INTRODUCTION:UNAIDS "90-90-90" strategy calls for 90% of HIV-infected individuals to be diagnosed by 2020, 90% of whom will be on anti-retroviral therapy (ART) and 90% of whom will achieve sustained virologic suppression. Reaching these targets by 2020 will reduce the HIV epidemic to a low-level endemic disease by 2030. However, moving the global response towards this universal test and treat model will pose huge challenges to public health systems in resource-limited settings, including global and local supply chain systems. These challenges are especially acute in Africa, which accounts for over 70% of the persons affected by HIV. DISCUSSION:From a supply chain perspective, each of the "90's" has possible complications and roadblocks towards realizing the promise envisioned by 90-90-90. For instance, ensuring that 90% of HIV-infected persons know their status will require a large increase in access to HIV tests compared with what is currently available. To ensure that there are enough anti-retrovirals available to treat the nearly 25 million people that will require them by 2020 represents a near doubling of the ARV supplied to treat the 13 million currently on treatment. Similarly, to monitor those on treatment means an unprecedented scale-up of viral load testing throughout Africa. CONCLUSIONS:Larger issues include whether the capacity exists at the local level to handle these commodities when they arrive in the most severely affected countries, including considerations of the human resources and costs needed to make this strategy effective. We believe that such "real world" analysis of proposed strategies and policies is essential to ensure their most effective implementation.

Jonathan Jay and colleagues draw lessons from the the global HIV response that could help guide the universal health coverage movement.

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.

BACKGROUND:Prevention of mother-to-child transmission of HIV (PMTCT) programs can greatly reduce the vertical transmission rate (VTR) of HIV, and Malawi is expanding PMTCT access by offering HIV-infected pregnant women life-long antiretroviral therapy (Option B+). There is currently no empirical data on the effectiveness of Malawian PMTCT programs. This study describes a surveillance approach to obtain population-based estimates of the VTR of infants <3 months of age in Malawi immediately after the adoption of Option B+.METHODS AND FINDINGS:A sample of caregivers and infants <3 months from 53 randomly chosen immunization clinics in 4 districts were enrolled. Infant dried blood spot (DBS) samples were tested for HIV exposure with an antibody test to determine maternal seropositivity. Positive samples were further tested using DNA PCR to determine infant infection status and VTR. Caregivers were surveyed about maternal receipt of PMTCT services. Of the 5,068 DBS samples, 764 were ELISA positive indicating 15.1% (14.1-16.1%) of mothers were HIV-infected and passed antibodies to their infant. Sixty-five of the ELISA-positive samples tested positive by DNA PCR, indicating a vertical transmission rate of 8.5% (6.6-10.7%). Survey data indicates 64.8% of HIV-infected mothers and 46.9% of HIV-exposed infants received some form of antiretroviral prophylaxis. Results do not include the entire breastfeeding period which extends to almost 2 years in Malawi.CONCLUSIONS:The observed VTR was lower than expected given earlier modeled estimates, suggesting that Malawi's PMTCT program has been successful at averting perinatal HIV transmission. Challenges to full implementation of PMTCT remain, particularly around low reported antiretroviral prophylaxis. This approach is a useful surveillance tool to assess changes in PMTCT effectiveness as Option B+ is scaled-up, and can be expanded to track programming effectiveness for young infants over time in Malawi and elsewhere.

Scott Kellerman and colleagues argue that the scope of the current HIV elimination agenda must be broadened in order to ensure access to care and treatment for all children living with HIV. Please see later in the article for the Editors' Summary

Objective: Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration. Design and Methods: Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience. Results: Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent. Conclusions: In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.

Treatment 2.0 is an initiative launched by UNAIDS and WHO in 2011 to catalyze the next phase of treatment scale-up for HIV. The initiative defines strategic activities in 5 key areas, drugs, diagnostics, commodity costs, service delivery and community engagement in an effort to simplify treatment, expand access and maximize program efficiency. For adults, many of these activities have already been turned into treatment policies. The recent WHO recommendation to use a universal first line regimen regardless of gender, pregnancy and TB status is a treatment simplification very much in line with Treatment 2.0. But despite that fact that Treatment 2.0 encompasses all people living with HIV, we have not seen the same evolution in policy development for children. In this paper we discuss how Treatment 2.0 principles can be adapted for the pediatric population. There are several intrinsic challenges. The need for distinct treatment regimens in children of different ages makes it hard to define a one size fits all approach. In addition, the fact that many providers are reluctant to treat children without the advice of specialists can hamper decentralization of service delivery. But at the same time, there are opportunities that can be availed now and in the future to scale up pediatric treatment along the lines of Treatment 2.0. We examine each of the five pillars of Treatment 2.0 from a pediatric perspective and present eight specific action points that would result in simplification of pediatric treatment and scale up of HIV services for children.

In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015. This increased focus on the elimination of maternal to child transmission (MTCT) is most welcome but is insufficient, as access to prevention of MTCT (PMTCT) programming is neither uniform nor universal. A new and more expansive agenda must be articulated to ensure that those infants and children who will never feel the impact of the current elimination agenda are reached and linked to appropriate care and treatment. This agenda must addresses challenges around both reducing vertical transmission through PMTCT and ensuring access to appropriate HIV testing, care, and treatment for all affected children who were never able to access PMTCT programming. Option B+, or universal test and treat for HIV-infected pregnant women is an excellent start, but it may be time to rethink our current approaches to delivering PMTCT services. New strategies will reduce vertical transmission to less than 1% for those mother-infant pairs who can access them allowing for the contemplation of not just PMTCT, but actual elimination of MTCT. But expanded thinking is needed to ensure elimination of pediatric HIV.

In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015. This increased focus on the elimination of maternal to child transmission (MTCT) is most welcome but is insufficient, as access to prevention of MTCT (PMTCT) programming is neither uniform nor universal. A new and more expansive agenda must be articulated to ensure that those infants and children who will never feel the impact of the current elimination agenda are reached and linked to appropriate care and treatment. This agenda must addresses challenges around both reducing vertical transmission through PMTCT and ensuring access to appropriate HIV testing, care, and treatment for all affected children who were never able to access PMTCT programming. Option B+, or universal test and treat for HIV-infected pregnant women is an excellent start, but it may be time to rethink our current approaches to delivering PMTCT services. New strategies will reduce vertical transmission to less than 1% for those mother-infant pairs who can access them allowing for the contemplation of not just PMTCT, but actual elimination of MTCT. But expanded thinking is needed to ensure elimination of pediatric HIV.

Each year over a million infants are born to HIV-infected mothers. With scale up of prevention of mother-to-child transmission (PMTCT) interventions, only 210000 of the 1.3 million infants born to mothers with HIV/AIDS in 2012 became infected. Current programmatic efforts directed at infants born to HIV-infected mothers are primarily focused on decreasing their risk of infection, but an emphasis on maternal interventions has meant follow-up of exposed infants has been poor. Programs are struggling to retain this population in care until the end of exposure, typically at the cessation of breastfeeding, between 12 and 24 months of age. But HIV exposure is a life-long condition that continues to impact the health and well being of a child long after exposure has ended. A better understanding of the impact of HIV on exposed infants is needed and new programs and interventions must take into consideration the long-term health needs of this growing population. The introduction of lifelong treatment for all HIV-infected pregnant women is an opportunity to rethink how we provide services adapted for the long-term retention of mother-infant pairs. (C) 2013 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins

The global plan to eliminate mother-to-child HIV transmission (eMTCT) and reduce HIV-related child mortality has made substantial progress since it was first announced in 2011 [1]. In low and middle-income countries (LMIC), where the majority of these infections occur, a 35% decline in new pediatric HIV infections has been observed between 2009 and 2012 [2]. Despite this progress, there is an estimated 210 000 infants born with HIV among the 21 eMTCT priority countries (where 90% of infections occur) in 2012 and challenges remain in identifying HIV-infected infants and linking them long-term care and treatment [3–6]. As of 2012, only 34% of treatment eligible children in LMIC countries were receiving ART [7] despite proven benefits of early initiation of antiretroviral treatment (ART) on child survival [8]. Without treatment, about 50% of HIV-infected children will die before their second birthday [9].

In 2011, Ambassador Eric Goosby of the U.S. President’s Emergency Plan for AIDS Relief and Michel Sidibe, the Executive Director of the Joint United Nations Programme on HIVand AIDS, announced a Global Plan for eliminating new HIV infections in children and keeping their mothers alive [1]. The elimination of maternal-to-child transmission (EMTCT) or Global Plan calls for three topline goals – decreasing new pediatric infections due to vertical transmission by 90%, halving maternal deaths, and halving pediatric deaths from HIV and AIDS by 2015 [1]. In June 2011, all United Nations member states committed to these targets. The Interagency Task Team, a 32-organization partnership coconvened by the United Nations Children’s Fund and WHO, is charged with coordinating technical support to countries, developing supportive guidance and tools and monitoring progress, with an emphasis on 22 countries that account for 90% of the total annual number of new HIV infections among children. This series of 11 articles addressing pediatric HIV care and treatment was created by the nearly 60 members of the Interagency Task Team Child Survival Working Group.

There are 3.4 million children infected with HIV worldwide, with up to 2.6 million eligible for treatment under current guidelines. However, roughly 70% of infected children are not receiving live-saving HIV care and treatment. Strengthening case finding through improved diagnosis strategies, and actively linking identified HIV-infected children to care and treatment is essential to ensuring that these children benefit from the care and treatment available to them. Without attention or advocacy, the majority of these children will remain undiagnosed and die from complications of HIV. In this article, we summarize the challenges of identifying HIV-infected infants and children, review currently available evidence and guidance, describe promising new strategies for case finding, and make recommendations for future research and interventions to improve identification of HIV-infected infants and children.

Estimating the size of populations most affected by HIV such as men who have sex with men (MSM) though crucial for structuring responses to the epidemic presents significant challenges, especially in a developing society. Using capture-recapture methodology, the size of MSM-SW in Nigeria was estimated in three major cities (Lagos, Kano and Port Harcourt) between July and December 2009. Following interviews with key informants, locations and times when MSM-SW were available to male clients were mapped and designated as "hotspots". Counts were conducted on two consecutive weekends. Population estimates were computed using a standardized Lincoln formula. Fifty-six hotspots were identified in Kano, 38 in Lagos and 42 in Port Harcourt. On a given weekend night, Port Harcourt had the largest estimated population of MSM sex workers, 723 (95%CI: 594-892) followed by Lagos state with 620 (95%CI: 517-724) and Kano state with 353 (95%CI: 332-373). This study documents a large population of MSM-SW in 3 Nigerian cities where higher HIV prevalence among MSM compared to the general population has been documented. Research and programming are needed to better understand and address the health vulnerabilities that MSM-SW and their clients face. Estimer la taille des populations les plus touchees par le VIH, comme les hommes ayant des rapports sexuels avec des hommes (HSH) bien que crucial pour la structuration des reponses a l'epidemie, presente des defis importants, surtout dans une societe en developpement. En utilisant la methode de capture-recapture, le nombre des prostitues hommes-HSH au Nigeria a ete estime dans trois grandes villes (Lagos, Kano et Port Harcourt) entre juillet et decembre 2009. Grâce a des entretiens avec des informateurs cles, les emplacements et les heures ou les hommes prostitues-HSH etaient a la disposition des clients masculins ont ete elabores et designes comme « points chauds ». Des comptages ont ete effectues pendant deux week-ends consecutifs. Les estimations de population ont ete calculees en utilisant une formule de Lincoln standardisee. Cinquante-six points nevralgiques ont ete identifies a Kano, 38 a Lagos et 42 a Port Harcourt. Une nuit d'un week-end donne, Port Harcourt avait la plus grande population estimee des hommes prostitues-HSH, 723 (CI : 594-892 95 %), suivi de l'Etat de Lagos avec 620 (CI : 517-724 95%) et l'Etat de Kano avec 353 (95 % CI : 332-373). Cette etude documente une grande population des hommes prostitues-HSH dans 3 villes nigerianes ou la prevalence elevee du VIH parmi les HSH par rapport a la population generale a ete documentee. La recherche et la programmation sont necessaires pour mieux comprendre et aborder les vulnerabilites de la sante auxquelles font face les prostitues-HSH et leurs clients.

Estimating the size of populations most affected by HIV such as men who have sex with men (MSM) though crucial for structuring responses to the epidemic presents significant challenges, especially in a developing society. Using capture-recapture methodology, the size of MSM-SW in Nigeria was estimated in three major cities (Lagos, Kano and Port Harcourt) between July and December 2009. Following interviews with key informants, locations and times when MSM-SW were available to male clients were mapped and designated as "hotspots". Counts were conducted on two consecutive weekends. Population estimates were computed using a standardized Lincoln formula. Fifty-six hotspots were identified in Kano, 38 in Lagos and 42 in Port Harcourt. On a given weekend night, Port Harcourt had the largest estimated population of MSM sex workers, 723 (95% CI: 594-892) followed by Lagos state with 620 (95%CI: 517-724) and Kano state with 353 (95%CI: 332-373). This study documents a large population of MSM-SW in 3 Nigerian cities where higher HIV prevalence among MSM compared to the general population has been documented. Research and programming are needed to better understand and address the health vulnerabilities that MSM-SW and their clients face.

In 2012, there were an estimated 2 million children in need of antiretroviral therapy (ART) in the world, but ART is still reaching fewer than 3 in 10 children in need of treatment. [1, 7] As more HIV-infected children are identified early and universal treatment is initiated in children under 5 regardless of CD4, the success of pediatric HIV programs will depend on our ability to link children into care and treatment programs, and retain them in those services over time. In this review, we summarize key individual, institutional, and systems barriers to diagnosing children with HIV, linking them to care and treatment, and reducing loss to follow-up (LTFU). We also explore how linkage and retention can be optimally measured so as to maximize the impact of available pediatric HIV care and treatment services. (C) 2013 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins

If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.

The objective of this study was to determine extent of HIV conspiracy belief endorsement among men who have sex with men (MSM) in Pretoria, and assess whether endorsement of HIV conspiracy beliefs are associated with inconsistent condom use and never testing for HIV. A cross-sectional survey using respondent-driven sampling was conducted between February and August 2009. A high proportion of respondents endorsed HIV conspiracy beliefs. MSM commonly endorsed beliefs related to AIDS information being held back from the general public (51.0%), HIV being a man-made virus (25.5%), and people being used as guinea pigs in HIV research and with HIV treatments (approximately 20%). Bisexually- or heterosexually-identified MSM were significantly more likely to endorse conspiracy beliefs compared to homosexually-identified MSM (38.5% vs. 14.7%). Endorsing conspiracy beliefs was not associated with unprotected anal intercourse; however, it was significantly associated with not having been HIV tested (AOR: 2.4; 95% CI: 1.1-5.7). Endorsing beliefs in HIV conspiracies reflects a mistrust in government institutions and systems which could be an impediment to seeking HIV-related services, including HIV counseling and testing.