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Last update: Sep 2012

Provide paediatric treatment

The challenge

An estimated 3.4 million (3.0–3.8 million) children under 15 were living with the human immunodeficiency virus (HIV) in 2010, while 390,000 (340,000–450,000) 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 10 per cent of all HIV infections, 14 per cent of new infections and 14 per cent of all HIV-related  deaths. Coverage will need to be greatly expanded if the Unite for Children, Unite against AIDS, goal of providing universal access to antiretroviral treatment (ART), cotrimoxazole prophylaxis or both to all children in need by 2015.

 

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.
 
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 2010, an estimated 250,000 (220,000–290,000) 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. 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 2010, about 456,000 children younger than 15 years were receiving antiretroviral therapy in low- and middle-income countries, a 29 per cent rise from a year earlier (354,600 in 2009) and  a sixfold increase since 2005 (75,000). These children represent an estimated 23 per cent (20–25 per cent) of all children younger than 15 years estimated to need antiretroviral therapy in low- and middle-income countries, up from 21 per cent (19–24 per cent) in 2009 and 6 per cent (5–7 per cent) in 2005, using the new treatment criteria retrospectively.


Number of children receiving antiretroviral therapy in low- and middle-income countries, 2005–2010

                 

Note: Regional totals do not add up to the total for low- and middle-income countries because of rounding.
Source: UNICEF calculations based on data collected through the Health Sector Response to HIV/AIDS reporting process and reported in Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011. Regions were recalculated according to UNICEF classification of regions.

 

In 2010, regional coverage of children (aged 0–14 years) receiving antiretroviral therapy varied, ranging from 5 per cent (3–7 per cent) in the Middle East and North Africa to 64 per cent (54–70 per cent) in Central and Eastern Europe and the Commonwealth of Independent States (CEE/CIS). In sub-Saharan Africa, 21 per cent (19–24 per cent) of children received ART.  However, coverage differed between Eastern and Southern Africa and West and Central Africa, at 26 per cent (23–29 per cent) and 9 per cent (8–11 per cent), respectively.

 

Percentage of children under 15 years old receiving antiretroviral therapy, 2010

   

 

Note: The lines on the bars show the uncertainty bounds for the estimates.
Source: UNICEF calculations based on data reported in Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011. Regions were recalculated according to UNICEF classification of regions.

 

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. 
 
Countries have made significant progress in expanding access to HIV-testing services at the point of care. But globally, the uptake of HIV testing among children remains low. In 65 countries reporting data on the number of children accessing this intervention in 2010, 28 per cent (24-30 per cent) of children born to mothers living with HIV were tested within the first two months of life, versus 6 per cent (5-7 per cent) in 2009. WHO’s revised treatment guidelines recommend that infants, if HIV-exposed, should be tested by four to six weeks of age using virological assays and those found positive should be started on antiretroviral therapy immediately upon diagnosis.

 

MDG Indicator
Percentage of children 0–14 years old with advanced HIV infection receiving antiretroviral therapy

Although progress is being made in expanding children’s access to antiretroviral therapy, less than one quarter of children in need received it in 2010.  With the new treatment guidelines, it is estimated that more children will be placed on therapy, and additional financial resources will be needed to cover the associated costs, and the requisite drug regimens will be more complex to implement.  It is also essential that countries devise and reinforce advocacy plans and policies to ensure that stock outs do not occur.  Moreover, scaling up services will require large-scale planning, coordination, training of health-care workers and provision of information/education materials.  Adequate planning and management at all levels are also critical to ensure that these changes are appropriately incorporated into national policy and practice

 

Improving need and coverage estimates of antiretroviral therapy among children

In December 2009, the UNAIDS Reference Group on HIV Estimates, Modelling and Projections convened a meeting to update and review the assumptions used in estimating the number of children living with HIV and the number of children in need of antiretroviral therapy. Upon a review of the literature and available evidence, key changes were made to the assumptions used to estimate paediatric needs.  These changes included more accurate survival curves, improvements in determining mother-to-child transmission rates, improvements in determining progression from infection to treatment need and revised WHO treatment guidelines for infants and children on the eligibility criteria for antiretroviral therapy initiation in children. The change in age-specific eligibility criteria, from younger than 12 months of age to younger than 24 months of age, took effect in 2010.

 

The new set of estimates, based on improved data on the distribution of regimens and of infant feeding practices, combined with the above changes in methods has resulted in a larger number of children newly infected than in previous estimates despite increases in reported coverage of interventions for preventing mother-to-child transmission. Past reported estimates probably under-reported the number of children newly infected. This, combined with longer survival of children who acquire HIV infection through breastfeeding, has resulted in increases in the number of children newly infected with HIV, more children living with HIV and therefore more children who need antiretroviral therapy. The estimated number of children who needed antiretroviral therapy in 2009 has been revised based on these new assumptions and has increased from 1,270,000 to 1,670,000. For 2010, the number of children who need antiretroviral therapy is an estimated 2,020,000. The large difference between 2009 and 2010 is explained by the change in age-specific eligibility criterion. These increases in the estimates of the number of children who need antiretroviral therapy are affecting the estimated coverage of antiretroviral therapy among children. As a result of these changes, comparisons between 2010 estimates and those from previous years cannot be made. The methodological revisions, however, have been applied retrospectively to all earlier HIV prevalence data, so that the estimates of incidence, prevalence and mortality from previous years allow an assessment of trends over time. 

 

References

UNAIDS, Global Report: UNAIDS report on the global AIDS epidemic, 2010, UNAIDS, Geneva, 2010. 

 

UNICEF, Progress for Children: Achieving the MDGs with Equity, No. 9, UNICEF, New York, 2010.

 

UNICEF, UNAIDS, WHO, UNFPA and UNESCO, Children and AIDS: Fifth stocktaking report, UNICEF, New York, 2010.

 

WHO, UNAIDS and UNICEF, Global HIV/AIDS Response: Epidemic update and health sector progress towards universal access, Progress Report 2011, WHO, Geneva, 2011.