HIV Testing for Children in Resource-Limited Settings: What Are We Waiting For?

In many African countries, HIV has reversed previously recorded declines in child mortality. Worldwide, children account for 18% of HIV-related deaths and 15% of HIV infections each year [1]–[3], an estimated 2.3 million children are infected, and 730,000 urgently need antiretroviral therapy (ART), which only about 275,000 currently receive. The mortality of untreated pediatric patients is very high in the first 2 years of life, and reaches 80% by age 5 [4]. While the number of children under age 15 in low- and middle-income countries receiving ART rose dramatically between 2005 and 2007 (Figure 1), it is nonetheless evident that those children currently on treatment still represent only a small proportion of those who need it. Coverage will need to be greatly expanded if the global community's goal of providing ART to 80% of children in need by 2010 is to be met [1]. Figure 1 Number of children under 15 receiving antiretroviral therapy in low- and middle-income countries, 2005–2007. As more low-cost fixed-dose combination antiretrovirals (ARVs) for children become available, the issue of access to medication is less of an impediment to treatment (Table 1). Why then are so few children in developing countries on ART? We propose that the primary reason is insufficient identification of infected children. There are many causes for this—including poor coverage of services for prevention of mother-to-child transmission (PMTCT), poor linkages to infant testing programs, provider uncertainty on how best to diagnose and treat infants, and insufficient numbers of pediatric HIV treatment sites—but the end result is that many infected children are either never identified or lost from the system before they can be enrolled into care. We believe it is essential for national HIV programs to recognize that HIV testing and counseling systems designed for adults do not meet the needs of children. The time has come to develop and implement specific strategies to increase opportunities for children to access HIV testing, especially in sub-Saharan Africa. Table 1 Costs of Pediatric ARV for Resource-Limited Settings, 2009. As criteria for treatment initiation evolve and ART programs are scaled up in resource-limited settings, the need to expand HIV testing will become more urgent. Surveys in sub-Saharan Africa document 39% of adult men and women as having at some time been tested and received their results, up from 15% just 2 years before [3]. However, even when strong adult testing programs exist, access to pediatric testing remains low. The 2004 World Health Organization (WHO) HIV testing guidelines did not identify children as a specific target group for testing [5]. More recent WHO guidance on provider-initiated HIV testing provides direction on how to overcome barriers to testing children but offers little on how to operationalize pediatric testing [6]. Data from the South African CHER study highlight the survival benefit of early treatment for infants, showing an overall 75% decline in mortality in those infants who were started on ART immediately after diagnosis [7]. In response, the WHO has changed its treatment recommendations, calling for treatment of all infected infants under 12 months of age, irrespective of clinical stage [8]. This is a critical advance in treatment policy, which national AIDS control programs should adopt as soon as possible. But without better ways to identify infected infants, the policy alone will not change the treatment landscape in the short term. Although infant diagnosis is now available in many PMTCT programs, at current rates of PMTCT coverage, the majority of HIV-infected infants are born to mothers who were never tested and never received PMTCT prophylaxis. These infants are very unlikely to be identified and get on to treatment without targeted testing strategies. Scale up of testing programs for children will no doubt require investment in key areas such as training and support for providers, improvement of laboratory facilities and referral networks, and community mobilization, but such investments are necessary to reduce the substantial mortality of HIV in children. Because of the marked survival advantage among those identified and treated in a timely manner, the US Centers for Disease Control and Prevention has recommended routine HIV testing for US adults during contact with medical facilities [9]. This represents a clear shift away from voluntary testing (which emphasizes personal choice) toward an emphasis on the public and individual health benefits of improved identification and control of HIV disease and prevention of HIV transmission. Of course, success in operationalizing these recommendations depends on a well-functioning health care system—which does not exist in many of the countries most affected by the AIDS epidemic. As such, these recommendations have not been widely implemented in the most affected parts of the world, where making a diagnosis is most critical, particularly in children.