The Children Left Behind: Why Pediatric HIV Remains a Global Health Challenge

Human immunodeficiency virus (HIV), once considered a life-threatening disease, is now a chronic yet manageable condition. Today, mother-to-child transmission (MTCT) of HIV is largely preventable thanks to antiretroviral (ARV) medications.

“While scientists are still working on a cure for HIV, we've made great leaps in understanding and averting cases of MTCT. The first goal is always to prevent cases in expectant mothers, then to catch infection early, and start treatment immediately. Untreated, MTCT risk runs as high as 45%. With sustained suppression, the risk of passing HIV on during pregnancy or birth is effectively zero, because U=U [undetectable equals untransmittable]. Breastfeeding transmission can be brought down to very low levels (less than 1%), but not zero”, said Allira Attwill, head of knowledge and policy intelligence at Policy Wisdom.

Yet, despite advances in modern medicine, an estimated 1.4 million children aged 0–14 were living with HIV at the end of 2024.

“Children are about 3% of people living with HIV but around 11% of AIDS-related deaths, and only about 64% even know their status,” Attwill said.

This article will explore how implementation gaps, health-system weaknesses, and stigma continue to prevent many children from benefiting from the tools needed to prevent and manage pediatric HIV.

Vertical transmission explained

Vertical transmission of HIV—the passage of the virus from a pregnant or breastfeeding woman to her fetus or infant—is the main route by which pediatric HIV infection is acquired. Vertical transmission can occur during three periods:

• During pregnancy (in utero): A fetus is susceptible to HIV infection while in utero as placental trophoblasts can become infected with the virus.
• During labor and delivery (intrapartum): Infected maternal blood and secretions from the birth canal can come into contact with the mucosal surfaces of the neonate, facilitating transmission.
• After birth (postpartum): Postnatal transmission can occur during breastfeeding.

In utero transmission is the least effective route of vertical transmission, whereas intrapartum transmission is the most common. The risk of vertical transmission via each route is highly influenced by the maternal viral load—the amount of HIV present in the mother’s blood.

Concerningly, “around a third of new HIV acquisitions in babies are attributable to women acquiring HIV during pregnancy or the postnatal period,” explained Attwill. “With proper access to screening, PrEP, and treatment, that share could be close to zero.”

Attwill emphasized that this isn’t the mother's fault and that several factors contribute to the high risk these cases carry. “Due to biological changes, women are roughly three to four times more vulnerable to acquiring HIV during late pregnancy and the postpartum period in the first place,” she said.

The window period for HIV, defined as the interval between transmission and the development of detectable infection markers, can range from 45–90 days depending on the test used. If a woman acquires HIV during pregnancy, standard antenatal tests may return a negative result if they are taken within this time-frame

In the meantime, viral load can continue to rise. As a result, “the highest-risk situations are also the ones most likely to go undetected,” stated Attwill.

Progress in the prevention of MTCT

In 1989, 25% of infants born to women living with HIV acquired the virus. This prompted the development of interventions to offset vertical transmission. A breakthrough came in 1994 with the Pediatric AIDS Clinical Trial Group Study, which reported a 67.5% reduction in the risk of vertical transmission with prophylactic antenatal, intrapartum, and postnatal zidovudine.

Further optimization of ARVs means that many countries have since eliminated the vertical transmission of HIV. The appropriate precautions include taking ARV medications before, during, and after the pregnancy, and ensuring the baby receives ARV medication following birth.

Prevention of mother-to-child transmission (PMTCT) programs have been set up to provide ARV therapies to HIV-positive pregnant women to prevent their infants from acquiring the virus.

HIV screening among pregnant women during antenatal care visits is another key strategy for preventing vertical transmission, which facilitates early initiation of treatment for infants who acquire HIV. The World Health Organization (WHO) recommends that infants born to mothers living with HIV are tested by two months of age and during and after breastfeeding.

Despite advances in ARV medicines and the introduction of PMTCT programs, global vertical transmission rates were still being reported as high as 11.94% in 2021.

“PMTCT programs have made extraordinary gains on paper; in practice, rural health posts run out of stock, community health workers operate without supervision, and mothers who test positive during antenatal care fall out of the treatment cascade before delivery,” said Dr. Vandana Arcot, MD, MPH, MBA physician and global public health specialist with over two decades of experience across four continents and founder of KOMSELJ.

When the science works but the system doesn’t

The barriers preventing elimination of pediatric HIV are increasingly operational rather than biological. Tools such as HIV self-tests, PrEP, and ARVs are only effective if they can reach the people that need them most, and supply chains need to be reliable and resilient to external shocks.

Liquid Biopsies in Cancer: Technologies, Applications, and Emerging Advances

This infographic provides an overview of liquid biopsy workflows, applications, and innovations addressing current limitations.

View Infographic

Advertisement

“Those supply chains and pathways tend to break at social, political, and/or funding points more than clinical ones,” Attwill explained.

Lack of supply and the costs of treatments tend to hit the youngest and most vulnerable hardest. “About a quarter of pregnant women and mothers living with HIV are aged 15 to 24, and antenatal services rarely address their specific concerns and needs,” said Attwill.

“If there is one thing we know about healthcare, sadly, it’s that access is typically distributed according to ‘ability to pay’, and not according to need. And, rarely (if ever) is need highest where people have the ability to pay,” she continued.

A lack of policy that supports access and delivery of HIV interventions remains a key barrier. “Underneath all of it, the 2025 cuts to PEPFAR and USAID [US-funded programs] have left decades of hard-won gains fragile, because without proper funding, access-related policies struggle to be implemented,” Attwill explained.

Arcot points to New York as an example of the inequity often seen in access to HIV care.

The South Bronx and Harlem were among the epicenters of the US HIV epidemic—not because of individual behavior but because of housing conditions. Overcrowded and under-maintained public housing created conditions in which HIV, tuberculosis, and substance use converged.

“From my early career of working with children in New York, I noticed the consequences were compounding in a different sense,” said Arcot. “Pediatric HIV in the early 2000s was concentrated almost entirely in communities of color living in poverty.”

Children born to mothers who had no access to prenatal HIV testing, treatment, and no housing stability already entered the health system with multiple disadvantages. Even as perinatal transmission declined dramatically with the introduction of ARVs, “the children who survived into adolescence often did so with interrupted schooling, caregivers lost to the epidemic, and their own medical histories embedded in stigma,” explained Arcot.

"What the New York story illustrates is something I have observed across every context I have worked in—high-resource and low-resource communities and post-conflict settings. Pediatric HIV has never been evenly distributed. It follows the geography of poverty, race, and political abandonment." — Dr. Vandana Arcot.

Cutting through every element of discussions around HIV is stigma, which is “consistently the single most cited barrier across the whole continuum of care,” explained Attwill.

Modern Methods for Faster Microbial Analysis

Rapid microbial analysis is essential for maintaining product quality, ensuring safety, and supporting efficient laboratory workflows, yet selecting the most appropriate analytical approach can be challenging.
View Webinar

Advertisement

What would it take to end pediatric HIV?

The lesson from New York is more than one of failure; it also provides an example of what investment in HIV interventions and care can achieve. “The Ryan White Program, harm-reduction infrastructure, and community health centers anchored in neighborhoods rather than hospital systems—these interventions moved the numbers,” Arcot said.

These interventions required sustained political will and funding that many other US states and countries around the world never built.

“The lesson from New York is not only about failure. It is about what becomes possible when a city decides that people who use drugs, people experiencing homelessness, and people living with HIV deserve healthcare designed around their actual lives—not around the assumption of stability they do not have,” continued Arcot.

Prevention requires stigma-free antenatal services, easier access to sexual and reproductive health services, and stronger engagement of male partners alongside community-led adherence support. Attwill pointed to mentor mother programs in several African countries as good examples of programs supporting pregnant and parenting adolescents to reach services and support for HIV.

For children already living with HIV, improved outcomes will require closing the case-finding gap through early diagnosis and accelerating the development of child-friendly drug formulations.

In 2022, UNAIDS, UNICEF, WHO, and partners created the Global Alliance for Ending AIDS in Children by 2030. The alliance was set up to fix one of the most glaring disparities in the HIV response and ensure that no child living with HIV is denied treatment, as well as to prevent new cases of MTCT.

“The job right now is to reliably finance and make that effort sustainable, including through capacity building programs and genuine partnerships that seek to build stronger, more resilient HIV programs embedded within primary and antenatal care, that can sustain programs long beyond donor withdrawal,” said Attwill.

Today, barriers to pediatric HIV care are rarely clinical. Effective treatments exist, but the architecture surrounding access continues to fail mothers and children living with HIV.

“The indirect benefits of better maternal adherence through long-acting PrEP and treatment are real—a mother who sustains viral suppression protects her child. But pediatric-specific formulations, dosing data for adolescents, and delivery models designed around young people's lives rather than adult clinical assumptions still lag behind the broader treatment advances,” concluded Arcot.