Provide paediatric treatment

The challenge

WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, Progress Report 2009.

Joint monitoring tool on the health sector response to HIV/AIDS

An estimated 2.1 million (1.2–2.9 million) children under 15 were living with the human immunodeficiency virus (HIV) in 2008, while 430,000 (240,000–610,000) were newly infected, mainly through mother-to-child transmission of HIV. Most of these new infections are believed to stem from transmission in utero, during delivery or post-partum as a result of breastfeeding. Children account for 6 per cent of all HIV infections, 16 per cent of new infections and 14 per cent of all HIV-related mortality. Coverage will need to be greatly expanded if the Unite for Children, Unite against AIDS, goal of providing antiretroviral treatment, cotrimoxazole or both to 80 per cent of children in need by 2010 is to be met.

Children under one year are among those most vulnerable to HIV and AIDS and, since the onset of the disease, among the least served. Evidence demonstrates that early initiation of antiretroviral treatment in infants with HIV can save lives. Yet very few children under age one are currently receiving such treatment. Recent studies find that the median age at which children with HIV begin antiretroviral treatment is between five and nine years old. This has serious repercussions.

Because the virus progresses rapidly in children, treatment is vital to the survival of infected children; without treatment, one third of children living with HIV will die in their first year of life, rising to almost half of the infected children by age two. Many HIV-related deaths among children could be avoided through early diagnosis of HIV and timely provision of effective care and treatment. International guidance recommends that, if HIV infection is detected in infancy, immediate antiretroviral therapy is crucial; currently most children entering treatment programmes are older, however. In 2008, an estimated 280,000 (150,000–410,000) children died of largely preventable AIDS-related causes. The vast majority of these deaths were preventable, either through treating opportunistic infections with antibiotics or through antiretroviral treatment. More than 90 per cent of children infected with HIV live in sub-Saharan Africa, providing a clear example of the need for antiretroviral treatment in Africa.

Progress

As of December 2008, about 275,700 children younger than 15 years were receiving antiretroviral therapy in low- and middle-income countries, up from 198,000 in 2007, 127,300 in 2006 and 75,000 in 2005. These children represent an estimated 38 per cent of all children younger than 15 years estimated to need antiretroviral therapy worldwide. Overall, the number of children receiving antiretroviral therapy in low- and middle-income countries increased by 39 per cent between 2007 and 2008 and by more than 3.5-fold between 2005 and 2008.

Number of children receiving antiretroviral therapy in low-and middle-income countries, 2005—2008

Source: UNICEF, Joint United Nations Programme on HIV/AIDS (UNAIDS), World Health Organization (WHO) and United Nations Population Fund (UNFPA), Children and AIDS: Third stocktaking report, 2008, New York, 2008. UNICEF calculations based on data collected through prevention of mother-to-child transmssion (PMTCT) initiative and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2009 (WHO, UNAIDS, UNICEF), Geneva, 2009. Regions were recalculated according to UNICEF classification of regions.

Regional coverage of antiretroviral therapy for children varies from 6 per cent (4–11 per cent) in the Middle East and North Africa to 82 per cent (54 per cent to >95 per cent) in Europe and Central Asia. All regions saw notable progress in the number of children younger than 15 years receiving treatment in 2008 versus 2007, except for Latin America, where coverage was already as high as 82 per cent (70 per cent to >95 per cent).

Percentage of children under 15 years old receiving antiretroviral therapy, 2008

Note: The lines on the bars show the uncertainty bounds for the estimates.

Source: UNICEF, UNAIDS, WHO and UNFPA, Children and AIDS: Third stocktaking report, 2008, New York, 2008. UNICEF calculations based on data collected through the PMTCT and Paediatric HIV Care and Treatment Report Card process and reported in Towards Universal Access: Scaling up HIV services for women and children in the health sector – Progress Report 2009 (WHO, UNAIDS, UNICEF), Geneva 2009. Regions were recalculated according to UNICEF classification of regions.

New evidence highlights early HIV diagnosis and antiretroviral treatment as particularly critical for infants with HIV. It indicates that a significant number of lives can be saved by initiating antiretroviral treatment for HIV-positive infants immediately after diagnosis within the first 12 weeks of life. The Children with HIV Early Antiretroviral Therapy (CHER) study from South Africa demonstrates a 76 per cent reduction in mortality when treatment was initiated within this time period. The reality, however, is that in 2007, only 8 per cent of children born to HIV-positive women were tested before they were two months old.

Countries have made significant progress in expanding access to HIV-testing services at the point of care. In 2008, 83 of 123 reporting countries (67 per cent) reported that they provide HIV-testing services, on site, through the use of dried blood spots or by referral to laboratory services. This represents an increase of 46 per cent from 57 countries that reported in 2007. But globally, the uptake of HIV testing among children remains low. In 41 countries reporting data on the number of children accessing this intervention in 2008, only 15 per cent of children born to mothers living with HIV in 2008 were tested within the first two months of life.

WHO recommends that all infants younger than one year with confirmed HIV infection should start antiretroviral therapy, irrespective of clinical or immunological stage. Research and observational data suggest that providing antiretroviral therapy early in infancy avoids death and disease progression.

Countries across all geographical regions have expanded both facility and population-based coverage of antiretroviral therapy for children during the past three years. HIV treatment and care for children is increasingly integrated into existing antiretroviral therapy sites for adult care and into maternal, newborn and child health services. Altogether, 10,300 facilities were reported to be providing antiretroviral therapy to children in 2008 versus 5,660 facilities in 2007, an increase of 82 per cent. Factors contributing to the expanded uptake of antiretroviral therapy for children include sustained global advocacy, enhanced national commitment, increased availability of antiretroviral products and reduced prices of drug formulations for children.

Although substantial progress has been made towards achieving universal access to antiretroviral therapy for children by 2010, worldwide two thirds of children living with HIV who need antiretroviral therapy are still not receiving treatment. This results in high rates of mortality directly attributable to HIV among children under five. In addition, the number of infants and children newly placed on antiretroviral therapy is still not keeping pace with the number of infants newly infected as a result of failure to prevent new infections. Further, most countries have low PMTCT uptake, including limited follow-up testing of HIV-exposed infants, lack of access to early diagnosis and poor implementation of cotrimoxazole prophylaxis. Additional investment in material and programmatic support, including greater uptake of services for early infant diagnosis of HIV infection, is needed to further increase the initiation of antiretroviral therapy for children living with HIV. Countries also need to begin preparing more intensively for the increasing number of children who need to receive second-line antiretroviral regimens and the associated programmatic challenges.

References

WHO, UNAIDS and UNICEF, Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector – Progress Report 2009, Geneva, 2009.

UNAIDS and WHO, Aids Epidemic Update, Geneva, 2009.

UNAIDS, Report on the global AIDS epidemic, Geneva, 2008. 
 

UNICEF, Progress for Children: A World Fit for Children Statistical Review, No. 6, New York, 2007.

UNICEF, UNAIDS and WHO, Children and AIDS: Fourth Stocktaking Report, New York, 2009.

UNICEF, UNAIDS, WHO and UNFPA, Children and AIDS: Third Stocktaking Report, New York, 2008.

WHO, UNICEF and UNAIDS, Towards Universal Access: Scaling up HIV Treatment, Care and Prevention Interventions in the Health Sector, Geneva, 2008.