HIV Treatment for Children in 20 African Countries, 2012–2016: Wider Eligibility, a Stubborn Gap

Children with HIV can deteriorate fast, and opportunistic infections make HIV deadly for children under 15. Antiretroviral therapy (ART) has cut childhood HIV illness and death over the past decade — and as evidence grew that starting early saves lives, the World Health Organization kept widening which children should be treated regardless of their clinical or immune status:

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has supported treatment for children with HIV since 2003, and the countries it supports have updated their national guidelines in step. CDC looked at how quickly 20 PEPFAR-supported sub-Saharan African countries with the heaviest burden of childhood HIV adopted the guidelines, and at UNAIDS estimates of how many children were actually being treated.

How fast countries adopted the guidelines

• In 2012, 95% of the countries treated children under 2 regardless of status.
• The 2013 guidelines (under 5): adopted by 6 (30%) countries in 2013, 16 (80%) by 2014, and all 20 by 2015 — two years late in some.
• The 2016 "treat all" guidelines: adopted by 13 (65%) countries by the end of 2016.

Lags are normal: new guidelines need review and approval by national experts and leaders, and most low- and middle-income countries took almost two years to adopt WHO's 2010 guidelines. Evidence that early treatment reduces deaths is strong for babies under 1 but limited for older children — though early treatment has shown benefits for their growth, brain development and staying in care — which may also slow adoption.

How many children were treated

The share of children with HIV on ART rose from 24% in 2012 to 44% in 2016, and the gap narrowed every year. Even so, about 750,000 children — 56% — were still not on treatment in 2016.

Children with HIV, and those on ART, in 20 PEPFAR-supported countries, 2012–2016 (UNAIDS estimates). CDC

By country, 2016: coverage ranged from 5% in South Sudan to 66% in Namibia; in 11 of the 18 countries with data it was under 50%.

Pediatric ART coverage in 18 PEPFAR-supported countries, 2016 (UNAIDS estimates). CDC

Closing the gap

Wider eligibility isn't enough on its own. Other obstacles include uneven funding and supply of child-friendly HIV medicines, the constant need to train clinicians on new guidelines, and whether caregivers accept and can give the medicines. What's needed, the authors say:

• Find the children — active case-finding for the undiagnosed children counted in UNAIDS estimates.
• Link them to care fast — ideally starting ART the same day as diagnosis.
• Keep them in care — community support for retention and adherence, and tracking to restart children who were once ineligible or lost to follow-up.
• Adopt WHO guidelines promptly, and study what holds implementation back.

Limits

Guidelines were dated by publication, which may not match when policy actually took effect. UNAIDS figures come from complex models that are refined every year; PEPFAR's Population-based HIV Impact Assessments are improving them. For Lesotho and Zimbabwe, 2015 estimates stood in for 2016, which likely slightly overstated the number of children with HIV and understated coverage.

Sources

Based on Burrage A, Patel M, Mirkovic K, et al., "Trends in Antiretroviral Therapy Eligibility and Coverage Among Children Aged <15 Years with HIV Infection — 20 PEPFAR-Supported Sub-Saharan African Countries, 2012–2016," MMWR volume 67, number 19, Centers for Disease Control and Prevention; a work of the United States government in the public domain.