7.1.4 When to start ART in children

Consolidated ARV guidelines, June 2013


Infants and young children have an exceptionally high risk of poor outcomes from HIV infection. Up to 52% of children die before the age of two years in the absence of any intervention (106). By five years of age, the risk of mortality and disease progression in the absence of treatment falls to rates similar to those of young adults (107,108).

The scaling up of early infant diagnosis programmes has increased the identification of infants infected with HIV, but initiating ART early for those who have been found to be infected remains poor. Most HIV-infected children who are eligible for ART are still not being treated, and ART coverage among children lags significantly behind that among adults (28% versus 57% globally in 2011) (11).

Diagnosing and retaining children exposed to HIV and children infected with HIV in care also presents unique challenges because of their dependence on a caregiver. Loss to follow-up has been particularly high along the continuum of care (109) , with retention especially challenging for children who are in HIV care but not yet eligible for ART.

Some countries are already introducing immediate ART for children younger than five years based on operational and programmatic grounds (110,111).

The 2010 WHO guidelines aligned clinical and immunological criteria for ART eligibility for children older than five years with those for adults (that is, treat for WHO clinical stage 3 or 4 disease or CD4 ≤350 cells/mm3) (105). They also recommended treating all children infected with HIV younger than two years of age regardless of clinical or immunological status. For children between two and five years of age, it was recommended that those with WHO stage 3 or 4, clinical disease or CD4 <25% or ≤750 cells/mm3 be treated (105).

The review of evidence in 2013, together with operational considerations and values and preferences expressed by care providers, has led to revised recommendations to simplify and expand treatment in children, including initiating ART in all children up to five years and to increase the CD4 count threshold for ART initiation to ≤500 cells/mm3 in children 5 years and older, aligning with the new threshold in adults.