Prioritizing Pediatric HIV Diagnosis, Care,
Support and Treatment
Pediatric Working Group
Interagency Task Team on Prevention and
Treatment of HIV Infection in Pregnant Women,
Mothers and their Children
July 2011
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Pediatric HIV disease remains a major
global health issue

The burden of pediatric HIV disease is high, despite PMTCT
 2.3 million children currently living with HIV
 This represents 7.5% of the total number of people with HIV
 370,000 new pediatric infections globally in 2009
 This represents 15% of the total number of new infections each year

Mortality in untreated children is very high
 260,000 deaths in children with HIV annually
 Without treatment, 50% of infected children will die before age 2

Treatment and PMTCT interventions can reduce MTCT rates to <5%
 But in 2009 only 50% of HIV+ pregnant women had access to PMTCT
 And 30% of those received suboptimal prophylaxis with sd-NVP
 Overall, pregnant women have the poorest access to treatment with only 15%
of those who are eligible on ART
Source: Universal Access Report, 2010
Interventions to test and treat children lag
significantly behind adults

Early infant diagnosis (EID) is essential to identify infected infants
 But despite significant scale up - only 15% of HIV-exposed infants have access
to EID

Treatment is a life-saving intervention and all infected infants and children
< 2 years are eligible for treatment
 Only 28% of children in need of treatment are on ART (compared to 37%
eligible adults)
 Access for infants is even lower

Adolescents living with HIV are a growing group in need of services.
Source: Universal Access Report, 2010
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Treatment 2.0 – re-galvanizing efforts to
reach universal access for adults and children
Treatment 2.0:
Is a global initiative to re-galvanize efforts to achieve universal access for adults
and children living with HIV and maximize the impact of HIV treatment on HIV
prevention to avert 10 million deaths by 2025
Treatment 2.0 comprises five key pillars:
1. Radically simplified HIV treatment with optimised drug regimens in once
daily combinations
2. Prioritize point-of-care and other simple-to-use diagnostics
3. Reduced costs of commodities
4. Improve and decentralize service delivery
5. Strengthen community mobilization
Elimination of MTCT – reducing new HIV
infections in children by 90%
The Global Plan to Eliminate Mother-to-Child Transmission (eMTCT) of
HIV and Keep Mothers and Children Alive:
Is a new effort to reduce new HIV infections in children by 90% or to fewer than
40,000 new pediatric infections globally over the next 4 years
Increased efforts to improve access to maternal treatment, to PMTCT and to
infant testing
These new global initiatives offer a real
opportunity to address HIV/AIDS in children

Both Treatment 2.0 and eMTCT provide an unprecedented opportunity to
address the burden of pediatric HIV and AIDS
 Elimination of MTCT will result in far fewer infected children
 EID scale up is necessary for global programme evaluation, and as more
HIV-exposed infants are tested, more infected infants will be identified
 As treatment becomes simpler and more decentralized, it will become easier
to provide access to children living both in urban and rural areas

Even as the most effective PMTCT interventions are widely scaled-up,
there will be a continuing need for pediatric treatment – both for the 2.3M
children already infected and for those that become infected despite PMTCT
services
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Why prioritize children?

Each day that goes by, almost 800 HIV-positive children die because of lack of
access to testing, treatment and care

With treatment, children with HIV can survive into adulthood and live healthy
and productive lives

Recent innovations include the introduction of infant diagnosis using dried blood
spots and the development of affordable pediatric fixed dose combination ARVs
which improve quality of care for children living with HIV and greatly simplify
ART

Mortality from pediatric HIV contributes significantly to overall child mortality
especially in high-burden countries. In order to achieve MDGs 4 & 6 by 2015, we
must take action now
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Policy
• Low level of political commitment
• Limited funding
• Poor understanding of child-specific issues
Operations
• Vertical programming not well linked to MCH
• Slow uptake of new pediatric drugs
• Few linkages from testing to treatment, so poor
retention
Infrastructure
2,300,000 children living with HIV
Bottlenecks occur at all levels to limit access
to ART for children
• Too few pediatric equipped sites
• Too few pediatricians to manage disease burden
• Low uptake of supportive interventions
356,400
children on
ART
Globally, only
28% of
children in
need
received ART
At policy level, there is a need to advocate
for child rights and fund child interventions

Incorporate child protection elements into the national discourse and legislative
procedures

Ensure appropriate funding allocation for pediatric activities within national and
donor budgets for pediatric HIV programming
In operations, address access to child FDCs
improve integration and decentralize care

Focus on integration to strengthen MCH through investments in pediatric
treatment and prevention

Improve access to quality affordable pediatric fixed dose combinations

Strengthen management capacity at national level

Decentralise diagnosis, care, support and treatment
Through infrastructure, strengthen human
and physical resources and capacity

Build up human resource capacity to manage pediatric HIV

Task shifting to nurses and other personnel enable scale-up of treatment services
in areas with pediatrician shortages

Empower all treatment sites to manage children in a family centred approach

Offer supportive interventions especially for vulnerable populations such as
adolescents
Six challenges, and six interventions for better
access to pediatric testing and treatment
1
Infants are hard to diagnose yet
very vulnerable
2 Too few pediatric specialists
Expand access to Early Infant
Diagnosis (EID)
Task shift pediatric ART
3
Fragmentation of the ARV
market by many similar products
Rationalise pediatric ARV
formularies
4
Increasing number. of
adolescents with particular needs
Meet special needs of
adolescents
5
Too many children are LTFU –
all along the care continuum
Increase pediatric retention
6
Access to pediatric treatment
lags partly due to low targets
Set higher targets for pediatric
testing and treatment
Contents
Current state of pediatric HIV & AIDS
Global initiatives in the fight against HIV in children
Why prioritize children?
Bottlenecks and challenges
Priority interventions
Priority intervention 1: Expand access to EID
Key Challenge: Infants are the most vulnerable to disease progression, and EID is
essential to diagnose infection in infants

Access to EID is currently limited (15% exposed infants globally) but is an
essential 1st step to begin pediatric treatment

Diagnosis of HIV infection in infants <18 mos. requires PCR or other types of
virologic testing

Innovative technologies and improved
communication strategies are now
available to scale-up access to EID
services even in resource-constrained
settings
Priority intervention 1: Expand access to EID

Several countries have successfully scaled up EID programs and improved
access to treatment for infants using centralized PCR, sample transport,
electronic result return and strong linkages to care

To increase EID coverage, different entry points for HIV exposed infants
need to make active referrals
Priority intervention 2: Task shifting for
Task Shift pediatric ART
pediatric ART
Key Challenge: There are too few pediatric specialists in resource limited countries
– task shifting is critical to increase access

Shortage of pediatricians in developing countries limits scale up of pediatric
HIV care and treatment

Task shifting to alternative personnel including to nurses is a cost-effective way
to address human resource gaps while maintaining a high standards of care

Effective task shifting includes adjusting policy, defining clear roles and
appropriate supervision

Most of the evidence to date on task shifting in HIV has focused on adult
services. Care must be exercised in task shifting to account for special issues
associated with diagnosing, caring for, and treating children.
Priority intervention 2: Task shifting for
pediatric ART

Multiple resource-limited countries (see map) have been able to demonstrate
successful ART initiation by training non-physician health workers
NIGERIA: Nurse ART
treatment helped reduce
waiting time by 4 hours
(Udegboka et al, 2009)
LESOTHO: Nurses treated both
children and adults, leading to
increased enrollment of
patients, increased enrollment
of children in care and
decreased numbers of adults
with very low CD4 counts
(<50). (Cohen, Lynch et al.
2009)
SOUTH AFRICA: Compared outcomes between
nurse and doctor-led management of adults
(neither group had previous HIV experience)
found no difference in mortality viral failure or
immune recovery. (Sanne, Orrell et al. 2010).
UGANDA: Both nurses and clinical
officers demonstrated strong
agreement with physicians in
assigning clinical staging and
deciding whether to initiate
antiretroviral therapy (Vassar,
Kenya Mugisha et al. 2009)
ZAMBIA: Good pediatric outcomes
reported in clinics managed by
clinical officers and nurses (BoltonMoore Mubiana-Mbewe et al. 2007)
MOZAMBIQUE: Non-physician
caregivers achieved higher levels of
adherence to ARVs in the first 6
months after initiating ART and
were less likely to be LTFU than
those seen by physicians (Sherr,
Micek et al 2010)
Priority intervention 3: Rationalize the
Rationalize pediatric ARV formularies
pediatric ARV formulary
Key Challenge: The pediatric ARV marketplace has become fragmented by
numerous duplicative products, which threatens sustainability
The CHAI-UNITAID program has served as one mechanism to decrease cost of
pediatric treatment by pooling procurement and rationalizing choices of pediatric
ARVs, however this program is ending in 2012
In order to ensure the sustainability of pediatric HIV treatment programs pediatric
ARV formularies should be optimized around the least number of products and
programs should phase out outdated formulations and regimens
Priority intervention 3: Rationalize the
pediatric ARV formulary
The optmization of the pediatric formulary is essential not
just to decrease costs but also to ensure sustainable and assured
access to current and new pediatric drugs
Governments should be encouraged to rationalize their
pediatric formulary and identify single-drug products and
syrups that can be phased out in favor of cheaper, easier to use
dispersible FDC formulations
To secure uninterrupted supply of pediatric ARVs national
HIV programs and their partners should consider
Rationalizing pediatric ARV formularies
Accelerating the phase out of old formulations
Participating in pooled procurement / coordinating
buying mechanisms
Priority intervention 4: Provide services
Meet
for
adolescents
special needs of adolescents
Key Challenge: Current programs do not address the needs of a growing adolescent
population

More children with HIV are now surviving into adolescence and adulthood

Adolescents living with HIV face a unique set of challenges not met through
pediatric or adult focused programs

Adolescent specific services are needed to address both physical and
psychological needs of this group
Whether infected at birth or
later in life, adolescents living
with HIV face a variety of
unique challenges that the
health sector is only now
beginning to recognise
Priority intervention 4: Provide services
for adolescents

Important areas of focus for this special population include:
 Mental health
 Transition from pediatric to adult care
 Sexual reproductive health issues

Meaningful involvement of adolescents living with HIV is essential to the
design, delivery, evaluation of treatment, care and support services.
Priority intervention 5: Improve pediatric
Increase pediatric Retention
retention
Key Challenge: Too many children are lost along the continuum of care

Over 50% of positive pediatric patients are estimated to be lost across the
between testing and initiation of treatment

Children have particular vulnerabilities that make pediatric retention a more
complex issue
(Pediatric HIV)
1
.
Testing here refers to Early Infant Diagnosis testing only, based on a 5-country analysis of all patients from sites available to CHAI (n=4970)
in Cameroon, Ethiopia, Kenya, Swaziland, and Zambia.
2 Based on 8-country analysis of all patient charts from sites at which data were made available to CHAI (n=18,077) in Cameroon, Dominican Source: CHAI 2010
Republic, Ethiopia, Kenya, Nigeria, Rwanda, Swaziland, and Zambia.
Priority intervention 5: Improve pediatric
retention
 Strategies to improve pediatric retention in care include:
1.
2.
3.
4.
Improving quality of service
Enhancing linkages between testing programs such as EID and treatment
Focusing on Pre-ART patients
Addressing costs of care to families
Priority intervention 6: Set ambitious targets
Aim higher for pediatric targets
for pediatric testing and treatment
Key Challenge: Target setting is not aggressive and access to pediatric treatment still
lags significantly behind adults
Resource-constrained HIV-programs often neglect specific needs of pediatric
patients
ART coverage is not equitable and far fewer children have access to ART compared
to adults
Setting new and ambitious targets for pediatric treatment prioritizes the need to
close this gap and save lives
Targets for testing and treatment should be set at national, district and facility levels
Priority intervention 6: Set ambitious targets
for pediatric testing and treatment

Countries should develop and utilize improved national pediatric treatment
targets that reflect and include the following:

An overall goal of at least 80% of children in need receiving ART

Sub-national numeric targets based upon the goal of at least 80% coverage

The same access to ART for
children as for adults

Specific targets for ART in
children under age 2

WHO recommendations for
universal testing of infants in
high burden settings
Summary
Current state of pediatric HIV & AIDS
 Pediatric treatment currently is currently lagging and thousands of children are
dying every year
Global initiatives in the fight against HIV in children
 Ambitious global commitments have been made towards battling HIV in
children, including Treatment 2.0 and the Campaign to eliminate MTCT
Why prioritize children?
 Expanding access to pediatric prevention, care and treatment is an essential
part of meeting global targets and necessary to prevent 800 deaths/day
Bottlenecks and challenges
 New technologies and strategies are being developed to expand access to
testing and treatment for all children in need
Priority Interventions
 Key interventions to increase access to pediatric care and treatment should be
used to help achieve the goal of providing a better future for our children