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HIV Treatment for Children
HIV develops very rapidly among infants and children and, without treatment, a third of children infected with HIV will die of AIDS before their first birthday.1 In 2011, there were 230,000 AIDS-related deaths in under-15s, most of which could have been prevented through early diagnosis and effective treatment.2 In many high-income countries, children who were infected with HIV at birth in the 1980s and 1990s are now entering adulthood as a result of access to antiretroviral treatment. Between 2011 and 2012, antiretroviral treatment access for adults rose by 21 percent, whereas the increase for children was just 11 percent.3
Identifying and testing children living with HIV
Providing treatment for children with HIV and AIDS essentially involves three stages: finding a child, testing a child and treating a child. Most children living with HIV become infected through mother-to-child transmission, and these children need to be tested as soon as possible after birth to find out if they are infected with the virus. If a child living with HIV is only diagnosed once they are ill, it may be too late for antiretroviral treatment to be effective.
In high-income countries, children can be tested soon after birth usually using polymerase chain reaction (PCR) tests, which can detect the genetic material of HIV.4 Where this technology is available, the longest a mother will have to wait for an accurate result is around six weeks.
In low- and middle-income countries, where PCR testing is generally unaffordable or unavailable, a mother may have to wait up to 18 months after giving birth before antibody tests (which are used in adults, and are more commonly available) can be used to accurately diagnose her child. This is how long it takes to be sure that the mother’s antibodies do not remain in the infant’s blood, creating the possibility of a false positive result.5
In some low- and middle-income countries, ‘dried blood spot’ testing has been introduced. This is where a small sample of blood is taken from a child, dropped onto paper, and sent to a laboratory where it can be tested. Since these samples do not need to be refrigerated and are easy to transport, they can potentially be sent miles away to places where PCR testing is available. This means that even children living in resource-poor areas can be tested relatively quickly. However, dried blood spot testing can be expensive and it can take a long time for test results to return. There is also evidence that when the drug nevirapine is used to prevent mother-to-child transmission of HIV, dried blood spot testing doesn't always detect HIV in the first few days of the child's life.6 7
Issues with testing
HIV testing among children born to mothers living with HIV remains low. Whilst the World Health Organization (WHO) recommends that infants be tested within two months of birth, the proportion of infants actually tested within two months stood at 35 percent in 2011. However, this is an improvement compared to the 28 percent coverage in 2010.8
A number of factors may prevent children from being tested. These include health authorities’ lack of technical ability, poor systems for laboratory analysis, problems with transportation of specimens and results, and low confidence among health care providers in caring for children.9
Where testing is unavailable, clinical diagnosis is used instead, using the child’s symptoms to ascertain that they are HIV-positive. However, this is nowhere near as reliable as using PCR testing. Only 58 percent of a group of children with HIV in Kenya who only had access to clinical diagnosis were successfully diagnosed, and it was found that using this method delayed diagnosis by 5.9 months, compared to testing.10
Furthermore, parents may be unwilling to take their child for an HIV test for fear that the child will face prejudice once diagnosed. A lack of knowledge about the existence of antiretroviral therapy to treat HIV and therefore the point of getting an infant tested could also lead to poor testing rates. Mothers who have not yet been tested may be fearful of discovering their child is infected, as this would be likely to mean they are infected also. Hospitals or clinics that provide testing may not be accessible; a mother may have to travel long distances to reach the nearest health service that can test her child, and this may be impractical and expensive. Additionally, hospitals sometimes lose contact with HIV-exposed infants for follow-up tests.11 Support and advice for parents and carers around disclosing, caring for and supporting a child living with HIV, and addressing some of the myths and prejudice around the condition, can make testing and treatment far more successful.12
Starting antiretroviral treatment in children with HIV
In June 2013, the World Health Organization (WHO) published a new set of HIV treatment guidelines for starting and adminstering HIV treatment to infants and children below five years of age, discussed below.13 Among older children, treatment initiation depends on their CD4 levels. There is a complex balance between the immediate benefits of providing treatment to children who are not showing any symptoms of AIDS-related illness, and concerns about long-term resistance and antiretroviral drug side effects if treatment is started too early.
Measuring the stage of HIV infection in children
CD4 counts in children
To judge whether an HIV-positive person requires treatment, or how well they are responding to treatment, a CD4 test is usually carried out. This measures the number of T-helper cells – white blood cells that are attacked by HIV – in an individual’s blood. It can either measure the absolute number of CD4 cells (absolute CD4 count), or the percentage of white blood cells that are CD4 cells (CD4%), in a sample of blood.
A falling CD4 count is a sign that HIV is progressing, and that the immune system is becoming weaker. However, it is difficult to judge the health of a child's immune system based on CD4 count alone. CD4 counts vary with age and are naturally less constant, and younger children usually have a much higher CD4 count than adults. Percentage CD4 count on the other hand does not vary in the same way as absolute CD4 count, and is therefore a better way of judging an under-five year-old’s immune system.14
In some cases, viral load testing (which measures the amount of HIV in an individual’s blood) is used alongside CD4 testing to guide decisions about treatment.
In resource-poor communities, the technology needed for CD4 counts and viral load testing is not always available. In the absence of these facilities, healthcare workers sometimes have to make a presumption that a child should begin treatment based on their stage of HIV infection as defined by a range of cancers and infections that are present.
When to start treatment
Infants under 18 months
ART should be initiated immediately to infants under 18 months of age who test positive on a viral test. If a viral test is unavailable, the infant should be clinically monitored and a treatment decision made at 9 months of age depending on whether the infant appears sick or well. The infant should have a conclusive HIV antibody test at 18 months or 6 weeks after cessation of breastfeeding. The diagram below outlines the steps to take when determining the HIV status of an infant under 18 months of age.15
A study that was influential in the above WHO recommendations was 'The Children with HIV Early Antiretroviral Therapy' (CHER) study of infants (aged six to twelve weeks) in South Africa. The study compared the outcomes of those starting limited treatment immediately with those deferring treatment until CD4 percentage dropped below certain levels or severe disease occurred. It found the risk of death for infants who began treatment immediately was 76 percent lower than the deferred treatment group.16 17
The United States also recommends treatment for all infants with HIV, regardless of CD4 percentage, clinical status or viral load.18 The 2009 guidelines produced by the Paediatric European Network for Treatment of AIDS (PENTA) also advocate treatment for all infected infants regardless of clinical or immunological stage.19 Other countries’ guidelines may be revised to reflect WHO recommendations and the CHER study’s findings.
Children less than five years, and older than five years
WHO's guidelines 2013 recommend that:
- HIV-positive children less than five years should now start ART regardless of CD4 count or clinical stage of infection.
- HIV-positive children five years and older should start ART with a CD4 cell count of 500 cells/mm3 or less.
- HIV-positive children showing severe or advanced clinical staging of HIV infection should start ART immediately regardless of age.
The following diagram shows at what point children should initiate ART, and which regimen is recommended.20
However, treatment initiation is still being contested, and trials continue to investigate best practice in this area. Arguments for earlier treatment include:
- Evidence that disease progression is faster in young children.23
- The association between severe HIV disease, which can be prevented through treatment, and neurocognitive problems in adolescent HIV patients.24
- Evidence that ART can reduce the risk of tuberculosis, encephalopathy and bacterial infections that occur even at high CD4 levels.25 26
- Evidence that treatment can improve the physical growth of children.27
Arguments for deferring treatment include:
- A lack of available research on the long-term effects of treatment, due to the short history of the HIV epidemic.
- The costs that are saved through prescribing treatment for a shorter period of time.
- The increased burden of adherence that comes with a longer overall period of treatment.28
- Research that suggests that it is early treatment initiation in infancy that has a positive affect on neuro-cognitive functions, whereas early treatment initiation in older children doesn’t help to prevent neuro-cognitive problems.29
Which antiretroviral (ARV) drugs should be used?
As with adults, antiretroviral therapy with at least three drugs is recommended for children as this prevents HIV from becoming resistant to any single drug. It is usually recommended that this therapy should consist of two nucleoside reverse transcriptase inhibitors (NRTIs) combined with either one non-nucleoside reverse transcriptase inhibitor (NNRTI) or a protease inhibitor (PI).30 31
If a child has been exposed to NNRTIs during treatment to prevent mother-to-child transmission (common in most PMTCT interventions in developing countries) then his or her treatment should contain PIs. However, this not really feasible in most countries where the need for this treatment is greatest as most PIs are expensive and may have special storage requirements such as refrigeration. The potential for integrase inhibitors as an option for adolescents with HIV, particularly as a second-line treatment for those experiencing resistance, is currently being expanded.32 For more information about the different types of treatment, see our treatment page.
There are many factors that can influence the choice of drugs for children. Considerations about medications that the mother may have received during pregnancy, the toxicity of certain drugs, and whether the child is still breastfeeding, all need to be taken into account when choosing a regimen. The WHO Treatment Guidelines released in 2013 state the recommended treatment regimens for infants and children based upon factors such as age and weight.33
How effective is antiretroviral treatment for children with HIV?
The most effective treatment for children with HIV is antiretroviral therapy, which reduces illness and mortality among children living with HIV in much the same way that it does among adults. However, there are specific challenges around ensuring that children living with HIV are treated effectively.
Case studies of ARV treatment in children
In one study in Brazil, three-quarters of HIV-positive children receiving antiretrovirals were alive after a four-year follow-up period.34 Positive outcomes have also been seen in paediatric ART programmes in Thailand, Kenya, and Ukraine.35 36 37 A study released in 2007, which monitored 586 HIV-positive children receiving antiretroviral treatment in 14 countries in Africa and Asia, found that 82 percent were still alive after two years.38
Some of the most compelling evidence that treatment works in children does not come from studies or statistics, but rather the stories of those who have witnessed HIV-positive children returning to health after starting treatment:
"You see scrawny, rashy, tired, lethargic kids come in, you start them on treatment and within weeks you’ve got bounding, podgy, gorgeous growing children. People often don’t believe, they’re often quite sceptical of the medications, and then you see this transformation and parents are like ‘The child’s got so much energy!’”Julie, UK nurse working with children living with HIV39
Unfortunately, for many children living with HIV it can be hard to ensure treatment success. A European study which looked at more than a thousand children on antiretroviral treatment found that 12 percent of children experienced treatment failure of three classes of drugs after 5 years, over two times the rate of adults.40 Additionally, there continue to be disparities between high-, and low- and middle-income countries relating to how well children respond to treatment; it was found that mortality rates among children who had accessed antiretroviral therapy were between five and nine times higher among children in lower-income countries.41
Dosing and drug formulations in children
The dose of antiretroviral drugs given to children is generally based either on weight or body surface area.42 Children’s bodies are constantly changing and developing and often it is vital that drug doses are altered to ensure that a child is not given too much, or too little, of a drug. The study of how a body reacts to medication is called pharmacokinetics (PK). Pharmacokinetic properties such as absorption, distribution, metabolism and excretion of a drug all influence the efficacy, toxicity and dosing regimen required in a child. Expert guidelines use a variety of ways to calculate doses of paediatric ARVs, so there is no uniform dosing system to follow.43
“Unfortunately, a lot of HIV medicine has an unpleasant taste, especially in syrups and powder form.”
Dosing is further complicated by the variety of forms that ARVs may take when provided to children, all of which require different measurements. Infants who are too young to swallow tablets ideally need to be provided with drugs that are more child friendly such as syrups, powders, sprinkles or ‘melts’, or administered through more innovative methods, such as through a baby pacifier. However, these formulations are only slowly becoming available and are expensive.44 45 Unfortunately, a lot of HIV medicine has an unpleasant taste, especially in syrups and powder form. This can make it difficult for children to take their ARVs daily. In addition, it is critical that children’s medicine has clear and concise labelling to ensure that caregivers are able to give an appropriate dosing and ensure adherence.
In areas where there is a lack of affordable paediatric ARV formulations, clinicians often have no choice but to divide adult fixed-dose combination drugs (FDCs) into measures appropriate for children. There is evidence that dividing tablets carries a risk of under- or over-dosing46 but equally, a significant 2006 study of eight countries concluded that the use of divided adult FDCs can achieve successful and satisfactory results in children.47 The World Health Organisation supports this practice in situations where no appropriate paediatric medications are available.48
“Since there are still no available, easy-to-use triple drug combinations for children, I do what most doctors are doing: I try to show caregivers such as grandparents how to break adult tablets, hoping that the children will get the doses they need.” Dr Fasineh Samura, Malawi49
An encouraging development is the relatively recent availability of FDCs, which combine multiple ARVs into a single tablet, for children. A successful initiative was the roll-out of fixed-dose combination treatment by the Clinton HIV/AIDS Initiative (CHAI), in conjunction with drug purchase facility, UNITAID, to children in 26 nations. In these countries CHAI’s monthly paediatric treatment formerly consisted of 12 bottles of liquid. For those children who can now access FDCs, only a small container of tablets is needed, making the therapy easier to store, transport and administer.50 Various fixed-dose regimens for children are now available and the WHO recommends that countries increase access by ensuring that they are integrated into treatment programmes.51
Access to appropriate treatment
“Mothers need to demand care for their children and remind the decision makers of the moral imperative” - Shaffiq Essajee, Senior Adviser in HIV at the Clinton Health Access Initiative52
A lack of appropriate treatment is one of the main reasons that treatment failures occur in children.53 Currently, there are too many different formulations being marketed, with too few real options that are effective.54 Many of the drugs that are conventionally used to treat adults living with HIV are not available in an appropriate form, or licensed/approved for use in children.55 Child versions are often impractical for carers to administer, unpalatable for children and react badly with tuberculosis (TB) treatment.56 Appropriate formulations that are available are often unaffordable in the areas where they are most needed.
One reason for the lack of ARVs for children is that the very low rates of mother-to-child transmission in high-income countries mean that there is little financial incentive for pharmaceutical companies to expand child-friendly HIV treatment.57 As more groups speak out about the unacceptably high cost of child-friendly formulations, some progress is being made. In December 2006, the Clinton HIV/AIDS Initiative (CHAI) announced that it had negotiated reductions in paediatric drug prices made by two Indian pharmaceutical companies. Under this agreement, 19 different ARVs that can be used for children were scheduled to be made available for an average 16 cents per day. This is 45 percent cheaper than previously available drugs.58 This agreement has probably contributed to child access to ARVs in recent years. Since CHAI and UNITAID partnered in 2006, they claim to have reduced the cost of leading child treatments by 64 percent in low-income countries.59
Since then, the Drugs for Neglected Diseases Initiative launched a drug development programme to address the unmet treatment needs of children living with HIV and AIDS in 2011.60 DNDi developed specifications such as “palatable, heat-stable, easily dispersible, and administered once daily or less” that needed to be met for paediatric drugs to be effective, and identified gaps in knowledge that needed to be filled through clinical studies.61
One UK-based reporter wrote about the effectiveness of antiretrovirals, “In what must be the most under-celebrated triumph of modern medicine, in the last two years, the oldest survivors of childhood HIV have grown into young adults”,62 With the wider provision of cheaper, simplified drug formulations, fixed-dose combination treatment and low-cost generic versions of paediatric drugs these achievements could benefit the far greater numbers of children in low-income countries living with HIV. However, as has been observed, "children are often a low priority when it comes to drug development and financing."63
Side effects of paediatric HIV treatment
Children receiving ARVs can suffer from the same drug side effects that adults experience. Because children’s bodies are still developing, and they are likely to be exposed to treatment for prolonged periods of time, they may be particularly vulnerable to some complications.64 Side effects can occur at various stages of a child’s course of treatment, and may be acute (occurring directly after drug administration), sub-acute (within one or two days after administration), or late (after prolonged drug administration). It can be difficult to distinguish between adverse events caused by ARVs given to a child and complications caused by HIV itself, so care should be taken to exclude other possible causes of illnesses before it is concluded that they are a result of ARVs.
The impact of side effects may vary from mild to severe and life-threatening. Some moderate or severe side effects may require drug substitution, or even the discontinuation of treatment. In general, mild side effects do not require such changes, and symptomatic treatment for them may be given. If side effects are regarded as life threatening, all ARVs should be stopped until the child has stabilised.65
Most children on HIV treatment need to take three or more types of ARVs every day for the rest of their lives. If drugs are not taken routinely at around the same time every day, HIV may become resistant to the therapy, causing it to stop working.
Adherence among children varies between and within countries.66 67 68 A review of 17 studies regarding paediatric HIV treatment adherence found adherence ranging from 49 percent to 100 percent.69 Surprisingly, most of the studies in low- and middle-income countries revealed adherence rates above 75 percent, whereas adherence in high-income countries was generally below 75 percent.
Many factors can lead to adherence problems. Some relate directly to the medicine, such as inadequate dosing, high pill burden, reluctance among young infants to take syrups and powders due to their unpleasant taste, dietary restrictions, and toxic side effects of drugs. The child’s social context can also have dramatic effects on whether they adhere to ARVs, with adherence affected by factors such as the socioeconomic status of the child, whether or not a child's status has been disclosed and medical fees.70 71
Studies that have analysed the rate of failure of antiretroviral treatment in children often cite inadequate adherence due to poor dosing by caregivers as one of the reasons that drug resistance develops in young children.72 73 Adherence issues can put an enormous strain on the daily lives of parents and caregivers, who are usually responsible for administering treatment. Some ARVs need to be taken with food, so carers may have to perform the, often difficult, task of providing a meal and administering drugs simultaneously. This is assuming that an adequate supply of food is actually available. As well as the unavailability of appropriate drugs, stigma surrounding HIV can also lead to adherence problems if parents and caregivers are unwilling to make it publicly known that the child in their care is HIV-positive. For instance, carers may be reluctant to fill out prescriptions in their local community, or may not make a child’s school aware of their condition, which can lead to them missing out on drug doses during the school day.74 75 They may also hesitate to administer ARVs if other people are present when a child is due to receive them.
“It's partly because I have to live this life of shame and secrecy that I find it so hard to take my meds.” Young person living with HIV76
Among older children and adolescents, a variety of social factors such as fear of stigma and discrimination, stress and anxiety and peer relations impact treatment adherence.77 Side effects, and the need to take treatment at different times of the day, also explain why adolescents may find it difficult to adhere to their treatment regimens.78
“There are days when I can't be bothered [to take my medications] like when I am tired or if I am at someone else's house and have to hide it or whatever, then it's hard.”13 year old HIV-positive girl79
Drug resistance in children
Drug resistance is when the Human Immunodeficiency Virus becomes resistant to certain antiretrovirals, making them ineffective against the virus. It is something that infants and children living with HIV are especially at risk of. One review of studies in low-income countries found that 90 percent of children experiencing treatment failure had one or more drug-resistant strains of the virus.80 There are three ways that this could occur: the infant can become infected with a drug-resistant HIV strain from their mother, they may become resistant to antiretroviral drugs when they are exposed to them during pregnancy, birth or breastfeeding because the mother takes them for prevention of mother-to-child transmission, or they could develop drug resistance during their own treatment.81
Various factors can worsen the risk. Many countries still administer single-dose nevirapine for PMTCT, despite the WHO recommending that this be phased out. The drug is less effective at PMTCT than other regimens, and infants that still become infected when their mother has taken single-dose nevirapine are at high risk of drug resistance.82 After the child is born, treatment doses may need to be modified in line with changes to their age and weight. However, a lack of suitable paediatric formulations and doses may increase the risk of developing drug resistance, as a result of bad adherence and incorrect dosing.83
Moreover, second-line therapy options, which are treatment regimens used if the initial first-line course fails, are also currently lacking for children, putting more pressure on the success of the first-line regimen. This has prompted widespread calls for policy makers, pharmaceutical companies and donor agencies to commit to the development of second-line regimens.84
Monitoring drug resistance can help to determine if a patient’s treatment needs to be switched (presuming that second-line regimens are available). Drug resistance testing is implemented in high-income settings, but this is challenging to implement in low- and middle-income countries where CD4 and HIV viral load testing are not widely available.85
To minimise the occurrence of resistance among children, countries need to ensure that children and caregivers are supported with adherence, and that treatment supplies are consistent and of a good quality.86 Continued research into the best possible regimens for reducing the likelihood of drug resistance is also necessary, as it is evident that certain drugs are more associated with resistance. Whilst the highest rates of resistance in a study review were found to be from nevirapine and efavirenz, there have been promising results in high-income countries from the use of etravirine among children, a drug not yet licensed for paediatric use.87
Nutritional support whilst on HIV treatment
Malnutrition is common in children living with HIV in low- and middle-income countries, and is a major cause of death.88 Ideally, children living with HIV who are asymptomatic need to consume 10 percent more calories than other children of their age and sex. Children who are symptomatic, or recovering from acute infections, need to consume 20-30 percent more calories than other children.89
If a child is suffering from malnutrition, it is recommended that their condition is stabilised before antiretroviral treatment is started. In poorer areas, however, this is not always possible. Even where it is possible to treat malnutrition, recovery from this condition is likely to be slow and limited in HIV-positive children. If a child has not been cured of malnutrition after six to eight weeks of special feeding or appropriate treatment, it may be decided that antiretroviral drugs should be administered despite their condition.
In the opposite situation, where a child experiences rapid weight gain as a result of ARVs, nutrition also needs to be monitored carefully. As a child’s weight changes, so does the recommended dosage of ARVs that they require, so drug doses need to be constantly reviewed.90
Opportunistic infections, which take advantage of weak immune systems, are a serious threat to children living with HIV. Tuberculosis (TB) and PCP (a form of pneumonia) are major causes of illness and death among infected infants.
Preventing opportunistic infections
Due to their weak immune systems, children living with HIV are very vulnerable to opportunistic infections, and need to be provided with preventative treatment (drug prophylaxis) to prevent such illnesses. For example, prophylaxis against PCP (one of the most common opportunistic infections in children living with HIV) is recommended for all children born to HIV-positive mothers, starting from about one month after birth.91 For children who have no access to ARVs, treatment for opportunistic infections may delay the need for antiretroviral treatment.
A particularly important treatment for children living with HIV is co-trimoxazole, an antibiotic that is included in PCP prophylaxis, that can help to prevent other infections such as TB. A study showed that it reduced AIDS-related mortality by 43 percent and hospital admission rates by 28 percent among children with HIV in a major trial in Zambia.92 Experts agree that co-trimoxazole should be widely provided to all children living with HIV, especially where ARVs are not available. It is also recommended that all children born to HIV-positive mothers should be provided with co-trimoxazole until tests confirm that they are HIV-negative. Co-trimoxazole prophylaxis can be given to a child from 4 to 6 weeks of age.93 As well as being effective, co-trimoxazole is cheap, costing as little as US$0.03 a day to provide. However, provision is low; in 2011, only 31 percent of infants, in reporting low- and middle-income countries, in need of co-trimoxazole received it within two months of birth.94
Even though many governments have increased efforts to distribute co-trimoxazole, financial and logistical barriers still stand in the way of its provision. Increasing the numbers of children receiving this relatively low-cost drug would save many lives.
Another important intervention is vaccination or immunisation against common infections. There are some risks associated with providing routine vaccines to children living with HIV, but these risks are far outweighed by the benefits of immunisation.95 96 However, it should be noted that ‘live vaccines’ are often not considered safe for use in HIV-positive children.
Treating opportunistic infections
Children are at particular risk of tuberculosis (TB) if they are suffering from a weak immune system due to HIV infection and if their mother is infected with TB.97 98 While the basic principles of TB treatment are the same in HIV-positive children and uninfected children, the situation is complicated by drug interactions between ARVs and drugs that are used to treat TB. Such interactions can lead to sub-therapeutic drug levels, where the drugs become ineffective, and an increased risk of toxic side effects. For HIV-positive children who are not yet receiving ARVs, it is recommended that treatment for TB should ideally be initiated some weeks before ARV treatment, allowing the child to stabilise on this therapy. For children who are diagnosed with TB while already receiving treatment, ARV regimens need to be carefully reviewed, and may need to be adjusted in accordance with official guidelines.99 In order to avoid late diagnosis of HIV, it has been suggested that all TB-infected children should be considered for an HIV test.100
Improving testing and treatment for children
While stepping up efforts to prevent mother-to-child-transmission (PMTCT) would decrease the need for paediatric treatment, it is likely that HIV will continue to infect many thousands of children for years to come. It is vital that the global focus on eliminating new infections in children does not overshadow the needs of children who are living with HIV. Paediatric antiretroviral treatment needs to be improved and made far more widely available.101
As HIV-related stigma and discrimination can affect children's testing and treatment adherence, negative attitudes towards those living with HIV need to be tackled. Efforts to maximise adherence should be strengthened and delivered before and alongside treatment.
General improvements in the health systems of low- and middle-income countries would allow for greater resources to be allocated towards treating children. Many countries lack the resources and capacity needed to help children living with HIV, and suffer from a shortage of healthcare workers that are trained to test and treat children. Rapidly expanding access to PCR testing, rather than relying on clinical diagnosis, would be a huge step in identifying those children who did need help.102
Just as with adults, antiretroviral treatment for children living with HIV is highly effective at reducing mortality and illness. In high-income countries, where access to testing and effective antiretroviral treatment for children living with HIV is more widespread than in low- and middle-income countries, children living with HIV are expected to survive well into adulthood.103 However, children with HIV face a number of challenges with regards to treatment; maintaining long term adherence despite a lack of suitable paediatric ARVs and dosing formulations, the risk of running out of drug options sooner in case of drug resistance, and the need for psychosocial support - particularly during adolescence.104 105
If improvements in these areas were made, the problems of HIV and AIDS among children could potentially be minimised. However, progress is not happening fast enough and hundreds of thousands of children with HIV continue to die every year. Greater advocacy, funding and effort on the part of governments, international organisations and donors are required if the challenges surrounding HIV treatment for children are to be overcome.
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