Provide paediatric treatment

The challenge

WHO, UNICEF and UNAIDS,Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, Geneva, 2008.

An estimated 2 million [1.9–2.3 million] children under 15 were living with HIV in 2007, while 370,000 children [330,000–410,000] were newly infected, mainly through mother-to-child transmission (MTCT) of HIV. More than 90 per cent of children were infected through MTCT. Children account for 6 per cent of all HIV infections, 17 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 old are among those most vulnerable to HIV and AIDS and traditionally 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 infected children’s survival; without treatment, one third of children living with HIV will die in their first year of life and almost half by age two. In 2007, an estimated 270,000 [250,000–290,000] 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 (ART).  Nearly 90 per cent of children infected with HIV live in sub-Saharan Africa, illustrating the need for antiretroviral treatment in Africa.

Progress

Significant advances have been made in scaling-up paediatric ART in the past few years, facilitated by several factors. These include integrating HIV care and treatment for children into both existing antiretroviral therapy sites focused on adult care and into maternal, newborn and child health services; reducing the prices of antiretroviral formulations for children; approving and prequalifying fixed-dose antiretroviral combinations for children by the United States Food and Drug Administration and the WHO Prequalification Programme; and increasing advocacy for improved access to HIV care and treatment for children.

As of December 2007, about 198,000 children under age 15 globally were receiving antiretroviral therapy, up from 127,300 in 2006 and 75,000 in 2005. This represents a 1.7-fold increase between 2006 and 2007 and a 2.6-fold increase between 2005 and 2007.  The increase is occurring in every region of the world, with the most significant gains in sub-Saharan Africa.  It is nonetheless evident that those children currently on treatment still represent only a small proportion of those who need it.

Number of children receiving antiretroviral therapy in low-and middle-income countries, 2005-2007

Source: UNICEF, UNAIDS, WHO and UNFPA, Children and AIDS: Third Stocktaking Report, 2008

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. However, the reality is that in 2007, only 8 per cent of children born to HIV-positive women were tested before they were two months old.

WHO recommends that all infants younger than one year of age 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. A total of 5,660 facilities were reported to be providing antiretroviral therapy to children in 2007, more than twice the 2,400 facilities in 2005. The number of facilities providing antiretroviral therapy to children in eastern and southern Africa has increased notably. Increased early infant diagnosis and case-finding and simplified care management for children have contributed to the expansion in the number of sites providing antiretroviral therapy to children.

Scaling up the use of dried blood spots has resulted in a significant increase in access to virological testing for children born to HIV infected mothers. The number of countries using dried blood spots for virological testing increased from 17 in 2005 to 30 in 2007. The use of dried blood spots enables blood samples to be collected in remote locations and allows countries with a limited number of specialized laboratories to expand access to virological testing.

The vast majority of children living with HIV are in 10 countries that also comprise more than 60 per cent of pregnant women living with HIV. Uptake of antiretroviral therapy in children increased in all 10 countries between 2005 and 2007. The number of children receiving antiretroviral therapy increased 2.6 times in South Africa, 3 times in Kenya, nearly 4 times in Mozambique and nearly 5 times in Zimbabwe.

Number of children (younger than 15 years) receiving antiretroviral therapy in the 10 countries with the highest estimated number of pregnant women living with HIV, 2005–2007

Source: UNAIDS, UNICEF and WHO, ‘Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector,’ Geneva, 2007.

Challenges, however, still exist toward reaching universal access to antiretroviral therapy for children in many countries by 2010. While tremendous progress has been made, most children living with HIV who need antiretroviral therapy globally are still not receiving treatment, resulting in high rates of mortality among children younger than five years of age directly attributable to HIV. 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. The inability of many health-care systems to track children’s HIV status even when mothers are known to be infected with HIV results in many missed opportunities. Because treatment for children is often provided in a clinic other than the one in which the mother received antenatal care or delivered her infant, children exposed to HIV often go unrecognized when they visit immunization clinics and other care-delivery points. Efforts must continue to expand early infant diagnosis and the provision of treatment and care for children.

References

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

Expanded Inter-Agency Task Team (IATT) on Prevention of HIV Infection in Pregnant Women, Mothers and their Children, A Report Card on Prevention of Mother-to-Child Transmission of HIV and Paediatric HIV Care and Treatment in Low- and Middle-Income Countries: Scaling up Progress from 2004—2005, 2007.

UNAIDS and WHO, Aids Epidemic Update, Geneva, 2007.

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

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

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

UNICEF, UNAIDS and WHO, Children and AIDS: A Stocktaking Report, New York, 2006.

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