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Children and HIV/AIDS
Introduction to HIV and Children
More than 1,000 children are newly infected with HIV every day, and of these more than half will die as a result of AIDS because of a lack of access to HIV treatment. 1 In addition, millions more children every year are indirectly affected by the epidemic as a result of the death and suffering caused in their families and communities.
Preventing HIV infection, providing life prolonging treatment and relieving the impact of HIV and AIDS for children and their families and communities is possible. However, a lack of necessary investment and resources for adequate testing, antiretroviral drugs, and prevention programmes, as well as stigma and discrimination, mean children continue to suffer the consequences of the epidemic.
The number of infected children
The figures below show the number of children (defined by UNAIDS as under-15s) directly affected by HIV and AIDS:
- At the end of 2011, there were 3.3 million children living with HIV around the world. 2
- An estimated 330,000 children became newly infected with HIV in 2011. 3
- This reflects a 24 percent drop in new infections since 2009. 4
- Most children living with HIV/AIDS– 90 percent – live in sub-Saharan Africa, the region of the world where AIDS has taken its greatest toll. 5
- Of the 1.7 million people who died of AIDS during 2011, 230,000 were children. 6
How children become infected with HIV
Mother-to-child transmission (MTCT)
Nine out of ten children infected with HIV were infected through their mother either during pregnancy, labour and delivery or breastfeeding. 7 Without treatment, around 15-30 percent of babies born to HIV positive women will become infected with HIV during pregnancy and delivery and a further 5-20 percent will become infected through breastfeeding. 8 In high-income countries, preventive measures ensure that the transmission of HIV from mother-to-child is relatively rare, and in those cases where it does occur a range of treatment options mean that the child can survive - often into adulthood. Antiretroviral prophylaxis has prevented MTCT in 409,000 children living in low- and middle- income countries between 2009-2011. 9 This shows that with funding, trained staff and resources, the infections and deaths of many thousands of children could be avoided.
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. In wealthier countries this problem has virtually been eliminated, but in resource-poor communities it is still an issue. The most large scale case of infections among children resulting from contaminated injections and unscreened blood transfusion occurred in Romania between 1987 to 1991 when more than 10,000 babies and children were infected with HIV as a result of unsafe medical practices. 10
Unsafe blood transfusions have also led to hundreds of HIV infections in countries in the Central Asia region, namely Kazakhstan, 11 Kyrgyzstan 12 and Uzbekistan 13 from 2006-2008. The widespread reuse of injection equipment as well as encouragement by doctors motivated by financial reasons to carry out 'unnecessary blood transfusions', led to the infection of at least 119 children in Kazakhstan and at least 150 in Uzbekistan from 2007-2008.
Although official statistics claim that unsafe injections account for a small percentage (2.5 percent) of HIV infections in sub-Saharan Africa, 14 this is contested by a number of researchers. HIV prevalence in children can be 1 to 3 times higher than that of pregnant women in antenatal clinics 15 and in one study as many as a fifth of children who were not sexually active had HIV negative mothers 16: suggesting that the children were infected through contaminated medical procedures.
Injecting drug use
In central and Eastern Europe, where injecting drug use fuels the spread of HIV, young people living on the street are found to be especially vulnerable to HIV through injecting drug use. In St Petersburg, a study of more than three hundred 15-19 year olds living on the street found that 40 percent of them were HIV positive. 17 In Ukraine, one study found a variety of HIV risk behaviours like sharing needles and unprotected and forced sex were prevalent among 10-19 year old street children, 18 while a multicity study found an HIV prevalence of 18 percent among street youth (aged 15-24). 19 Police harassment and the general attitude of society that sees street children as ‘outcasts’ and ‘criminals’ means that that they are difficult to reach with health and social services.
Sexual transmission does not account for a high proportion of child infections but in some countries children are sexually active at an early age. This is potentially conducive to the sexual spread of HIV among children, especially in areas where condom use is low and HIV prevalence is high. In sub-Saharan Africa 16 percent of young females (aged 15-19) and 12 percent of young males reported having sex before they were 15 in 2007. In 2011, in The Republic of Congo, 27 percent of young people reported having sex before the age of 15, and in Mali this figure was 21 percent. 20 In developing countries overall it is estimated that 6 percent of boys and 11 percent of girls have had sex by age 15. 21 22
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 lifetime partners, higher rates of coerced sex and lower rates of condom usage. 23
Children are also at risk of becoming infected with HIV through sexual abuse and rape. In some parts of Africa, the myth that HIV can be cured through sex with a virgin has led to rapes, sometimes of very young children by infected men - although whether or not this is a significant factor in child sexual abuse in the region is disputed. 24 25 26 27 In some cases, young children are trafficked into sex work, which can put them at a very high risk of becoming infected with HIV. 28 29
HIV prevention for children
Prevention of Mother-to-child transmission (PMTCT)
To prevent mother-to-child transmission ( PMTCT) of HIV, antiretroviral drugs are given to the mother before birth and during labour, to the baby following birth and safer infant feeding is also promoted. This approach can almost eliminate the risk of transmission from mother-to-child. Unfortunately, prevention of mother-to -child transmission (PMTCT) services fail to reach many women in resource-poor countries. In 2011, 57 percent of HIV-infected pregnant women in low- and middle-income countries received drugs to protect their babies from infection. 30 Reasons for this lack of coverage are discussed in our PMTCT worldwide page.
In order to eliminate the risk of a child being infected with HIV in medical settings, either through contaminated needles or blood transfusions, a number of steps can be taken. These include adopting safer injecting practices for injections and screening all donated blood for blood borne viruses.
Read more about blood safety and HIV.
HIV/AIDS education is an important way of reaching young people with knowledge on sexual health and drug abuse. There are many ways to reach young people: including through school, the media, and peer outreach. Whatever the medium, HIV/AIDS education should not only address the biological facts of HIV and STI transmission and provide information on how to prevent transmission, but it should also take into account the realities of young people’s lives - such as peer pressure or gender inequality.
Read more about HIV/AIDS education for young people.
HIV testing for children
It is important that HIV infected children are diagnosed as quickly as possible, so they can be provided with appropriate medication and care. However, testing children for HIV can be complicated, especially for those recently born to HIV-positive mothers. Antibody tests, which are used to diagnose HIV in adults, are ineffective in children below the age of 18 months. Instead, children below this age are usually diagnosed through polymerase chain reaction (PCR) testing and other specialist techniques. This is referred to as early infant diagnosis and is important because mortality is very high amongst HIV infected infants who go untreated. However, among 65 reporting countries, it was found that only an estimated 28 percent of children born to HIV-positive mothers received an HIV test within the first two months of life. 31 Moreover, it has been found that false-negative 18 month confirmation tests among children, previously diagnosed with HIV and taking antiretroviral treatment, are common and can lead to the discontinuation of antiretroviral treatment in children. 32
A multi country study in Africa showed that without treatment, half of HIV infected children die by 2 years of age. 33 Even when children do survive into adolescence without treatment, they are likely to be stunted, severely underweight or suffering from opportunistic infections. 34 However, the methods for testing children early require expensive laboratory equipment and specially trained staff which are generally unobtainable in the resource-poor areas where they are needed the most.
The use of dried blood spot testing can be more practical in resource poor settings. This method allows small samples of blood to be collected on paper, and sent away to a laboratory where PCR (or similar testing) is available. Unlike testing methods that use liquid samples, dried blood spots can be stored for a long time and easily transported, so even if the nearest laboratory is some distance away, it may still be possible to use PCR technology on a sample of a child’s blood. However, dried blood spot testing can be expensive and it can take a long time for test results to return.
Where health facilities can diagnose infants early through PCR testing they should immediately be linked to care and treatment services. However, an increase in access to testing is not always matched with access to treatment. One study in Cameroon found that only a third of infants who had been diagnosed early were alive and receiving treatment after one and a half years and another multi country study found that half of all infants who had tested HIV positive were not receiving treatment. 35 A multi-country review of developing countries conducted in 2009 found that only one quarter to one third of children who were tested early actually went on to start treatment. 36
HIV testing for older children
Among older children aged 6-15 years old, there is growing concern in sub-Saharan Africa that healthcare workers are not offering them provider-initiated HIV testing and counselling (PITC). The main reason for this was how the healthcare worker perceived the accompanying adult, and their relationship to the child. With many children orphaned by AIDS (up to 30% in some countries), it is important that the relationship of an adult to a child does not prevent HIV testing, and that age of consent laws are relaxed in order to increase access to HIV testing among older children. 37
HIV treatment for children
HIV treatment for children slows the progress of HIV infection and allows infected children to live much longer, healthier lives. Yet, only 28 percent of the children who could be benefiting from this therapy in low and middle-income countries are receiving it. 38
Children ideally need to be given drugs in the form of syrups or powders, due to difficulties in swallowing. However, drug treatments involving syrups for children are generally more expensive. As a result, carers are often forced to break adult tablets into smaller doses, running the risk that children are given too little or too much of a drug. Studies suggest that breaking down adult tablets into smaller doses can work effectively although this should only really be seen as a last resort. 39
Although the cost of first line therapy for children has reduced dramatically due to the availability of generic drugs ($50 a year on average in 2009 compared to about $20,000 a few years before) 40, when a child develops drug resistance and needs to begin a second course of drugs, treatment becomes far more expensive. More drugs suitable for children are qualified by the WHO every year, but without access to cheap generic versions of them the majority of HIV infected children will not benefit. The latest WHO guidelines (2010) recommend that HIV-infected children under the age of two start ART treatment straight away, and children between two and five years should initiate ART when they have either a CD4 count of 750cells/mm3 or below, or a CD4 percentage of 25 or below, whichever is lower. 41 It is also suggested that where necessary, children receive a complex set of drugs including protease inhibitors to reduce the likelihood of drug resistance. However, this will require more resources and higher levels of funding. 42
“More drugs suitable for children are qualified by the WHO every year, but without access to cheap generic versions of them the majority of HIV infected children will not benefit.”
Another major problem for children living with HIV is childhood illnesses, such as mumps and chickenpox. These illnesses can affect all children, but since children living with HIV have such weakened immune systems they may find that these illnesses are more frequent, last longer, and do not respond as well to treatment. Opportunistic infections, such as tuberculosis (TB) and PCP (a form of pneumonia), are also a serious risk to the health of children living with HIV. An estimated 74,000 children died from 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. 43
Opportunistic infections can be prevented using drugs such as cotrimoxazole: a cheap antibiotic that has been proven to significantly reduce the rate of illness and death among HIV-positive children. Countless lives could be saved if cotrimoxazole were made more widely available, but at the moment it is estimated that only 14 percent of children who could be benefiting from the drug are receiving it. 44
One of the greatest challenges when it comes to treating children with HIV is loss to follow up. This is when a patient tests HIV positive but does not return to a health facility to receive treatment. Some of the reasons children are lost to follow up include "clinical organization and data flow of results, lack of caregiver contact information, stigma and counselling challenges, the burden on patients to return for results, and weak follow-up within clinics." 45 Globally, around 80 percent of children are retained on treatment at 12 months. 46 In certain parts of West Africa it has been found that 25 percent of children who were tested early and began to receive treatment stopped treatment after 18 months. One suggested reason for this was the price of user fees demanded for laboratory tests for infants. Generally, however children's adherence to treatment has been found to be "as good or better" in low and middle-income countries compared to richer countries, although it should be noted that this is highly variable even within countries. 47 48 49
Read more about treatment for children with HIV/AIDS.
Families and communities
Families, friends, and the wider community are the first line of protection and support for children, providing for their practical and material needs, as well as social, psychological and emotional needs. Yet in countries with a high HIV prevalence, AIDS places an economic burden on families and communities, making it difficult for them to provide and support for their children. The main reason for this is that AIDS normally affects adults when they are most economically productive. 50 Reduced household income combined with increased expenses (for example for treatment, transport, funerals) may push families into poverty, which has negative outcomes for children in terms of nutrition, health status, education and emotional support. For children who have lost one or more parents to AIDS, an estimated 95 percent live with a surviving parent or extended family member. 51 Most children (9 out of 10) orphaned by AIDS still have a surviving parent, and if they are put into residential care it is most often due to extreme poverty rather than the child not having any family. 52
Families are often a more long-term, stable form of care for a child than an institution or care-programme. 53 As a family and community centred approach to care for a child affected by AIDS is the most beneficial for a child’s development, it has been emphasised that taking children away from their families should be a last resort. 54 Supporting a family holistically can be the best way to ensure a good quality of life for the child. 55 For this reason, social protection schemes that provide external assistance to poorer families in areas where HIV prevalence is high are now seen as a valuable part of improving the lives of children affected by AIDS. 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. Moreover, children benefit from the emotional support that is provided through the family.
The most simple social protection measure is the cash or income transfer. These are ‘cash disbursements to individuals or households identified as highly vulnerable’. They may be conditional or unconditional. For example, a cash transfer programme in Ghana requires households receiving financial assistance to ‘keep children in school, register with the National Insurance Scheme, and bring children to health facilities for regular check-ups’. 56 One analysis has found that a cash transfer of $15 per month to the poorest 10 percent of households in sub-Saharan Africa would cost 3 percent of the aid to the region pledged at a summit of world leaders in 2005. 57
Faith-based and community organisations provide much of this support but it is now widely recognised that supporting children affected by AIDS primarily through their families and communities can be done most effectively through a national strategy. A number of sub-Saharan countries (Ghana, South Africa, Kenya, Malawi) have already introduced government–led initiatives that include providing vulnerable children with some sort of external support. 58
Keeping adults alive and economically productive is essential to providing for children affected by AIDS. Kinship structures are already strong in many African countries where children are most affected; in fact more than 90 percent of children who are infected with HIV or whose parents are infected are living with their extended family. 59 However, more needs to be done to ensure that these vital sources of protection for children affected by AIDS are supported and strengthened.
The effects of the HIV/AIDS epidemic on children are manifold: hundreds of thousands of children every year are infected with HIV, most are left undiagnosed, do not access treatment and die very young. Those who are not infected may live in families and communities where AIDS reduces the productivity of their households and aggravates poverty. Only a combination of factors can improve the situation. These include 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.
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- 11. Reuters (2007, January 19th) ' Trial opens in Kazakhstan over child HIV infections'
- 12. BBC News (2008, March 20th) ' Kyrgyzstan rocked by HIV scandal'
- 13. CBC News (2010, April 1st) ' Uzbek child HIV deaths punished'
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- 51. International HIV/AIDS Alliance / Save the Children (2012) ' Good Practice Guide on Family Centred HIV Programming'
- 52. Joint Learning Initiative on Children and HIV/AIDS (2009) ' Home Truths: Facing the Facts on Children, AIDS and Poverty'
- 53. International HIV/AIDS Alliance / Save the Children (2012) ' Good Practice Guide on Family Centred HIV Programming'
- 54. Joint Learning Initiative on Children and HIV/AIDS (2009) ' Home Truths: Facing the Facts on Children, AIDS and Poverty'
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