Box 10.6 : Key implementation considerations for programme managers: scaling up treatment for children – treating all children under 5 years and raising the CD4 threshold in older children from 350 to 500 cells/mm3

Consolidated ARV guidelines, June 2013

Expanding ART coverage should be the first priority. Since all treatment regimen options have been shown to reduce morbidity and mortality, the use of less preferred options is better than leaving children untreated.

Younger children are at greater risk of poor outcomes. Children younger than two years living with HIV have higher mortality rates and more rapid disease progression than older children. Early diagnosis and prompt initiation of ART are especially critical for infants and young children.

Strengthen links between diagnosis and treatment. Diagnosis and treatment for children are often performed at different facilities, increasing the risk of their being lost to follow-up. Improving links between early infant diagnosis and ART sites is essential to minimize such losses and improve uptake of ART among children. Family-based approaches to HIV testing and provider-initiated testing and counselling are important approaches to increase HIV diagnosis and treatment among children.

Optimize and improve the choice of ARV formulations available. It is critical to accelerate regulatory approval of preferred formulations. Scored dispersible fixed-dose combinations for children with dosage based on weight bands can support the scaling up of ART for children in remote areas.

Leverage existing infrastructure and channels. Making ART available for children wherever adult ART and PMTCT interventions are provided is key to improving access and uptake, especially as service delivery is decentralized to lower-level health facilities.

Promote retention and adherence. Children depend on adults for their treatment. It is important to design and implement family-based care strategies that can support and facilitate retention and adherence among children. Interventions must also take into account the special adherence challenges of children who move between households.