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HIV Treatment for Children

An HIV-positive child in South Africa

Treating children who are diagnosed HIV-positive with antiretroviral drugs within their first 12 weeks of life reduces mortality by 75 percent. 1 Without treatment, a third of children living with HIV die before their first birthday, and half before their second. 2

The World Health Organisation published international recommendations on antiretroviral treatment (ART) for HIV among children (paediatrics) in 2013. The guidelines on this page reflect the WHO recommendations. 3

Testing children for HIV

Most children living with HIV become infected through mother-to-child transmission. Children born to mothers living with HIV need to be tested as soon as possible after birth to find out if they are infected with the virus and start antiretroviral treatment if necessary. Unfortunately, only 35 percent of children in this situation are tested. 4

Testing infants under 18 months

Polymerase Chain Reaction (PCR) tests

PCR testing checks for any trace of HIV genetics in an infant's blood, and can usually be done at the clinic where the infant is being tested. 5 Where this technology is available, the longest the infant will have to wait for an accurate result is around six weeks. 6

Dried blood spot tests

If PCR testing is unavailable at the clinic, dried blood spot testing takes samples of the infant's blood which is collected on paper and sent to a laboratory where the dried blood is tested for HIV. As dried blood spots can be stored for a long time and easily transported, this is a common way for infants to receive an HIV diganosis in many countries.

An infant being tested for HIV This diagram outlines the steps taken to determine the HIV status of an infant under 18 months of age. 7

Testing children older than 18 months

Rapid diagnostic testing

Children older than 18 months should be tested using rapid diagnostic testing, which detects HIV antibodies in the blood. This is appropriate for children older than 18 months as they have developed their own antibodies to HIV, and no longer carry their mother's. 8

Antiretroviral treatment for children living with HIV

Children who start antiretroviral treatment early, before their immune system is badly affected, recover their CD4 levels more quickly. CD4 levels refers to the level of immune system cells remaining in the body that have not been destroyed by the HIV virus. 9

Children who are able to lower the virus in their body before they reach one year old, tend to have lower levels of the virus when they reach 8-20 years old. 10

When to start HIV treatment for infants under 18 months

  • ART should be given immediately to infants under 18 months of age who test positive. 11

If an HIV test is unavailable, the infant should be 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 breastfeeding has finished. 12

When to start HIV treatment for children under five years & over five years old

  • HIV-positive children less than five years old should start ART regardless of CD4 count or stage of infection.
  • HIV-positive children five years and older should start ART with a CD4 cell count of 500 cells/mm3 or less. The drug regimen depends on the age and weight of the child.
  • HIV-positive children showing severe or advanced symptoms of HIV infection should start ART immediately regardless of age. 13

Which antiretroviral (ARV) drugs should be used?

This diagram shows when children should start ART, and which drugs are recommended. 14 Individual countries will have their own guidelines, and so some healthcare professionals will recommend different drugs.

A healthcare professional will consider what medications the mother may have received during pregnancy, whether the child is still breastfeeding, and the child's age and weight. 15

Keeping children on HIV treatment healthy

“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 Initiative 16

Types of HIV drugs for children

Different antiretroviral drugsThere are many forms of antiretrovirals for children: tablets, syrups, powders and 'melts'. Infants often find it hard to swallow tablets and so may be given one of the other forms of ARVs. Research is underway to create ‘sprinkles’ that would dissolve in the mouth and be more palatable for children to take, as current liquids do not taste very nice. 17

However, these formulations are only slowly becoming available and are expensive. 18 19 Fixed-dose combination (FDC) drugs - where different ARV drugs are contained in one pill - are only really available for older children, as they near adult doses. 20

Dosing of ARV drugs for children

The dose of antiretroviral drugs given to children is generally based on their weight and age. 21 Children’s bodies are constantly changing and developing and it is vital that drug doses are altered to ensure that a child is not given too much, or too little of a drug. It is important for children to attend follow-up appointments so that healthcare professionals can know when to alter their dose. 22

In places where there is a lack of affordable ARVs for children, healthcare workers often divide adult fixed-dose combination drugs (FDCs) into smaller measures appropriate for children. However, this carries a risk of under- or over-dosing. 23

Monitoring CD4 count in children

To monitor the effectiveness of HIV treatment in a child, a CD4 test is carried out periodically. This measures the number of T-helper cells – white blood cells that are attacked by HIV – in an individual’s blood.

A falling CD4 count is a sign that HIV is progressing, and that the immune system is becoming weaker. However, CD4 counts vary with age, and younger children usually have a much higher CD4 count than adults.

In some cases, viral load testing (which measures the amount of HIV in a child’s blood) is used alongside CD4 testing to guide decisions about treatment. However, if no CD4 test or viral load test is available (as they are very expensive), the healthcare worker has to make a judgement about when a child should begin treatment depending on their stage of HIV infection, and based upon any other illnesses that the child may have. 24

Side effects of HIV treatment in children

Children taking ARVs can suffer from the same drug side effects as adults. Children are also likely to be exposed to treatment for longer than adults, as they have to take treatment throughout childhood and adulthood. 25

Some moderate or severe side effects may require switching drugs, or stopping the treatment altogether - this decision must only be made by a healthcare professional. In general, mild side effects do not require such changes, and treatment for the side effects may be given. 26

Adhering to HIV treatment

Children performing a play about the benefits of ARV medicineMost 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 at around the same time every day, HIV may become resistant to the treatment, causing it to stop working.

It can be difficult for children to take treatment, especially if there are many pills to take, the medicines taste bad, they must be taken with food or at specific times of the day. However, caregivers must support a child to ensure they always take their medication.

Drug resistance in children

Drug resistance is when certain antiretroviral drugs become unable to fight off HIV.

There are three ways that this could occur. The infant may have:

  • been infected with a drug-resistant HIV strain from their mother
  • inherited drug resistance from their mother during pregnancy, birth or breastfeeding
  • developed drug resistance during their own treatment. 27

It is important that a child on HIV treatment is routinely monitored, so that the treatment can be changed if their CD4 levels drop, or when they grow and put on weight. 28 29

Nutritional support whilst on HIV treatment

Children living with HIV who have no symptoms need to consume 10 percent more calories than other children of their age and sex. Children who have symptoms, or are recovering from infections, need to consume 20-30 percent more calories than other children. 30

When a child experiences rapid weight gain or loss as a result of ART, nutrition needs to be monitored carefully. As a child’s weight changes, so does the recommended dosage of ARVs, requiring drug doses to be constantly reviewed. 31

Opportunistic infections in children living with HIV

Opportunistic infections take advantage of weak immune systems, and often affect children living with HIV. Tuberculosis (TB) and PCP (a form of pneumonia) are major causes of illness among children living with HIV.

Preventing opportunistic infections

Children living with HIV need to be provided with treatment to prevent opportunistic infections. For children who have no access to ARVs, treatment for opportunistic infections may delay the need for antiretroviral treatment. 32

  • Co-trimoxazole

Co-trimoxazole is an antibiotic that can help to prevent infections such as pneumonia and TB. It is recommended that all children born to HIV-positive mothers take co-trimoxazole from 4 to 6 weeks of age, until tests confirm that they are HIV-negative. 33

  • Isoniazid preventive therapy (IPT)

IPT is treatment that prevents the development of tuberculosis (TB). It is recommended that HIV-positive children who have poor weight gain, a fever, a cough, or have had contact with a TB patient, but do not yet have TB, should be offered IPT regardless of their age. 34

  • Vaccines

Infants and children who are exposed to HIV via mother-to-child transmission should be given all routine vaccinations, as set out in that country's national guidelines. Children who have severely affected immune systems should be considered for inactivated vaccines, rather than live vaccines. 35

Health conditions in children living with HIV

A child born HIV-positive in ZimbabweAs well as opportunistic infections, it is important to be aware of other health conditions that children living with HIV are more vulnerable to. They vary between children, but usually are a result of a falling CD4 count or a high viral load, stressing the importance of children adhering to their treatment correctly. 36 For example:

  • Neurocognitive conditions

Children who are born to mothers living with HIV are more at risk of language issues as they grow up, including difficulty understanding spoken language, and expressing themselves verbally. 37 38 39  40 Adhering to paediatric antiretroviral treatment can prevent neurocognitive conditions from becoming severe. 41 42

  • Underdeveloped weight and height

Some children living with HIV will be shorter and more underweight than HIV-negative children. 43 The more severe the child’s HIV-related symptoms, the bigger the impact on their growth. 44

  • Bone density

Low bone mineral density has been found in children living with HIV. 45 Among HIV-positive children growing older with HIV, disruptions to their bone development can be problematic as this is a period of rapid growth and development. 46

Successful HIV testing and treatment for children

Parents and carers of children living with HIV need to provide practical and emotional support to their child, giving them the knowledge to become more independent as they grow older with HIV. 47 48

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