at the same time. In many settings, robust, if still flawed, service systems have been developed for certain populations (eg, pregnant women, children) or for priority health conditions (eg, maternal and child health, HIV, and other communicable diseases). However, health systems as a whole are largely unprepared for providing care that is holistic, universal, and well coordinated. In the still-early years of the SDG era, the gap between reality and the vision of sustainable health remains gaping. In the midst of uncertainty about the long-term feasibility of an exceptionalist HIV approach and the prospects for achieving the lofty health targets in the SDGs, the International AIDS Society (IAS)-Lancet Commission on the Future of Global Health and the HIV Response was established in 2016 to critically examine future prospects for global health and the HIV response. The Commission was tasked with assessing the future of the HIV response in a more integrated global health and development agenda, with the aim of advising how best to achieve global control of the HIV pandemic in an era in which health and development priorities are proliferating. The Commission studied the history of the HIV response to discern how experience in responding to HIV might inform and strengthen global health more broadly. Modelling exercises were undertaken to assess the effect of various approaches to improve integration of HIV and non-HIV-related services. The most salient threats to global health and to the goal of universal health coverage were identified. With this report, we summarise the findings of the Commission, and we seek to articulate a vision for the future of the HIV response and global health that builds common cause across health and development movements and sectors. Rather than despair over the trends and patterns of the past several years, we must instead look to the extraordinary achievements of the past two decades to embolden us and reinforce our resolve to rejuvenate the HIV response and strengthen the broader cause of global health. By taking on board the lessons of the HIV response, the global health field can be made fit for the purpose of realising the vision of sustainable health for all. Global health can serve as a driving force to repudiate and discredit the continuing retreat from international solidarity, human rights, reason, scientific evidence, and open societies. Global health can serve as a pioneer in a re-engineering of the development project, from one based on charity from the high-income countries to one that tackles the central determinants of global health inequities. Just as the HIV response has demonstrated that global problems demand global solutions, the future health and wellbeing of our planet relies on us to recognise, celebrate, and build on our common humanity. With respect to the flagging response to HIV, the Commission hopes that this report serves as a wake-up call. Without a thorough rejuvenation of the HIV response and a change of course, we are likely to see a resurgence of the epidemic. After such history-making successes from unprecedented global solidarity and collaboration, the world can and must do better. To realise the vision of sustainable health for all, we must ensure that health systems are equipped to bring communicable diseases under control and to respond effectively to the growing burden of NCDs. A focused response and categorical HIV funding will remain crucial to avoid a resurgence of HIV and to bring the global pandemic under control. However, immediate and incremental steps are needed to strategically integrate HIV services into co-located primary care platforms and toward the longer-term goal of creating fully integrated, co-located, and patient-centred health-service systems. The Agenda for Sustainable Development envisages "a world free from poverty, hunger, disease and want, where all life can thrive."11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar SDG 3 calls for concerted action to ensure healthy lives and promote wellbeing for all at all ages.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar SDG 3 also calls for ending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases; eliminating preventable deaths in children younger than 5 years; and reducing by a third the number of deaths from NCDs.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar Under the Agenda for Sustainable Development, universal health coverage serves as the primary vehicle for continuing and fully leveraging the momentum on health.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar The health targets of SDG 3 build on historic gains made under the MDGs (panel 1).12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google Scholar The health gains during the MDG era coincided with, and were enabled by, advances across the broader development agenda. Whereas nearly half of the population in LMICs lived on less than $1·25 per day in 1990, this proportion had fallen to 14% by 2015.12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google Scholar Primary school attendance worldwide increased between 2000 and 2015, and differences in secondary school attendance between boys and girls diminished or disappeared altogether in some regions.12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google ScholarPanel 1Health targets for Sustainable Development Goal 3•By 2030, reduce the global maternal mortality ratio to less than 70 deaths per 100 000 livebirths•By 2030, end preventable deaths of newborn babies and children younger than 5 years, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 livebirths and under-5 mortality to at least as low as 25 deaths per 1000 livebirths•By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases•By 2030, reduce by a third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and wellbeing•Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol•By 2020, halve the number of deaths and injuries from road traffic accidents globally•By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information, and education and ensure the integration of reproductive health into national strategies and programmes•Achieve universal health coverage, including financial risk protection, access to quality and essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all•By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination•Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate•Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all•Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small-island developing states•Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks •By 2030, reduce the global maternal mortality ratio to less than 70 deaths per 100 000 livebirths•By 2030, end preventable deaths of newborn babies and children younger than 5 years, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 livebirths and under-5 mortality to at least as low as 25 deaths per 1000 livebirths•By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases•By 2030, reduce by a third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and wellbeing•Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol•By 2020, halve the number of deaths and injuries from road traffic accidents globally•By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information, and education and ensure the integration of reproductive health into national strategies and programmes•Achieve universal health coverage, including financial risk protection, access to quality and essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all•By 2030, substantially reduc

Abstract: While the Interagency Task Team on the Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and Children (IATT) partnership existed before the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), its reconfiguration was critical to coordinating provision of technical assistance that positively influenced country decision-making and program performance. This article describes how the Global Plan anchored the work of the IATT and, in turn, how the IATT's technical assistance helped to accelerate achievement of the Global Plan targets and milestones. The technical assistance that will be discussed addressed a broad range of priority actions and milestones described in the Global Plan: (1) planning for and implementing Option B+; (2) strengthening monitoring and evaluation systems; (3) translating evidence into action and advocacy; and (4) promoting community engagement. This article also reviews the ongoing challenges and opportunities of providing technical assistance in a rapidly evolving environment that calls for ever more flexible and contextualized responses. The effectiveness of technical assistance facilitated by the IATT was defined by its timeliness, evidence base, and unique global perspective that built on the competencies of its partners and promoted synergies across program areas. Reaching the final goal of eliminating vertical transmission of HIV infection and achieving an AIDS-free generation in countries with the highest HIV burden requires that the IATT partnership and technical assistance remain responsive to country-specific needs while aligning with the current programmatic reality and new global goals such as the Sustainable Development Goals and 90-90-90 targets.

Countries where adult male circumcision has reached high coverage should consider national early infant male circumcision (EIMC) programs where EIMC is feasible and culturally acceptable. Ministries of health that intend to set up a routine offer of EIMC should put systems in place to ensure that its introduction (1) does not compromise adult male circumcision programs, (2) does not weaken routine service delivery platforms, (3) is done safely, and (4) adheres to the rights of the child.

To maintain high circumcision prevalence, voluntary medical male circumcision programs in Eastern and Southern Africa need to plan for sustainability and conduct transition assessments early on, rather than waiting until the saturation of priority targets at the end of the program.

Introducing early infant male circumcision (EIMC) can sustain voluntary medical male circumcision (VMMC) programs. This Global Health: Science and Practice supplement presents lessons learned, research findings on demand creation, and cost comparisons of various models of EIMC introduction.

Objective. To improve PMTCT and antenatal care-related service delivery, a pack with centrally prepackaged medicine was rolled out to all pregnant women in Lesotho in 2011. This study assessed acceptability and feasibility of this copackaging mechanism for drug delivery among pregnant and postpartum women. Methods. Acceptability and feasibility were assessed in a mixed method, cross-sectional study through structured interviews (SI) and semistructured interviews (SSI) conducted in 2012 and 2013. Results. 290 HIV-negative women and 437 HIV-positive women (n = 727) participated. Nearly all SI participants found prepackaged medicines acceptable, though modifications such as size reduction of the pack were suggested. Positive experiences included that the pack helped women take pills as instructed and contents promoted healthy pregnancies. Negative experiences included inadvertent pregnancy disclosure and discomfort carrying the pack in communities. Implementation was also feasible; 85.2% of SI participants reported adequate counseling time, though 37.8% felt pack use caused clinic delays. SSI participants reported improvement in service quality following pack introduction, due to more comprehensive counseling. Conclusions. A prepackaged drug delivery mechanism for ANC/PMTCT medicines was acceptable and feasible. Findings support continued use of this approach in Lesotho with improved design modifications to reflect the current PMTCT program of lifelong treatment for all HIV-positive pregnant women.

BACKGROUND:Integration of HIV infant testing into immunization sessions is one of the strategies designed to increase coverage of early infant diagnosis. OBJECTIVE:To determine the evidence on the outcomes of such integration. METHODS:A systematic review of peer-reviewed and grey literature was undertaken from electronic sources such as MEDLINE, Google Scholar, websites of international agencies, past conferences and ministries of health reports published between year 2002 and 2013. Randomized controlled trials, observational and qualitative studies were searched and those meeting selection criteria were selected and relevant information extracted using structured tool. Statistical pooling was not possible owing to the heterogeneity of the study designs and outcome measures. RESULTS:Of the nine articles which met the selection criteria, none used a randomized controlled design. Of these, five articles measured mother's acceptability of their infants being tested for HIV during its first pentavalent or DPT vaccination visit, and 89·5-100% accepted. Four articles reported the proportion of mothers who returned for HIV test results, ranging from 56·8% to 86·0%. Increased uptake of HIV testing following integration was confirmed by two articles. Only one study in Tanzania determined the uptake of vaccinations following integration, with urban facilities showing stable or slight increase of monthly vaccine uptake while decreases were observed across the rural sites. In two articles, stigma was perceived by service-providers and mothers as the potential risk following integration, particularly in rural settings. DISCUSSION:Despite the limited number of articles, the findings in this systematic review suggest that HIV testing during immunization clinic visits is acceptable and feasible as a possible model for service delivery. However, the impact on vaccination uptake needs further study.

Introduction: Integration of HIV into child survival platforms is an evolving territory with multiple connotations. Most literature on integration of HIV into other health services focuses on adults; however promising practices for children are emerging. These include the Double Dividend (DD) framework, a new programming approach with dual goal of improving paediatric HIV care and child survival. In this commentary, the authors discuss why integrating HIV testing, treatment and care into child survival platforms is important, as well as its potential to advance progress towards global targets that call for, by 2020, 90% of children living with HIV to know their status, 90% of those diagnosed to be on treatment and 90% of those on treatment to be virally suppressed (90-90-90).Discussion: Integration is critical in improving health outcomes and efficiency gains. In children, integration of HIV in programmes such as immunization and nutrition has been associated with an increased uptake of HIV infant testing. Integration is increasingly recognized as a case-finding strategy for children missed from prevention of mother-to-child transmission programmes and as a platform for diffusing emerging technologies such as point-of-care diagnostics. These support progress towards the 90-90-90 targets by providing a pathway for early identification of HIV-infected children with co-morbidities, prompt initiation of treatment and improved survival. There are various promising practices that have demonstrated HIV outcomes; however, few have documented the benefits of integration on child survival interventions. The DD framework is well positioned to address the bidirectional impacts for both programmes.Conclusions: Integration provides an important programmatic pathway for accelerated progress towards the 90-90-90 targets. Despite this encouraging information, there are still challenges to be addressed in order to maximize the benefits of integration.