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
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.
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