I. Executive Summary

The challenge

Approximately 2.1 million children under age 15 are living with HIV/AIDS, including almost 1.3 million in the 15 focus countries of the President�s Emergency Plan for AIDS Relief (the Emergency Plan).1 HIV-positive children are especially vulnerable and, without treatment, the majority of infected children die before they are two years of age.

Preventing, diagnosing and treating pediatric HIV/AIDS all present daunting challenges. The limited capacity of health systems in resource-poor nations affects pediatric HIV/AIDS care, as it does a range of other health issues.

The most effective way to prevent HIV in children is through the prevention of mother-to-child transmission (PMTCT). PMTCT is challenging in resource-limited settings, beginning with difficulty in getting pregnant women to access antenatal care and HIV prevention programs in the first place. Even when women are reached with prevention services, there are significant barriers of stigma, reluctance to return for HIV test results, issues related to delivering short-course preventive antiretroviral drugs (ARVs) in situations where women have their babies at home, and the complexities of infant feeding for an HIV positive mother. Prevention in older children is best promoted through abstinence until marriage programs.

Diagnosis of children � especially the young children most likely to be infected -- is complex and expensive. Technologies to improve pediatric diagnosis are not yet widely available, and shortages of trained health workers are a major problem.

Long-term combination antiretroviral treatment (ART) for children also poses special challenges. ARVs are often unavailable in pediatric formulations, partly because they are often much more costly than adult drugs. Pediatric regimens can be difficult to follow because of the complexity of dosing by weight. Communities do not always focus on the special issues of children with HIV/AIDS, whose parents may be ill or dead, and their caregivers often lack needed support. Even where there is a community response, older children in particular have issues that may be neglected.

The Emergency Plan response

The Emergency Plan has brought U.S. leadership to bear on the pediatric HIV/AIDS crisis, as part of the U.S. response to the overall emergency. With governmental and nongovernmental host country and international partners, the U.S. Government is scaling up a family-based approach to prevention, treatment and care for children infected with and affected by HIV/AIDS. Total funding for these program areas in the focus countries is shown in Table 1, while Table 2 summarizes early Emergency Plan results in providing a range of prevention, treatment and care services to children in the focus countries.

[Editor's note: The following table also is available as text-only.]

Table 1: Funding levels for child prevention, care and treatment programs by program area and fiscal year in focus countries, 2004-2005
  Total FY04 obligations
(a) (b)
Total Planned Funding
for FY05 (a) (c)


$36,321,956 $83,015,188


$62,825,193 $79,205,052


$9,850,331 (e)

ARV Drugs

$161,443,865 $221,981,452

ARV Services

(d) $204,207,607

Laboratory Support

$26,477,855 $58,620,461

(a) Totals reflect country-managed budgets and central funding.
(b) Total obligations as of September 2004.
(c) Planned funding for FY05.
(d) In FY04, all funding for anti-retroviral therapy (ART) (other than PMTCT+) was included in the antiretroviral (ARV) drugs line item; in FY05, it was broken out into ARV drugs and ARV services.
(e) The PMTCT+ program expanded PMTCT programs to include ART for eligible HIV-infected mothers and other members of the mother�s immediate family. Beginning in FY05, it was integrated into the ARV drugs and ARV services categories.

[Editor's note: The following table also is available as

Table 2: Summary of child prevention, treatment and care results in focus countries, 2002-2005
Timeframe October 2002 - March 2004 October 2003 - September 2004 October 2004 - March 2005 October 2003 - March 2005
  2003 FY04 Upstream Results (a) FY04 Downstream Results (b) FY04 Total Results (c) FY05 Mid-year Upstream Results (a) FY05 Mid-year Downstream Results FY05 Mid-year Total Results (c) Emergency Plan Upstream Results: cumulative total of FY04 and FY05 mid-year results (a) Emergency Plan Downstream Results: cumulative total of FY04 and FY05 mid-year results (b) Emergency Plan Total Results: cumulative total of FY04 and FY05 mid-year results (c)
Total Number of Infant Infections Averted (d) 6,422 14,706 9,063 23,766 6,460 7,410 13,851 21,166 16,473 37,696
Number of Pregnant Women Receiving PMTCT Services 355,300 671,100 600,200 1,271,300 227,700 593,600 821,300 898,800 1,193,800 2,092,600
Number of Women Receiving Short-Course Preventive ARVs for PMTCT 33,800 77,400 47,700 125,500 34,000 39,000 72,900 111,400 86,700 198,400
Number of OVC Served (h) 78,700 551,500 630,200 343,500 445,800 789,300 (e) (e) (e)
Total Number of Children (0-14) on ART (h) (f) 4,800 4,800 (f) 9,500 9,500 (f) (g) (f),(g)

NOTES: Numbers may be adjusted as attribution criteria and reporting systems are refined. Reporting in 2003 was for an 18-month period, from October 2002 through March 2004 as the International Mother and Child HIV Prevention Initiative was integrated into the Emergency Plan. Reporting in FY04 was from October 2003 through September 2004. As such, there is some overlap in reporting during the months between October 2003 and March 2004.
(a) Number of individuals reached through upstream systems-strengthening includes those supported through contributions to national, regional, and local activities such as training, laboratory support, monitoring and evaluation, logistics and distribution systems, and protocol and curriculum development. See text box on �How U.S. support is provided.�
(b) Number of individuals reached through downstream, site-specific support includes those receiving services at USG-funded service delivery sites. See text box on �How U.S. support is provided.�
(c) Total results are the sum of upstream and downstream results, with exceptions cited in other footnotes.
(d) The number of infant infections averted was calculated by multiplying the total number of pregnant women who received short course preventive ARVs (upstream and downstream) by the efficacy rate of this intervention, currently estimated to be 19%. Estimates for infant infections averted are not rounded to ensure consistency with estimates previously published in Engendering Bold Leadership: The President's Emergency Plan for AIDS Relief, First Annual Report to Congress, March 2004.
(e) Because the extent of overlap between OVCs served in different time periods is uncertain, it is not possible to sum the 2004 and 2005 totals.
(f) Age data for persons who receive upstream support for ART is not available.
(g) ART support figures are �snapshots� as of the end of the reporting period and thus cannot be added.
(h) Significant USG support for OVC and ART programs began in FY04.

Support for pediatric HIV prevention

It is estimated that over 90% of childhood HIV infections result from transmission from mothers to their children during and soon after birth. Preventing childhood infections through PMTCT programs has been one of the highest priorities of the U.S. Government in the fight against AIDS. The President�s International Mother and Child HIV Prevention Initiative launched some of the first programs in this critical area, and provided the foundation for current work under the Emergency Plan. PMTCT programs offer short-course preventive ARVs to mothers and infants to prevent HIV transmission to their babies. This short course can reduce the risk of HIV transmission of HIV to children by approximately 50 percent. These programs took the first step in addressing HIV/AIDS in environments where long-term ART was not available. The programs were also among the first to address the critical need to treat mothers and fathers who were sick with AIDS and needed long-term ART, as well as children who may have become infected in spite of short-course ARVs, preserving families and preventing a generation from being orphaned.

Beginning in FY2004, the first year of Emergency Plan implementation, emphasis was placed on supporting national strategies to expand PMTCT programs as well as ART for pregnant women and their families. This required strengthening health care systems, including infrastructure and human capacity, and improving monitoring of PMTCT programs. Through March 2005, the Emergency Plan supported training for approximately 37,600 health care workers in PMTCT services, and provided support for 2,200 PMTCT service sites in the focus countries.

Through March 2005, the Emergency Plan provided support for counseling and testing of over 2 million pregnant women. Nearly 200,000 HIV-positive pregnant women in the focus countries received short-course preventive ARVs. Under internationally accepted standards for calculating infections averted, the Emergency Plan has supported programs that have prevented the infection of an estimated 37,600 newborns. In addition to short-course preventive ARVs, Emergency Plan-supported PMTCT services include follow-up after birth to ensure that exposed children receive adequate diagnosis and treatment for opportunistic infections.

Support for pediatric HIV diagnosis

Diagnosing children, especially infants, with HIV/AIDS is difficult because the traditional tests used for adults are not effective until after the child is 18 months old. Because 50 percent of children die before the age of 2, early diagnosis is essential. The Emergency Plan is supporting host country efforts to make diagnostic tests more widely available, improve the capacity of laboratories, and ensure the availability of appropriate technologies for testing children. Efforts to expand a network of laboratory services to rapidly reach the largest possible number of children have initially emphasized development of national laboratory strategies, infrastructure renovations, training of personnel, and development of quality-assured laboratory services. Support has been, and continues to be, provided for these efforts in each of the focus countries.

U.S. Government support is helping to make these newer polymerase chain reaction (PCR) tests available.  PCR tests are effectively used to identify HIV-positive children before they are 18 months old.  The USG is pioneering the use of dried blood spot tests that can bring down costs and ease the burden of testing.

In addition, the Emergency Plan supports expanding information and training related to testing children and, where testing is not an option, improving clinical diagnosis based on symptoms. As with all Emergency Plan interventions, support is provided with an eye to long-term sustainability by developing local capacity and strengthening systems.

Support for pediatric HIV treatment

Because ARV doses are dependent on weight and other biologic factors that may differ for adults and children, pediatric ARV formulations are necessary, and the Emergency Plan is working to ensure their availability. The U.S. Government has created an expedited review process for generic versions of ARVs, including pediatric formulations, and is hopeful that such products will be submitted for review and approval, providing additional sources of high-quality, inexpensive products.

Children exposed to HIV or living with AIDS may require a broad range of additional health interventions. The Emergency Plan thus promotes a comprehensive package of other services to prevent other infections that can lead to illness or death. This pediatric preventive care package includes life-saving interventions such as cotrimoxazole prophylaxis to prevent opportunistic infections and diarrheal disease; screening for tuberculosis and malaria; prevention of malaria using long-lasting insecticide-treated mosquito nets; and support for nutrition and safe water.

From the outset, the Emergency Plan has recognized the importance of supporting treatment for children and has required the dissaggregation of treatment data so that the number of children served can be determined. The Emergency Plan is the only major global HIV/AIDS program to require such reporting. Therefore, age-specific data are available only for programs for which the U.S. Government provides downstream support.

In FY2004, a minimum of 4,800 children received life-saving ART with support from the U.S. Government. According to data from the first half of FY2005, the number of children receiving support for treatment has increased sharply, to a minimum of 9,500. This represents almost 7% of the total number of patients for whom the Emergency Plan is supporting ART treatment through downstream program support. These figures likely underrepresent the actual numbers, as there are a number of sites that have not yet disaggregated patients by age.

Considering the constraints, these numbers represent important initial steps. However, there are still many more children who need help, and the U.S. Government plans to accelerate progress in FY2006. Key initiatives include: establishing targets for children on treatment at the country level; working with international partners to ensure affordable pediatric ARV formulations and diagnostic techniques; training health care providers in pediatric treatment; and working at the community level to fight stigma and provide support to children and their caregivers.

Future priorities

Despite encouraging progress, the challenges in combating pediatric HIV/AIDS are significant. The Emergency Plan is taking steps on several fronts to address these challenges. Incorporating a family-based approach and increasing the capacity of both adult treatment centers and maternal and child health programs to integrate pediatric HIV prevention, treatment and care is an important beginning. Stronger linkages among providers are key, as progress is made toward seamless PMTCT, treatment, care and community services for children and families.

Ensuring that ARVs are available that are appropriate for children to take and easy for caregivers to dispense will also improve adherence to what will be a lifetime of treatment.

Across all efforts, there will always need to be a focus on defeating stigma.

The Emergency Plan is already working to improve assessment of the impact of ART on children and monitoring and evaluation of pediatric programs. Disaggregation of data by age will remain a high priority, and the FY2006 Country Operational Plans (COPs) will improve attribution of resources to pediatric programs.

A recently-created, interagency PMTCT/Pediatric HIV Working Group, which has drawn on some of the world�s experts in the area, has developed guidelines for focus countries for FY2006.  These guidelines will help country teams to identify treatment targets for children, improve infant diagnosis and follow-up, systematize infant and childhood HIV testing, and increase access to treatment.

1 The fifteen focus countries are: Botswana, Cote d�Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia.

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