Children with HIV left behind in the race towards treatment for all

Ahead of this week’s 20th International AIDS Conference, experts have warned that children are being left behind in the goal to reach universal access to HIV treatment.

Ahead of this week’s 20th International AIDS Conference, experts have warned that children are being left behind in the goal to reach universal access to HIV treatment.

Community workers and non-governmental organisations came together at the Children and HIV symposium (18-19 July), to discuss how to tackle this issue and improve HIV treatment for children. According to UNICEF, globally, children under 15 account for about nine per cent of all people living with HIV, 11 per cent of new HIV infections and 13 per cent of all AIDS-related deaths. Children under one year of age are among those most vulnerable to HIV and among the least served by treatment and care services.

Abel, 7, is from Abidjan, Côte d’Ivoire and he is living with HIV. Whenever he takes his drugs his brother Tresor, 3, looks at him with envy. “I know these drugs make him smarter. I don’t know why mummy doesn’t want to me to have some,” he says sadly. In fact Abel and the boys’ parents, Anne and Patrice, are also living with HIV.

Anne says: “We found out about our status when both children fell sick and we were all required to get tested. Abel has already started the treatment while Tresor has not. The doctor says it is very difficult to initiate treatment with him considering his age. So we are still waiting.”

Treatment coverage for children living with HIV

Evidence shows that early initiation of antiretroviral drugs (ARVs) in infants with HIV can save lives, yet coverage among children remains too low – 34 per cent in 2012. In Côte d’Ivoire, out of the 450,000 people living with HIV, 63,000 are children. But while adult treatment coverage is estimated at 55 per cent, children’s treatment coverage is around just 16 per cent.

This situation is explained by many factors. Bukiki Sylvere, regional director at ITPC West Africa explains: “There is unavailability of point-of-care early infant diagnosis. There is also unavailability of most effective and adapted pediatric formulations for use in our resource-poor settings. Moreover, intellectual property rights and trends in pediatric formulation markets also constitute barriers.”

A pediatric doctor who did not want to be named said: “Antiretrovirals are developed for adults, most clinical trials are in adults, with doses and dosage forms designed for adults. But children cannot simply be dosed like small adults, as their metabolic capacity to absorb ARVs is not simply proportional to their weight. Safety, efficacy and dosage need to be determined via specific pediatric trials. Most ARVs were developed in tablet form, yet these are impractical for children under five, who require special liquid formulations. While older children can take tablets, those intended for adults often contain too large a dose. So you can understand it is very difficult to initiate treatment for children.”

Pediatric HIV treatment

Children ideally need to be given drugs in the form of syrups or powders, due to difficulties in swallowing. However, drug treatments involving syrups for children are generally more expensive. As a result, carers are often forced to break adult tablets into smaller doses, running the risk that children are given too little or too much of a drug.

Simplified treatment guidelines coupled with a range of fixed-dose combinations of ARVs that require only one or two pills twice a day make it easier to treat HIV in adults, but development of simplified drugs for children lags behind.

According to Bukiki: “Despite the 2013 World Health Organization simplified treatment guidelines that specify which drugs to use for children, countries have difficulty in getting simple and affordable combinations of the drugs. Two generic fixed-dose combinations should enter clinical trials this year, but there are frighteningly few second-line ARV drugs available for children in countries with large numbers of infected children.”

Pediatrics Aids on the agenda of the new aids response

Maya, 6, resides with her grandmother in Abidjan and is living with HIV. She lost her parents to AIDS-related illness years ago. Her grandmother is unemployed and there is barely enough money for food or medicine. Despite this, Maya is one of the lucky ones – every few days she is taken to Centre Intégré de Recherches Biocliniques d’Abidjan, the main centre that provides ARVs. “I am happy she is given drugs. I know the doctors will take good care of her so that she will live long,” her grandmother says smiling.

But Maya is one of the lucky ones. While everyone acknowledges achievements in reducing global rates of AIDS-related deaths, among children living with HIV the numbers have risen.

The theme of the conference taking place in Melbourne this week is ‘stepping up the pace’, and until this happens, Anne, Patrice and the other parents of children living with HIV will continue to rely on nothing but providence to protect their children.

As the UNAIDS executive director, Michel Sidibe said in his opening address: “We cannot run away from the crisis in pediatric AIDS. We must ensure 100 per cent treatment coverage for all children living with HIV. No child should die of an AIDS-related illness.”

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