Globally, children under age 15 account for about 5 per cent of all people living with HIV, 10 per cent of new HIV infections and 15 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.
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.
HIV burden in children
Fast fact:
- Of the estimated 1.72 million [1.23 million-2.17 million] children under 15 years of age living with HIV, 89 per cent live in sub-Saharan Africa.
In 2020, 63 [51-85] per cent of the estimated infants exposed to HIV were tested for HIV within two months of birth globally while in the UNICEF’s Strategic Plan HIV priority countries, this figure was a bit higher at 66 [54-90] per cent. International guidelines advise that immediate antiretroviral therapy is crucial if HIV infection is detected in any child under the age of 5 years. In reality, most children entering treatment programmes are older, with only 20 per cent of all children under 15 years of age on antiretroviral therapy being under the age of 5 years in 2020.
An estimated 1.72 million [1.23 million-2.17 million] children under age 15 were living with HIV in 2020 – 88 per cent of which were from UNICEF’s 35 HIV priority countries in the UNICEF Strategic Plan. In 2020, 160,000 [100,000-240,000] children were newly infected with HIV, mainly through transmission of the virus from their mothers during pregnancy, delivery or while breastfeeding. Approximately 80 per cent of these new paediatric infections occurred in the 35 HIV priority countries.
In 2020, an estimated 86,000 [59,000-140,000] 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. About 80 per cent of these AIDS-related deaths occurred in the 35 HIV priority countries.
There has been some progress in antiretroviral coverage for children living with HIV
Fast facts:
- In 2020, about 924,000 children under age 15 were receiving antiretroviral therapy (ART) globally, up from about 417,000 in 2010.
- This means that just over half of children under the age of 15 living with HIV are receiving ART (54 [37-69] per cent).
In 2020, 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 36 [25-47] per cent in West and Central Africa to >95 [57->95] per cent in South Asia. Coverage data for Eastern Europe and Central Asia, North 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. Globally, more than 40 per cent of children living with HIV do not know their status, with the lowest proportion of knowledge of status being 36 per cent in West and Central Africa and the highest being 96 per cent in South Asia.
Even among those children who know their HIV status, concerning proportions of children are either 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 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 2020, nearly 136,000 children aged out at age 15 globally – 91 per cent of which were in the 35 UNICEF HIV priority countries. More than 70 per cent of these children aging out at age 15 are found in Eastern and Southern Africa, followed by 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.
Protection, care and support for children affected by HIV and AIDS
A growing number of countries are developing national action plans for orphans and other vulnerable children. As of 2020, an estimated 15.4 million [10.6 million-20.9 million] children worldwide had lost one or both parents to due to AIDS-related causes. Three quarters of these children (11.5 million [8.1-15.4 million]) live in sub-Saharan Africa. Children orphaned due to AIDS make up 10 per cent of all orphans worldwide, but 21 per cent of all orphans in sub-Saharan Africa
Risks faced by orphans and other vulnerable children
Orphans and children considered vulnerable for other reasons, including HIV and AIDS, are at higher risk of missing out on schooling, living in households with less food security, and suffering from anxiety and depression. They are also in greater danger of exposure to HIV. Their experiences differ across families, communities and countries, and are influenced by a complex mix of variables, including children’s relationships to their caregivers, the wealth of their household and community, HIV prevalence in the area and many other factors. To care properly for orphans and vulnerable children, a minimum package of support is needed and includes access to services such as education, health care, social welfare and protection. However, without laws, policies and services that assist families and communities in caring for children at risk, such support tends to remain low.
Developing routine monitoring indicators and tools for collecting data on orphans and vulnerable children is difficult since a standard definition of ‘vulnerability’ has not been established and a minimum package of services has yet to be determined. In addition, poor coordination of services means there is the strong possibility that children will receive multiple services and be counted more than once, skewing the data used to inform programmes. Greater attention needs to be given to defining optimum services and beneficiaries as well as strengthening coordination and reporting on the services provided to orphans and vulnerable children.
Progress: National-level responses
The shift towards inclusive programming to help all vulnerable children, including those directly affected by AIDS, is making an impact. The growing call for a broader, more inclusive definition of vulnerability is reflected in many national action plans. In Zimbabwe, for instance, the National Plan of Action for Orphans and Other Vulnerable Children embraces a broad definition of vulnerability that extends beyond orphanhood and the impact of HIV and AIDS.
National-level responses to orphans and vulnerable children have increasingly become part of broader social welfare and assistance to vulnerable populations, including children, such as social protection programmes that are HIV-sensitive. In sub-Saharan Africa, social protection programmes have been scaled up significantly.
For information on UNICEF’s programme and policy work, visit the Children & AIDS community of practice.
