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Children, HIV and AIDS
HIV among children
Despite this, more than 240,000 children were infected with HIV during 2013 - 700 new infections every day. 2 In addition, millions more children every year are indirectly affected by the impact of the HIV epidemic on their families and communities.
Regular HIV testing, treatment, monitoring and care for children living with HIV can enable them to live long and fulfilling lives. However, a lack of necessary investment and resources for adequate testing, paediatric antiretroviral drugs (ARVs), and prevention programmes mean children continue to suffer the consequences of the epidemic.
The number of children living with HIV
The figures below show the number of children (defined by UNAIDS as under-15 years of age) directly affected by HIV and AIDS:
- 3.2 million children living with HIV around the world at the end of 2013.
- 240,000 children became newly infected with HIV in 2013.
- 58 percent drop in new infections since 2002, and a 43 percent drop since 2009.
- 91 percent of children living with HIV live in sub-Saharan Africa.
- 24 percent of children needing antiretroviral treatment received it in 2013.
- 190,000 children died of AIDS-related illnesses during 2013, out of 1.5 million people overall. 3
How do children become infected with HIV?
Mother-to-child transmission (MTCT)
The majority of children living with HIV were infected via mother-to-child transmission, during pregnancy, labour, delivery or breastfeeding. However, preventing mother-to-child transmission (PMTCT) is one of the greatest HIV medical success stories. Administrating antiretroviral drugs (ARVs) to mother and child keeps the mother healthy and prevents the risk of HIV passing to the child.
It is vital that children who were infected via mother-to-child transmission receive treatment to keep them healthy. If they are not on antiretroviral treatment (ART), a third of children who are living with HIV will not reach their 1st birthday, and half will not reach their 2nd birthday. 4 This shows that with funding, trained staff and resources, new infections among many thousands of children could be avoided.
There has been a global decrease in the number of young people who report having sex under the age of 15. 5 However, girls under the age of 15 can still marry with their parents consent in 52 countries around the world. 6 This and other cultural norms lead to children becoming sexually active at a young age, or being subjected to sexual violence.
The lower the age of first sex, the higher the lifetime risk of HIV infection. This is because early sexual debut is often associated with older partners, higher rates of coerced sex and lower levels of condom use. 7
Children who inject drugs
Global and national figures for the number of children under 15 who inject drugs are limited. This is despite studies reporting that some begin to inject drugs as young as age 10. 8 Children who inject drugs are more likely to share needles and not access harm reduction services, as a result of restrictions due to their age. This makes them more vulnerable to HIV infection.
Children who inject drugs are more likely to be living on the street, orphaned, and out of school. Orphaned and vulnerable children are often marginalised in society, making it difficult to reach them with healthcare and HIV services. 9
Although very rare today, HIV infection can occur in medical settings. For instance, through needles that have not been sterilised or through blood transfusions where infected blood is used. Between 1987 to 1991, more than 10,000 babies and children were infected with HIV as a result of unsafe medical practices that used contaminated injections and unscreened blood transfusions in Romania. 10
More recently, it was reported during 2012 that over the past decade in Kyrgyzstan, 270 children have been infected with HIV in hospitals as a result of doctors not following universal precautions during medical procedures. 11
HIV prevention for children
Prevention of mother-to-child transmission (PMTCT)
The 2013 World Health Organisation (WHO) guidelines to prevent mother-to-child transmission ( PMTCT) of HIV state that countries must decide whether to offer women ART for life regardless of their CD4 count after finishing breastfeeding, or to offer ART after breastfeeding if their CD4 count drops below 500 cells/mm ³. 12
These universal guidelines will make the application of treatment programmes for pregnant women and mothers simpler and more robust. This will have a dramatic effect upon preventing mother-to-child transmission of HIV both for a woman's current pregnancy and for future pregnancies. 13
Despite this medical knowledge, pregnant women's access to HIV testing and ARVs is lagging behind. During 2013, around 54 percent of pregnant women did not receive an HIV test, and were therefore unaware of their HIV status. Of those who did receive a test and were diagnosed positive, 7 out of 10 received the treatment needed to prevent mother-to-child transmission of HIV (PMTCT). This helped avert 900,000 new HIV infections in children between 2009 and 2013. 14
Only 49 percent of women continue to take antiretroviral drugs during the breastfeeding stage, compared to 62 percent of women during pregnancy and delivery, highlighting the urgent need for education about the importance of continuing treatment. Breastfeeding is responsible for half of all HIV transmissions from mother-to-child. 15
Children and adolescents are sharing an increasing burden of the global HIV epidemic, which could be tackled by ensuring children's rights within society are granted. This includes the right to education, contraception, involvement in HIV programmes, safety from violence, gender equality and a lack of stigma. 16
Schooling and HIV education
All children living with HIV have the right to attend school, just as any other child does. Policies need to be in place to ensure a child living with HIV at school is not subjected to stigma and discrimination or bullying, and that their status is kept confidential. 17
The inclusion of sex and HIV & AIDS education for young pupils is vital to tackling the stigma surrounding HIV, and to teach others the facts about HIV transmission. 18 HIV-awareness programmes are important to encourage openness about HIV rather than silencing it. 19
There are many ways to reach young people: including through social groups, the media, and peer outreach - not just school.
Preventing child marriages
Globally, around 11 percent of young girls are forced into marriage before the age of 15. This puts young girls at risk of HIV as they may be unable to negotiate condom use, or prevent sexual violence. Early motherhood also risks a young girl who may not know her HIV status passing HIV on to her baby. 20 HIV prevention programmes need to reach young girls who are forced to marry early.
HIV testing for children
The World Health Organisation (WHO) treatment guidelines of 2013 state that infants born to women living with HIV should be tested for HIV within two months, using a virological test. 21 However only 42 percent of infants in this situation were tested during 2013. 22
Issues with testing
Investment into point-of-care technology needs expanding, to enable infants to be diagnosed at the clinic they attend, enabling them to start treatment as soon as possible. 24 Starting treatment early has shown to have greater long-term benefits than delaying treatment. 25
In many rural, inaccessible areas, HIV testing is simply unavailable. Healthcare professionals must use clinical diagnosis instead, using the child’s symptoms to ascertain that they are HIV-positive. Unfortunately this results in a lot of infections going undetected. 26
HIV treatment and care for children
Antiretroviral treatment guidelines for children
The World Health Organisation (WHO) treatment guidelines of 2013 state that all children below the age of 5 who are diagnosed with HIV should begin antiretroviral treatment immediately, regardless of CD4 count. The likelihood of death for a child living with HIV is declined by 75 percent, if the child is given antiretroviral treatment within its first 12 weeks of life. 27 Yet, 76 percent of the children who could be benefiting from this therapy in low and middle-income countries are not receiving it. 28
Children ideally need to be given drugs in the form of syrups or powders, due to the difficulty of swallowing a tablet. However, they are more expensive. As a result, carers often break adult tablets into smaller doses, running the risk that children are given too little or too much of the drug. 29
Adhering to treatment
Children have to take antiretroviral treatment (ART) on average 20 years longer than adults do, heightening adherence issues. As more children are growing older with HIV, the vastly inadequate services for older children are coming to light. This includes the complexity of adhering to treatment whilst going through puberty when children want freedom not strict medical regimes, confusion around ARV regimes as they grow out of child treatments and into adult ones, and a lack of targeted services for age groups that do not fall strictly into ‘children’ or ‘adults’. 30
Globally, around 80 percent of children are retained on treatment at 12 months - almost equal to the rate among adults. 31
Loss to follow up
However, many children simply stop turning up for healthcare check-ups to receive treatment. A study involving 13,611 children from low-income countries in Asia and Africa found that at 18 months after initiation of ART, 5.7 percent had died, 12.3 percent were lost to follow up, and 8.6 percent had transferred to other clinics. Loss to follow up was much greater in West Africa (21.8 percent) compared to Asia (4.1 percent). 32
Children are more vulnerable to being lost to follow up than adults because they rely on their parents or caregivers to gain access to healthcare services. 33 Some of the reasons children are lost to follow up include "lack of caregiver contact information, stigma and counselling challenges, the burden on patients to return for results, and weak follow-up within clinics." 34
Challenges of treatment for children living with HIV
- Treatment costs
Although the cost of first line therapy for children has reduced dramatically due to the availability of generic drugs, if a child develops drug resistance and needs to begin a second course of drugs, treatment becomes far more expensive. WHO qualifies new antiretroviral drugs suitable for children regularly, but without access to cheap generic versions of them the majority of children living with HIV will not benefit. 35 The incentive for pharmaceuticals to develop paediatric drugs is also diminishing as the number of infants born HIV-positive is declining so rapidly, disallowing the price of drugs to fall. 36
Many caregivers delay disclosing a child their status, because they are anxious about the child's well-being, are concerned about being blamed, and are worried about stigma from the community. It is important for a healthcare worker or carer to disclosure a child's status to them, to prevent the child feeling isolated and finding out their status accidentally, or in public. It is thought that disclosure gives the child greater mental stability and health. 37
- Psychosocial well-being
Many children living with HIV experience tough life events that could impact their psychosocial well-being, such as losing caregivers to AIDS-related illness, stigma, shock about their status and not understanding the importance of adhering to treatment. To mitigate these events, it is important to encourage children to have a positive outlook on life, which can be helped by making full use of services such as support groups. 38
- Childhood illnesses
Childhood illnesses, such as mumps and chickenpox can affect all children, but since children living with HIV have weakened immune systems they may find that these illnesses are more frequent, last longer, and do not respond as well to treatment. An estimated 74,000 children died from tuberculosis (TB) in 2012. However, this number is thought to be much higher as many countries only report HIV as the underlying cause of death, with tuberculosis as the contributory cause. 39
Read more about treatment for children living with HIV.
Family support for children living with HIV
Kinship structures are already strong in many African countries where children are most affected by HIV. As a result, families often provide a more long-term, stable form of care for a child who is living with HIV, or has been orphaned by AIDS, than an institution or care-programme. 40 It has been emphasised that taking children away from their families should be a last resort, as families are more likely to be a source of emotional support. 41
Supporting a family holistically can be the best way to ensure a good quality of life for the child. This should include social protection schemes that provide external assistance to poorer families in areas where HIV prevalence is high. Such schemes are now seen as a valuable part of improving the lives of children affected by HIV. 42
Financial support for children living with HIV
Reduced household income combined with increased expenses (for example for treatment, transport, funerals) can push families into poverty, which has negative outcomes for children in terms of nutrition, health status, education and emotional support. By reducing a household’s economic vulnerability, children benefit from better nutrition, the opportunity to go to school instead of work and better access to healthcare. 43
A successful social protection measure is the cash or income transfer. These are ‘cash disbursements to individuals or households identified as highly vulnerable’. The number of these programmes has doubled in Africa between 2000 and 2012, supporting US$10 billion worth of transfers during this period. 44
To ensure that children are the focus of these transfers, some have conditions, such as one programme in Ghana which requires households to ‘keep children in school, register with the National Insurance Scheme, and bring children to health facilities for regular check-ups’. 45
The future of the HIV epidemic among children
Children are disproportionately affected by the HIV epidemic, and continue to be left behind in the provision of life saving antiretroviral treatment. Considering the success rates of providing a pregnant woman with ARVs to prevent mother-to-child transmission of HIV, it is unfortunate that all pregnant women living with HIV are not benefitting from these drugs.
Moreover, testing and treatment opportunities for children need to be scaled up to bring them in line with the adult population. Alongside this, there needs to be greater access to the drugs that can prevent mother-to-child transmission, appropriate testing, efficient linkages to care and treatment, and support for the families and communities that provide the material, social, and emotional foundation for a child’s development.
- 1. UNAIDS (2014, July) ' The Gap Report'
- 2. UNAIDS (2014, July) ' The Gap Report: Epi Slides'
- 3. UNAIDS (2014, July) ' The Gap Report'
- 4. UNAIDS (2014, July) ' The Gap Report'
- 5. UNAIDS (2013) ' Global Report: UNAIDS Report on the Global AIDS Epidemic 2013'
- 6. UNAIDS (2014, July) ' The Gap Report'
- 7. Pettifor, Audrey et. al, (2009) ' Early Coital Debut and Associated HIV Risk Factors Among Young Women and Men in South Africa' International Perspectives on Sexual and Reproductive Health 35(2):74-82
- 8. Harm Reduction International (2012, September) ' Injecting Drug Use Among Children and the Child’s Right to Health'
- 9. Harm Reduction International (2013, December) 'Injecting Drug Use Among Under-18s: A Snapshot of Available Data'
- 10. Human Rights Watch (2006, August) ' Life Doesn't Wait - Romania's Failure to Protect and Support Children and Youth Living with HIV'
- 11. The Telegraph (2012, February) ' Kyrgyzstan officials say another 70 children are infected with HIV/AIDS virus'
- 12. WHO (2013, June) ' Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach'
- 13. WHO (2013, June) ' Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach'
- 14. UNAIDS (2014, July) ' The Gap Report'
- 15. UNAIDS (2013) ' Global Report: UNAIDS Report on the Global AIDS Epidemic 2013'
- 16. UNDP (2012) ' Global Commission on HIV and the Law Risks, Rights & Health'
- 17. Children and Young People HIV Network & National Children's Bureau (2005) ' HIV in Schools'
- 18. Children and Young People HIV Network & National Children's Bureau (2005) ' HIV in Schools'
- 19. Anouk Amzel et al (2013) ' Promoting a Combination Approach to Paediatric HIV Psychosocial Support,' AIDS Journal, Vol 27, S2
- 20. UNICEF (2012, September) ' Committing to Child Survival: A Promise Renewed'
- 21. WHO (2013, June) ' Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach'
- 22. UNAIDS (2014, July) ' The Gap Report'
- 23. UNAIDS (2014, July) ' The Gap Report'
- 24. Aidsmap (2012, July) ' UNITAID commits US$140 million to bring HIV diagnostic technologies to the ‘point of care’'
- 25. Prof Mark F Cotton et al (2013, August) ' Early time-limited antiretroviral therapy versus deferred therapy in South African infants infected with HIV: results from the children with HIV early antiretroviral (CHER) randomised trial', The Lancet online
- 26. Aidsmap (2012, 13th September) ‘ Symptom screen frequently misses HIV in children and delays treatment, Kenyan study shows'
- 27. UNAIDS (2014, July) ' The Gap Report'
- 28. UNAIDS (2014, July) ' The Gap Report'
- 29. O'Brien DP et. al, (2006) ' In resource-limited settings good early outcomes can be achieved in children using adult fixed-dose combination antiretroviral therapy' AIDS 20(15): 1955-60
- 30. Sarah Bernays et al (2014, February) ' Children growing up with HIV infection: the responsibility of success', The Lancet
- 31. aidsmap (2012) ' HIV treatment for children: how programmes are improving diagnosis and retention'
- 32. Valeriane Leroy et al (2013) ' Outcomes of Antiretroviral Therapy in Children in Asia and Africa: A Comparative Analysis of the IeDEA Pediatric Multiregional Collaboration', JAIDS Journal
- 33. Sarah Bernays et al (2014, February) ' Children growing up with HIV infection: the responsibility of success', The Lancet
- 34. UNICEF/UNAIDS (2009) ' Children and AIDS Fourth Stocktaking Report'
- 35. UNICEF/UNAIDS (2009) ' Children and AIDS Fourth Stocktaking Report'
- 36. UNITAID (2013) ' Annual Report 2013: Transforming Markets, Saving Lives'
- 37. Anouk Amzel et al (2013, November) ' Promoting a Combination Approach to Paediatric HIV Psychosocial Support', AIDS Journal, Vol 27, S2
- 38. Anouk Amzel et al (2013, November) ' Promoting a Combination Approach to Paediatric HIV Psychosocial Support', AIDS Journal, Vol 27, S2
- 39. Graham, S.M. et al (2014) ' Importance of tuberculosis control to address child survival' The Lancet 6736(14):60420-7
- 40. International HIV/AIDS Alliance / Save the Children (2012) ' Good Practice Guide on Family Centred HIV Programming'
- 41. Joint Learning Initiative on Children and HIV/AIDS (2009) ' Home Truths: Facing the Facts on Children, AIDS and Poverty'
- 42. International HIV/AIDS Alliance / Save the Children (2012) ' Good Practice Guide on Family Centred HIV Programming'
- 43. International HIV/AIDS Alliance / Save the Children (2012) ' Good Practice Guide on Family Centred HIV Programming'
- 44. UNICEF/UNAIDS (2013) ' Towards an AIDS-Free Generation – Children and AIDS: Sixth Stocktaking Report, 2013'
- 45. UNICEF/UNAIDS (2009) ' Children and AIDS: Fourth Stocktaking Report'