New progress and guidance on HIV diagnosis and treatment for infants and children
Update on children with HIV
Global efforts to provide access to HIV treatment to children living with HIV have reached a new milestone, with 355 000 children receiving life-saving antiretroviral treatment at the end of 2009 compared to 276 000 at the end of 2008.
If tested and treated for HIV early, children born with HIV can survive and stay healthy. The most cost-effective way to tackle paediatric HIV globally is to both prevent young women from acquiring HIV and to use ARVs to reduce mother-tochild HIV transmission in HIV-positive pregnant women. However, every day, there are nearly 1 200 new HIV infections and more than 700 AIDS deaths among children.
HIV diagnosis and treatment in infants and children
2010 Guidelines: "HIV diagnosis and treatment in infants and children"
While there has been significant progress in the scale-up of HIV treatment in children, much remains to be done to sustain and improve prevention efforts and treatment services to reach all those in need.
WHO is now launching new guidance on paediatric HIV. The new guidelines seek to address the ongoing paediatric treatment gap by making a series of bold recommendations that are focused on expanding access to testing, increasing the number of infants and children eligible for treatment, and improving the care of children with HIV.
- It is strongly recommended that all
infants with unknown or uncertain HIV
exposure being seen in health-care
facilities at or around the time of birth
or at the first postnatal visit (usually 4 –
6 weeks), or other child health visit,
have their HIV exposure status ascertained.
[This will help to ensure that
infants whose mothers were not tested
during pregnancy or delivery can still
benefit from counselling and treatment
to prevent breast-milk transmission. In
addition, the identification of previously
unrecognized exposed infants will also
serve to identify women living with
HIV, which, in turn, allows programs to
provide treatment and care to women,
and prevent transmission of HIV during
- It is strongly recommended that all infants who are known to be exposed to HIV be tested at 4-6 weeks with virological assays to determine infection status. [This will promote the early identification of infected infants and enable those children to access lifesaving treatment.]
- It is strongly recommended to initiate
ART in all HIV-infected infants diagnosed
in the first year of life, irrespective
of the CD4 count or whether the
infant is sick. [This recommendation
has been in place since 2008 but has
not been adequately implemented.
The strength of the recommendation
has been increased in light of recent
findings that highlight the dramatic
improvements in mortality seen when
HIV- positive infants are initiated on
treatment immediately at diagnosis.]
- There is a conditional recommendation
to initiate children between 12 and
24 months on ART irrespective of
clinical and immunological stage.
[While there is lack of direct evidence
to support this strategy, paediatric
mortality is very high throughout the
first year of life as long as children
- For all children above 2 years there
are simplified criteria for treatment
eligibility. [Previous recommendations
were often too complicated for providers
in primary and secondary healthcare
settings who lacked access to
more sophisticated diagnostic capabilities.
The simplified criteria offer a
single threshold for CD4 eligibility and
more straightforward clinical criteria to
determine which children require treatment.]
- It is strongly recommended that all
HIV-positive children diagnosed with
TB start ART as soon as possible after
initiation of TB therapy. [New clinical
evidence shows that when TB and
HIV occur together, survival is greatly
improved when treatment for both diseases
is administered concurrently
rather than sequentially.]
- It is strongly recommended that HIVpositive
infants and young children
who were exposed to nevirapine or
efavirenz during pregnancy, delivery
or breastfeeding start on treatment
using a protease-inhibitor. [Although
protease inhibitor drugs are usually
reserved for second-line treatment
because of cost and availability, new
evidence shows that in infants and
young children who become infected
despite the use of ARVs for prevention
of mother-to-child transmission, treatment
outcomes are much improved
when the regimen contains proteaseinhibitor
- Stavudine is no longer among the recommended
ARVs except when there
are no other options. [Increasing evidence
of the toxicity of stavudine has
resulted in a global shift away from the
use of stavudine as a primary option
for treatment. Stavudine toxicity is not
seen as often in children but as the
range of options for paediatric treatment
have improved it is preferable
not to use this drug as a first-line
choice. Almost all ARVs have some
toxicity, but avoiding drugs which are
known to cause irreversible toxicities
such as stavudine is an important step
to improving the quality of treatment.]
- Further simplification of second-line regimens with a shift away from didanosine as a second-line drug. [As increasing numbers of children initiate second-line treatment it is important to make second-line therapy as convenient and simple as first-line. The move away from didanosine (ddI) as a second- line drug for children allows second- line regimens to be delivered using simple, easy- to-use fixed-dose combination tablets.]
TB and HIV management in children
- It is strongly recommended that isoniazid preventive therapy (IPT) be given to all HIV-positive children over 1 year of age without active TB disease as an element of comprehensive HIV care. [IPT has not previously been recommended as a routine intervention for HIV-positive children in whom there is no known exposure to TB. This recommendation is based on new data showing that IPT is highly effective as a means of preventing TB in children living with HIV.]
Benefits and challenges
Early treatment will reduce HIVassociated mortality in children and in some high-burden settings will also significantly reduce overall infant and under-five mortality.
Adoption of recommendations to screen infants for HIV exposure are adopted will result in more infants being identified as exposed while helping to identify other infected individuals.
All exposed infants are born to infected mothers, and many of those women will have HIVpositive partners and/or other HIV-positive children. The infant is an index case that helps to identify a family living with HIV; this could be a critical route to expanding the reach of testing.
Use of simpler first- and second-line regimens will enable countries to facilitate scale-up and lower costs by using paediatric FDCs.
Paediatric HIV treatment programmes are weak and often not seen as a priority, even in highburden settings, unlike treatment of adults, including pregnant women.
Systems to perform early infant diagnosis are still nascent and require sending testing samples to a few large laboratories for diagnosis. Point-of-care virologic tests are necessary to scale up access to early infant diagnosis especially in rural communities.
There is a degree of reluctance among health care providers to test and treat children, especially young children or healthy-looking children, due to a lack of understanding of the lifesaving benefits of early treatment for children.