Now or never: The urgency of closing the treatment gap for children living with HIV/AIDS

An estimated 3.3 million children currently live with HIV, but only about a third of those in need of treatment receive it, compared with over half for adults. Without treatment, more than half of HIV-positive children will die before they turn 2, and 80% will die before the age of 5. Early diagnosis and treatment of babies with HIV is therefore an urgent public health priority – yet collectively we are failing in this area. While the World Health Organization's new HIV treatment guidelines recommend immediate ART for all children under 5, turning these recommendations into reality requires international and country-level political will and policy changes.

It is time for the international community led by UNAIDS to set an ambitious but feasible target for the number of HIV-positive children to be put on treatment. Countries with the highest paediatric HIV burdens, primarily in sub-Saharan Africa, must take the lead to scale up treatment coverage for their HIV-positive children.

In order to reach a global treatment target, development of new and improved health tools is urgently needed. Many babies born with HIV are not getting diagnosed and treated for various reasons, including limited access to HIV testing for pregnant women and failure to keep HIV-positive mothers and babies in antenatal, post-natal, and HIV care. Also, current rapid tests do not detect HIV in infants and very young children, and sophisticated laboratory requirements for early infant diagnosis (EID) limit the availability of early testing in resource-limited settings. We urgently need a simple, point-of-care EID test that can rapidly diagnose HIV in primary health care centers at the village level. The community can play an important role in building a support system for families affected by AIDS and in reaching out to more children at risk of HIV.

Even if EID is achieved, the lack of appropriate medicines for children is a major hindrance for scaling up treatment. Currently available ARV formulations for infants and young children taste horrible, contain alcohol, are difficult to store and transport, require refrigeration, have complex dosing requirements, and have undesirable interactions with tuberculosis drugs. Also, current ARV formulations do not meet the new WHO guidelines recommending the use of protease inhibitor-based first-line regimens for all children under 3 years of age.

To address this gap, the Drugs for Neglected Diseases initiative (DNDi) is partnering with Cipla to develop two 4-in-1 ARV fixed-dose combinations (LPV/r/AZT/3TC and LPV/r/ABC/3TC) designed specifically for children under the age of 3, or until they are able to swallow tablets. This new formulation will be in the form of taste-masked granules that can be mixed with food or drink, with easy dosing for caregivers and health care workers and requiring no refrigeration. To counteract the interaction with TB drugs, a stand-alone ritonavir granule formulation is also in development.

With no political voice or visibility, young children with HIV continue to be neglected. Collectively we must speak and act for children living with HIV/AIDS to make available new, game-changing health technologies and to work together towards closing the treatment gap urgently. There can be no excuses for continuing to let children with HIV/AIDS fall by the wayside in the global fight against HIV/AIDS. (By Janice Lee, Program Manager of DNDi's Paediatric HIV Programme and Dr. Marc Lallemant, Head of DNDi's Paediatric HIV Programme).

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