GFO Issue 466, Article Number: 5
ABSTRACT
This article highlights that, more than forty years after the discovery of HIV, children in French-speaking Africa remain the most affected by the epidemic. Despite progress in adult treatment, the pediatric response remains insufficient, especially in West and Central Africa. The text describes a fragile prevention–testing–treatment chain, hindered by delayed diagnoses, supply shortages, and fragmented governance. It calls for stronger integration of mother–child health services, widespread use of optimized pediatric treatments (pALD), better community follow-up, and improved financial planning to achieve the goal of ending AIDS in children by 2030.
Introduction
Over four decades since HIV was discovered, children in French-speaking Africa continue to bear the brunt of the epidemic. Although adult treatment coverage has improved, the paediatric response is lagging behind, threatening the 2030 goals of the Global Alliance to End AIDS in Children. The most recent data (Global Fund, UNAIDS, WHO, UNICEF ) The technical briefs shared for this report paint a clear picture: the prevention-screening-treatment chain for children is still vulnerable in West and Central Africa (WCA). This analysis provides an overview that highlights the risks and outlines appropriate, innovative solutions to accelerate the response.
A paediatric continuum that is too fragile and widens the gap
The most recent data on responses shows stark contrasts between adults and children. Treatment coverage is around three-quarters among adults, while globally, just over one in two children are on antiretroviral therapy (ART). In West and Central Africa (WCA), fewer than four in ten children are receiving treatment (Figure 1).
Figure 1: Antiretroviral treatment coverage in 2024 among children
This gap encompasses the entire chain, from the prevention of mother-to-child transmission (PMTCT) and early detection to the rapid initiation of treatment and viral retention and suppression. The entry point remains too narrow: in the WCA region, almost 60% of infants exposed to HIV do not receive a diagnosis within two months, resulting in irreversible delays (Figure 2).
Figure 3: EID Testing ≤2 Months (2024)
Coverage of antiretroviral therapy (ART) among pregnant and breastfeeding women remains heterogeneous, with a regional average of two-thirds and significant variations between countries. Such levels, if they persist, will make the elimination of vertical transmission unattainable (Figure 3).
Figure 3: PMTCT ARVs (2024)
This observation is all the more frustrating given the modernisation of the technical arsenal. The availability of optimized and dispersible pediatric combinations , first and foremost ABC/3TC/DTG ( pALD ), It makes it possible to simplify regimens, improve adherence and bring paediatric results closer to adult standards. WHO guidelines and clinical data confirm the efficacy and safety of these products, and access has improved thanks to group purchasing initiatives. However, operational adoption is stalling due to incomplete transitions, poorly disseminated dosing tools, irregular supply chains, team training that does not reach all sites and delayed feedback. Innovation exists, but its impact is diluted if it is not delivered 'to the last mile' as part of integrated, predictable services.
The fragility of the paediatric continuum is exacerbated by unstable humanitarian and security contexts. In several French-speaking countries, from the Sahel to eastern DRC, insecurity hinders the continuity of RMNCAH care, the mobility of teams, the availability of tests and ARVs, and even the simple act of keeping appointments. The fragmentation of providers and tools (vertical programmes, multiple donors, and heterogeneous standards and registries) complicates family pathways. Adolescents, who are caught between paediatric and adult systems, experience losses to follow-up and psychosocial barriers. Finally, data quality and timeliness remain uneven, with late returns of results, insufficient disaggregation and discrepancies in denominators. This 'by sight' management approach prevents efforts from being concentrated exactly where the greatest losses occur, such as post-breastfeeding, nutrition services, hospital paediatrics and paediatric TB, and maintains the dynamic of paediatric delay, which is not inevitable, but an entirely system-related problem.
Risks threatening the trajectory: five knots to untie and lessons from the field
The first risk is macro-financial and political. The HIV response, and within it pediatrics, which is often less visible, is exposed to funding volatility and shifts in priorities. Cuts, delays or inflexibility in funding can, within weeks, lead to shortages of EID testing, insufficient ARV supplies and a reduction in community activities. In 2025, the system demonstrated its acute sensitivity to external shocks: when funding is limited, it is the paediatric services—PMTCT, EID at the point of care and family support—that suffer first. Paediatric performance must therefore be interpreted not as isolated 'technical' aggregates, but as sentinel indicators of a financing model that is struggling to secure the final stages.
The second issue is the identification–initiation–retention 'funnel'. Too many pregnant and breastfeeding women remain undiagnosed, or do not initiate or maintain ART. Too many infants are not tested promptly, and too many diagnosed children are not initiated on treatment promptly, or are quickly lost to follow-up. This funnel narrows further for adolescents, during weaning and service transitions, when stigma and unfavourable gender norms take effect. Low male participation in MCH pathways hinders disclosure and family support, while social barriers complicate adherence and mental health remains under-addressed. Concrete examples in Côte d’Ivoire and Senegal show the potential for reversal: PMTCT-SRH integration, point-of-care offerings and active community networks have led to improved EID and paediatric ART initiations. Conversely, geographic dispersion, insecurity and fragmentation in the DRC and Chad exacerbate the child-adult gap. In Cameroon, the expansion of POC EID and paediatric DTG has produced localised gains, but post-PMTCT retention remains problematic when the test-care link is not supported.
The third node is the supply chain. Pharmaceutical innovations only have an impact if they are available in the right place at the right time. Inaccurate forecasts, late orders and insufficient buffer stocks at district level, as well as the absence of flexible intra-country redistribution mechanisms, result in disruptions and suboptimal regimens continuing. Fourth node: the architecture and governance of delivery. Too many paediatric services remain 'annexed' to adult or hospital platforms, whereas integration at the primary care level (ANC/CPoN, immunisation, nutrition, malaria) with seamless referral and screening offered by the provider is the winning axis. Fifth node: information for action. Programmes without monthly, disaggregated and 'bottleneck'-oriented dashboards with rapid improvement loops disperse efforts and weaken operational accountability. Resolving these five issues does not require reinventing the wheel, but rather aligning technology, logistics, financing and management with the same goal: delivering sooner, faster and closer to families.
Accelerate now and maintain the momentum: a pragmatic plan of action.
The priority is to transform the PMTCT–EID–ART chain into an integrated pathway centred on mothers, children, and families. Specifically:, this involves aligning national plans with the WHO triple elimination framework (HIV, syphilis, HBV) ; systematically offering screening where families already come (ANC/CPoN, vaccinations, nutrition, paediatrics); institutionalising family screening from index cases; and generalising EID at the point of care so that the 'result → initiation' time is measured in days, not weeks. These choices are not just a matter of directives; they require pathway engineering, practical tools such as referral sheets, reminder text messages and electronic exposure logs, and coordination between programmes that too often evolve in isolation.
The second priority is to complete the therapeutic transition to optimised paediatric regimens and make pALD the standard. '90-day campaigns' can quickly convert the majority of eligible children if we synchronise the rapid training of clinicians, ensure guaranteed availability and provide close clinical supervision. At the same time, dedicated teams must 'recover' children on suboptimal regimens using nominal lists, reinforced parental counselling and local monitoring. This scaling up must be supported by robust quantification plans, buffer stocks at district level and flexible redistribution mechanisms to avoid shortages, because nothing is more discouraging for teams than a prescribed protocol with no available product.
Thirdly, the funnel must be closed by identifying and reaching out to invisible children. The key lies in intelligently cross-referencing immunisation, nutrition, TB and PMTCT registries in order to identify affected children and issue invitations proactively. Community liaison officers and peer groups, such as mentor mothers, male champions and parent-child clubs, play an irreplaceable role here by reminding people of appointments, supporting disclosure and adherence, and reducing losses to follow-up during risky periods, such as after breastfeeding, during adolescence and when transitioning to adult care. Differentiated delivery models — such as multi-month dispensing, community collection points and tailored time slots — improve retention at a modest marginal cost when integrated into service routines rather than being implemented as pilot projects.
Finally, resilience must be planned for, rather than imposed. Donors and programmes are interested in securing 'protected' paediatric lines for critical supplies (e.g. EID tests and paediatric ARVs). synchronizing funding cycles to avoid 'cliffs', use 'district-led' performance contracts with quality bonuses on simple, verifiable paediatric indicators (EID ≤ 2 months, initiation ≤ 7 days, viral suppression < 12 months) where appropriate. Monthly dashboards disaggregated by age, sex and district must form the backbone of governance, with rapid reviews of bottlenecks and improvement plans looping back to front-line teams. The battle is played out in these 'last metres' — fine logistics, clinical micro-supervision and family support. By investing more where the marginal value is greatest, French-speaking Africa can catch up with its paediatric lag and protect its gains against the inevitable future shocks.
Open conclusion:
The figures are unambiguous: Francophone Africa lags behind in terms of the number of children living with HIV. However, the necessary tools are available: modern formulations, WHO triple elimination frameworks and proven community-based strategies. The priority now is to align governance, financing and implementation as closely as possible with families. If partners prioritise paediatrics in the 2025–2027 programming, refocus resources on identified bottlenecks and operationalise integration with RMNCAH, the region could close the gap by 2030. Inaction would be the worst option; the best would be a coordinated offensive on early identification, rapid access to pALD, and sustainable retention.
Introduction
Over four decades since HIV was discovered, children in French-speaking Africa continue to bear the brunt of the epidemic. Although adult treatment coverage has improved, the paediatric response is lagging behind, threatening the 2030 goals of the Global Alliance to End AIDS in Children. The most recent data (Global Fund, UNAIDS, WHO, UNICEF ) The technical briefs shared for this report paint a clear picture: the prevention-screening-treatment chain for children is still vulnerable in West and Central Africa (WCA). This analysis provides an overview that highlights the risks and outlines appropriate, innovative solutions to accelerate the response.
A paediatric continuum that is too fragile and widens the gap
The most recent data on responses shows stark contrasts between adults and children. Treatment coverage is around three-quarters among adults, while globally, just over one in two children are on antiretroviral therapy (ART). In West and Central Africa (WCA), fewer than four in ten children are receiving treatment (Figure 1).
Figure 1: Antiretroviral treatment coverage in 2024 among children
This gap encompasses the entire chain, from the prevention of mother-to-child transmission (PMTCT) and early detection to the rapid initiation of treatment and viral retention and suppression. The entry point remains too narrow: in the WCA region, almost 60% of infants exposed to HIV do not receive a diagnosis within two months, resulting in irreversible delays (Figure 2).
Figure 3: EID Testing ≤2 Months (2024)
Coverage of antiretroviral therapy (ART) among pregnant and breastfeeding women remains heterogeneous, with a regional average of two-thirds and significant variations between countries. Such levels, if they persist, will make the elimination of vertical transmission unattainable (Figure 3).
Figure 3: PMTCT ARVs (2024)
This observation is all the more frustrating given the modernisation of the technical arsenal. The availability of optimized and dispersible pediatric combinations , first and foremost ABC/3TC/DTG ( pALD ), It makes it possible to simplify regimens, improve adherence and bring paediatric results closer to adult standards. WHO guidelines and clinical data confirm the efficacy and safety of these products, and access has improved thanks to group purchasing initiatives. However, operational adoption is stalling due to incomplete transitions, poorly disseminated dosing tools, irregular supply chains, team training that does not reach all sites and delayed feedback. Innovation exists, but its impact is diluted if it is not delivered 'to the last mile' as part of integrated, predictable services.
The fragility of the paediatric continuum is exacerbated by unstable humanitarian and security contexts. In several French-speaking countries, from the Sahel to eastern DRC, insecurity hinders the continuity of RMNCAH care, the mobility of teams, the availability of tests and ARVs, and even the simple act of keeping appointments. The fragmentation of providers and tools (vertical programmes, multiple donors, and heterogeneous standards and registries) complicates family pathways. Adolescents, who are caught between paediatric and adult systems, experience losses to follow-up and psychosocial barriers. Finally, data quality and timeliness remain uneven, with late returns of results, insufficient disaggregation and discrepancies in denominators. This 'by sight' management approach prevents efforts from being concentrated exactly where the greatest losses occur, such as post-breastfeeding, nutrition services, hospital paediatrics and paediatric TB, and maintains the dynamic of paediatric delay, which is not inevitable, but an entirely system-related problem.
Risks threatening the trajectory: five knots to untie and lessons from the field
The first risk is macro-financial and political. The HIV response, and within it pediatrics, which is often less visible, is exposed to funding volatility and shifts in priorities. Cuts, delays or inflexibility in funding can, within weeks, lead to shortages of EID testing, insufficient ARV supplies and a reduction in community activities. In 2025, the system demonstrated its acute sensitivity to external shocks: when funding is limited, it is the paediatric services—PMTCT, EID at the point of care and family support—that suffer first. Paediatric performance must therefore be interpreted not as isolated 'technical' aggregates, but as sentinel indicators of a financing model that is struggling to secure the final stages.
The second issue is the identification–initiation–retention 'funnel'. Too many pregnant and breastfeeding women remain undiagnosed, or do not initiate or maintain ART. Too many infants are not tested promptly, and too many diagnosed children are not initiated on treatment promptly, or are quickly lost to follow-up. This funnel narrows further for adolescents, during weaning and service transitions, when stigma and unfavourable gender norms take effect. Low male participation in MCH pathways hinders disclosure and family support, while social barriers complicate adherence and mental health remains under-addressed. Concrete examples in Côte d’Ivoire and Senegal show the potential for reversal: PMTCT-SRH integration, point-of-care offerings and active community networks have led to improved EID and paediatric ART initiations. Conversely, geographic dispersion, insecurity and fragmentation in the DRC and Chad exacerbate the child-adult gap. In Cameroon, the expansion of POC EID and paediatric DTG has produced localised gains, but post-PMTCT retention remains problematic when the test-care link is not supported.
The third node is the supply chain. Pharmaceutical innovations only have an impact if they are available in the right place at the right time. Inaccurate forecasts, late orders and insufficient buffer stocks at district level, as well as the absence of flexible intra-country redistribution mechanisms, result in disruptions and suboptimal regimens continuing. Fourth node: the architecture and governance of delivery. Too many paediatric services remain 'annexed' to adult or hospital platforms, whereas integration at the primary care level (ANC/CPoN, immunisation, nutrition, malaria) with seamless referral and screening offered by the provider is the winning axis. Fifth node: information for action. Programmes without monthly, disaggregated and 'bottleneck'-oriented dashboards with rapid improvement loops disperse efforts and weaken operational accountability. Resolving these five issues does not require reinventing the wheel, but rather aligning technology, logistics, financing and management with the same goal: delivering sooner, faster and closer to families.
Accelerate now and maintain the momentum: a pragmatic plan of action.
The priority is to transform the PMTCT–EID–ART chain into an integrated pathway centred on mothers, children, and families. Specifically:, this involves aligning national plans with the WHO triple elimination framework (HIV, syphilis, HBV) ; systematically offering screening where families already come (ANC/CPoN, vaccinations, nutrition, paediatrics); institutionalising family screening from index cases; and generalising EID at the point of care so that the 'result → initiation' time is measured in days, not weeks. These choices are not just a matter of directives; they require pathway engineering, practical tools such as referral sheets, reminder text messages and electronic exposure logs, and coordination between programmes that too often evolve in isolation.
The second priority is to complete the therapeutic transition to optimised paediatric regimens and make pALD the standard. '90-day campaigns' can quickly convert the majority of eligible children if we synchronise the rapid training of clinicians, ensure guaranteed availability and provide close clinical supervision. At the same time, dedicated teams must 'recover' children on suboptimal regimens using nominal lists, reinforced parental counselling and local monitoring. This scaling up must be supported by robust quantification plans, buffer stocks at district level and flexible redistribution mechanisms to avoid shortages, because nothing is more discouraging for teams than a prescribed protocol with no available product.
Thirdly, the funnel must be closed by identifying and reaching out to invisible children. The key lies in intelligently cross-referencing immunisation, nutrition, TB and PMTCT registries in order to identify affected children and issue invitations proactively. Community liaison officers and peer groups, such as mentor mothers, male champions and parent-child clubs, play an irreplaceable role here by reminding people of appointments, supporting disclosure and adherence, and reducing losses to follow-up during risky periods, such as after breastfeeding, during adolescence and when transitioning to adult care. Differentiated delivery models — such as multi-month dispensing, community collection points and tailored time slots — improve retention at a modest marginal cost when integrated into service routines rather than being implemented as pilot projects.
Finally, resilience must be planned for, rather than imposed. Donors and programmes are interested in securing 'protected' paediatric lines for critical supplies (e.g. EID tests and paediatric ARVs). synchronizing funding cycles to avoid 'cliffs', use 'district-led' performance contracts with quality bonuses on simple, verifiable paediatric indicators (EID ≤ 2 months, initiation ≤ 7 days, viral suppression < 12 months) where appropriate. Monthly dashboards disaggregated by age, sex and district must form the backbone of governance, with rapid reviews of bottlenecks and improvement plans looping back to front-line teams. The battle is played out in these 'last metres' — fine logistics, clinical micro-supervision and family support. By investing more where the marginal value is greatest, French-speaking Africa can catch up with its paediatric lag and protect its gains against the inevitable future shocks.
Open conclusion:
The figures are unambiguous: Francophone Africa lags behind in terms of the number of children living with HIV. However, the necessary tools are available: modern formulations, WHO triple elimination frameworks and proven community-based strategies. The priority now is to align governance, financing and implementation as closely as possible with families. If partners prioritise paediatrics in the 2025–2027 programming, refocus resources on identified bottlenecks and operationalise integration with RMNCAH, the region could close the gap by 2030. Inaction would be the worst option; the best would be a coordinated offensive on early identification, rapid access to pALD, and sustainable retention.
