Antiretroviral therapy of HIV infection in infants and children: towards universal access

Recommendations for a public health approach

The most efficient and cost-effective way to tackle paediatric HIV globally is to reduce mother-to-child transmission (MTCT). However, every day there are nearly 1500 new infections in children under 15 years of age, more than 90% of them occurring in the developing world and most being associated with MTCT (1). HIV-infected infants frequently present with clinical symptoms in the first year of life, and by one year of age an estimated one-third of infected infants will have died, and about half by 2 years of age (2, 3). There is thus a critical need to provide antiretroviral therapy (ART) for infants and children who become infected despite the efforts being made to prevent such infections.

In countries where it has been successfully introduced, ART has substantially changed the face of HIV infection. HIV-infected infants and children now survive to adolescence and adulthood. The challenges of providing HIV care have therefore evolved to become those of chronic as well as acute care. In resource-limited settings, many of which are countries hardest hit by the epidemic, unprecedented efforts made since the introduction of the ‘3 by 5’ targets and global commitments to rapidly scale up access to ART have led to remarkable progress. However, this urgency and intensity of effort have met with less success in extending the provision of ART to HIV-infected children. Significant obstacles to scaling up paediatric care remain, including limited screening for HIV, a lack of affordable simple diagnostic testing technologies, a lack of human capacity, insufficient advocacy and understanding that ART is efficacious in children, limited experience with simplified standardized treatment guidelines, and a lack of affordable practicable paediatric antiretroviral (ARV) formulations. Consequently, far too few children have been started on ART in resource-limited settings. Moreover, the need to treat an increasing number of HIV-infected children highlights the primary importance of preventing the transmission of the virus from mother to child in the first place.

WHO guidelines for the use of ART in children were considered within the guidelines for adults published in 2004 (4). Revised, stand-alone comprehensive guidelines based on a public health approach have been developed in order to support and facilitate the management and scale-up of ART in infants and children.

The present guidelines are part of WHO’s commitment to achieve universal access to ART by 2010. Related publications include the revised treatment guidelines for adults (i.e. the 2006 revision), revised guidelines on ARV drugs for treating pregnant women and preventing HIV infection in infants, guidelines on the use of co-trimoxazole preventive therapy (CPT),(i) and revised WHO clinical staging for adults and children (5). (i) These three documents are currently in preparation and are expected to be published by WHO in 2006.