7.1.4 When to start ART in children
Consolidated ARV guidelines, June 2013
Rationale and supporting evidence (part 2)
Community values and preferences
Expanding ART to every child younger than five years of age is expected to be well accepted. Assessment of the values and preferences of people living with HIV, caregivers and health care providers of children with HIV showed that earlier initiation is preferable because it is believed to facilitate family-based care, prevent loss to follow-up and improve adherence (116). Nevertheless, there is a risk of resistance if treatment is initiated early in young children and adherence is poor or drug supplies are suboptimal; this is particularly the case for the youngest children, among whom harmonizing the formulations for children and adults is most difficult. However, the benefits of treatment are likely to outweigh these risks.
Where access to immunological testing is limited, the burden of paediatric HIV disease is high and paediatric ART coverage is low, simplifying the eligibility criteria for initiating ART may significantly improve the overall health outcomes for children with HIV (117). National programmes need to determine how best to implement this recommendation and whether to recommend universal treatment for all children younger than five years or to focus on universal treatment for infants younger than one year and apply clinical and immunological criteria for children one to five years old. When ART initiation is expanded regardless of clinical and immunological status beyond infancy to all children younger than five years, treatment of children younger than two years should be given priority because of their higher risk of death and rapid disease progression. In addition, expanding ART services will require ensuring retention in care and should be matched with concomitant expansion of interventions to support adherence.
Evidence for increasing the CD4 threshold to 500 cells/mm3
The criteria for initiating ART in children five years of age and older are the same as for adults. Although there are limited data to assess the clinical impact of treating children with a CD4 count between 350 and 500 cells/mm3 and the benefits of ARV drugs in preventing sexual transmission are not a factor for this population, this approach has programmatic advantages resulting from harmonizing the criteria with those for adults. It may be most feasible in settings with high ART coverage. As in the case of adults, treating children with CD4 counts ≤350 cells/ mm3 should be a high priority since they have the highest risk of disease progression.
Coinfection with HIV and HBV
Small cohort studies in which both HIV and HBV are endemic report rates of chronic HBV among children with HIV between 1% and 49% (118). HBV is often acquired in infancy or early childhood and, unlike among adults, may have an immunotolerant phase that lasts throughout childhood and adolescence. Unfortunately, the natural history of the disease among children with HIV is still poorly known, and the benefits from initiating ART earlier in these children remain to be assessed.
Clinical considerations for scaling up ART among children
Section 10.6 discusses implementation considerations relevant to programme managers (see Box 10.6). An additional important implementation consideration for clinicians and other health care providers is that expanding the initiation of ART regardless of clinical and immunological status to children younger than five years eliminates the need for determining the CD4 count to initiate treatment in this age group and avoids delaying ART in settings without access to CD4 testing. However, the availability of CD4 testing, including determining the baseline CD4 count and percentage, remains important to ensure appropriate treatment monitoring in the absence of viral load monitoring.