HIV/AIDS is one of the main causes of mortality for children under the age of five worldwide and seriously threatens the well-being of older children in many different ways.

Since the beginning of the pandemic, of the over 5 million infants who have been infected with HIV, 90 percent were born in Africa. In sub-Saharan 3.8 million people need treatment now, but as of June 2004, only 150,000 were on ARVs - less than four percent of the total. The remaining 96 percent - those parents, workers and children denied access to life-prolonging drugs will, unless there is urgent intervention, inevitably join the other 30 million lives already claimed by the pandemic.

HIV infection is a major contributing factor to childhood disease and mortality. In developing countries it is threatening gains made in infant and child survival and health over recent decades. AIDS manifests itself more severely and more rapidly in children because compared to adults they have immature immune systems. The majority of children born with HIV die before the age of five. Globally, between seven and eight percent of deaths in children under 5 are now attributable to AIDS. In hard-hit countries AIDS causes between 30 and 50 percent of deaths among under-fives. Dr Keith Bolton who works as Head of Child Health at South Africa's Coronation Hospital in Johannesburg, remembers that when he treated children in the 1990s, the death of a patient was still relatively infrequent, on average one child died each week. Now, he and his colleagues see one child die every day. In 2002, less than one in 12 children worldwide passed away before age five. According to the UNICEF report, Progress for Children: A Child Survival Report Card, childhood deaths in much of sub-Saharan Africa rose dramatically between 1990 and 2002, the latest year for which comprehensive data is available. In Botswana, a middle-income country, child mortality nearly doubled during the period to 110 deaths per 1,000 children. In South Africa, a nation of 45 million that boasts some of the continent's most sophisticated infrastructure, 65 of every 1,000 children died before the age of five in 2002, up from 60 deaths per 1,000 children in 1990. By comparison, only eight of every 1,000 children born in the United States died by age five in 2002. "HIV/AIDS is unmistakably the main contributor to the reversal in childhood deaths in southern Africa," noted John Clarke, spokesperson for the World Health Organization in South Africa.

After his recent trip to Malawi and Tanzania Stephen Lewis, The UN Special Envoy for HIV/AIDS in Africa, expressed concern over the lack of pediatric anti-AIDS formulas. He told reporters that the apparatus of HIV/AIDS treatment had been assembled as though children did not exist. He referred to the lack of child-friendly AIDS formulas as a "doomsday" scenario for infected children. Lewis stated that: "Incredibly enough, we don't even have pediatric formulations. When treatment takes place, doctors and nurses fumble over breaking capsules into several pieces to estimate the dosage for a child, or scramble around to find a syrup solution." Dr. Charles Gilks, Director and Coordinator, HIV Treatment, Prevention and Scale-Up for WHO called the WHO-UNAIDS 3 x 5 initiative an unprecedented opportunity to reach millions of people with life-saving drugs. He also highlighted that, “We must ensure that children are part of the equation and that we come up with child-specific approaches that address their unique needs.”

Challenges to providing treatment for children with AIDS also include a lack of facilities and technologies for early diagnosis of HIV in children, poor health infrastructure and systems, and a lack of trained and skilled health personnel. Despite pediatric syrup having been made more widely available, not all caregivers, particularly those living in remote rural areas, have the refrigeration facilities needed to store the medication.

The adherence of children to the drugs is another challenge. According to Noreen Ramsden from the Children's Rights Centre in Durban, only 70 percent of children adhered to the treatment plan. "Because of the multiple side effects of ARVs, children need a lot of encouragement to stick with the medication," she explained. Orphaned children in child-headed households in both urban and rural areas, who lack supportive care and proximity to treatment centers, find it even more difficult to access the drugs.

Another obstacle to providing free drugs to children is the prohibitive cost of specialised tests for diagnosing HIV in children younger than 18 months. This test is not widely available, is substantially more expensive than rapid tests and is also not very reliable. The lack of pediatric ARV formulations makes determining and administering doses complex and burdensome. Doctors are forced to break tablets in two or crush and dissolve them. Care providers have to give small children foul-tasting syrups and large pills. Syrups and oral solutions are not suitable for older children because of the large amounts needed, but low-dosage tablets and capsules are not produced for most ARVs. And the pediatric formulations that do exist come at a very high price. Both first and second-line ARV treatments for children cost several times more than those for adults.

Treatment for children is not that simple. Medecins Sans Frontieres (MSF) estimated that around 50 percent of all children with HIV/AIDS die before reaching the age of two. While MSF began treating children with ARVs in early 2002, only five percent of the organisation's patients were children under 13 by March 2004. MSF is now attempting to include more children in its AIDS projects but those efforts are frustrated by the lack of proper tools. MSF, who has been publicly campaigning for child ARVs, claims that children living with the virus are needlessly dying because medicines have not been simplified for widespread dispersal. They called for pressure to be placed on pharmaceutical firms to manufacture AIDS medicines adapted to the needs of children. The medical humanitarian agency alleges that because most children with HIV/AIDS live in the developing world, there is little commercial interest in creating and marketing child-friendly treatments, and instead children are given small portions of adult doses.