Paediatric care and treatment

Fast fact:

• Of the 1.37 million [1.11 million-1.73 million] children aged 0-14 living with HIV globally, only 57 [41-75] per cent were receiving life-saving antiretroviral therapy (ART) in 2023.

Globally, children under age 15 account for about 3 per cent of all people living with HIV, 9 per cent of new HIV infections and 12 per cent of all AIDS-related deaths. Children under 1 year of age are among those most vulnerable to HIV. Evidence shows that early initiation of antiretroviral drugs in infants with HIV can save lives; yet coverage of critical intervention among children remains too low. Due to the slow progress reported in scaling up access to treatment for children living with HIV, the 90-90-90 treatment targets, which called for 90 per cent of those living with HIV to know their status, 90 per cent of those who know their status to be on treatment, and 90 per cent of those on treatment to be virally suppressed and sustained, were not met. However, there has been a renewed focus to meet 95-95-95 targets by 2025 including the the Global Alliance to End AIDS in children.

Renewed focus has been called to strategically target more decentralized diagnostics and clinical management for children exposed and living with HIV, as well as integration with maternal, child and adolescent services at facilities and within communities. The 2025 targets underscore the need to remove societal and legal barriers to service delivery, as well as recognize that the HIV response is essential in the wider effort to realize the right to health and other human rights and other goals within the 2030 Agenda for Sustainable Development.

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HIV burden in children

Fast fact:

• Of the estimated 1.37 million [1.11 million-1.73 million] children under 15 years of age living with HIV, 86 per cent live in sub-Saharan Africa.

In 2023, 67 [58-83] per cent of the estimated infants exposed to HIV were tested for HIV within two months of birth globally. International guidelines advise that immediate antiretroviral therapy is crucial if HIV infection is detected in any child under the age 5 years. In reality, most children entering treatment programmes are older, with only 29 per cent of all children under 15 years of age on antiretroviral therapy being under the age of 5 years in 2023.

An estimated 1.37 million [1.11 million-1.73 million] children under age 15 were living with HIV in 2023. In 2023, 120,000 [83,000-170,000] children were newly infected with HIV, mainly through transmission of the virus from their mothers during pregnancy, delivery or while breastfeeding.

In 2022, an estimated 76,000 [53,000-110,000] children under age 15 died of AIDS-related causes globally. The vast majority of these deaths were preventable, either through antibiotic treatment of opportunistic infections and/or through antiretroviral treatment.

There has been some progress in antiretroviral coverage for children living with HIV

Fast facts:

• In 2023, about 777,000 children under age 15 were receiving antiretroviral therapy (ART) globally, up from about 444,000 in 2010. However, it is worth noting that the number of children under age 15 accessing ART declined by 81,000 between 2020 and 2023.
• This means that just over half of children under the age of 15 living with HIV are receiving ART (57 [41-75] per cent).

In 2023, coverage of eligible children under age 15 receiving ART varied widely, ranging from under 10 per cent in some countries to over 95 per cent in others. Regionally, coverage of ART for children ranged from 35 [29-44] per cent in West and Central Africa to 93 [75->95] per cent in South Asia. Coverage data for America and Western Europe are not available.

Despite some progress in antiretroviral therapy coverage for children living with HIV, there are alarming proportions of children who do not know their HIV status and are therefore being left behind in the response especially when compared to adults aged 15 years or older. Globally, 34 per cent of children living with HIV do not know their status compared to only 13 per cent of adults who do not know their status. Furthermore, only 57 per cent of all children living with HIV are on antiretroviral therapy compared to 77 per cent of adults, and 48 per cent of children living with HIV are virally suppressed compared to 73 per cent of adults.

The 95-95-95 cascade shows stark differences globally between adults and children.

There is considerable regional variation in the 95-95-95 cascade, with children being left behind across most regions when compared to adults.

There is substantial regional variation in progress towards the 95-95-95 targets especially when comparing children aged 0-14 with adults ages 15 years or older. In only two regions do children have greater progress towards the 3 95s when compared to adults – South Asia (children: 94-93-77 vs adults: 74-63-62) and Eastern Europe and Central Asia (children: 75-73-63 vs adults: 60-51-43). In all other regions, children have far lower progress on the 3 95s compared to adults with the greatest discrepancy being in West and Central Africa (children: 39-35-30 vs adults: 84-79-73).

Even among those children who know their HIV status, concerning proportions of children are either those not on ART or on ART and not virally suppressed. Concerted efforts are needed to ensure that these children are not being left behind and being linked to care.

Early diagnosis and timely initiation on treatment are particularly critical in the case of infants. The ‘Children with HIV Early Antiretroviral Therapy’ study from South Africa demonstrated a 76 per cent reduction in mortality when treatment is initiated in the first 12 weeks of life among infants who test positive for HIV.

Countries have made some progress in expanding access to early infant HIV-testing services, but testing rates are still low. WHO’s revised treatment guidelines recommend that infants, if HIV-exposed, should be tested by 4 to 6 weeks and 9 months of age using virologic assay, and when the child stops breastfeeding with a rapid antibody test. Those found positive should be started on antiretroviral therapy immediately upon diagnosis.

With progress in expanding access to early infant HIV-testing services and antiretroviral treatment for children, we are seeing these children surviving and aging out of childhood into adolescence. In 2023, nearly 120,000 children aged out at age 15 globally. More than 70 per cent of these children aging out at age 15 are found in high burden regions of Eastern and Southern Africa, followed by about 20 per cent in West and Central Africa. However, the gains that were made in the early 2000s have begun to plateau in recent years.

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