Trials in the United States and Western Europe have demonstrated that HAART is effective in suppressing HIV viral replication and reversing immunodeficiency in children [4,5]. The result has been a reduction in pediatric hospital admissions and a decrease in morbidity and mortality due to HIV/AIDS [6-9]. The introduction of combination ART including protease inhibitors has resulted in striking reductions in HIV-related mortality [10-12]. However, these therapeutic regimens are very complex, often requiring that patients take numerous pills multiple times a day with specific timing and food restrictions or requirements. Failure to adhere very closely to the regimens appears to be related to continued viral replication, treatment failure and the emergence of drug-resistant strains of HIV [13-15].

Adherence is a special issue in pediatrics not only because of social situations but also because many of the drugs are not child friendly [21]. This study found an estimated prevalence of caregivers' report of adherence to antiretroviral treatment to be 93.1% in 3 days and 86.9% in a 7-day recall period. Adherence rate in other studies ranged from 26% to 97% [22-30]. The possible explanations for the greater adherence in our study might be that the majority of the children started ART recently, the children were taking medication with a twice-daily dosing schedule, or the children and caregivers were given strict adherence counseling sessions before starting ART in the hospitals and the majority of caregivers (97.4%) had a favorable attitude toward administration of ARV to children.

In this study children whose caregivers paid for medication before ART were more adherer than those who did not pay. Hence, people tend to give value for their health when they spend money for treatment of their illness. Similarly, studies [31,32] revealed that costs have an implication for adherence. However, it varies at different stages of HIV infection, such that patient's who present late, especially if more immuno-suppressed, use more services at greater cost than those who are less immuno-suppressed. An increasing adherence rate was observed in children with more advanced HIV [33]. Again, a similar pattern has been reported in adults [34,35].

One of the entry points that complicated the issue of adherence for HIV infected children is the issue of disclosure of HIV status to the child [36]. Studies showed that complete parental disclosure helps to motivate HIV-infected children to adhere to their daily medical regimen. It enables children to understand HIV infection and to make sense of disease-related experiences and the importance of adherence [37,38]. In this study, however non-disclosure had a significant relevance for adherence to the recommended regimen. It is consistent with other studies, which showed no effect of disclosure on adherence to ART [22,39], which is also the case in the Multicenter National Study in Italy [33].

Interestingly, those who took co-trimoxazole prophylaxis besides taking ARV medications were more likely to adhere than those who did not use the treatment. Prophylaxis is probably at least as important as ART in preventing the onset of AIDS in children [40,41]. It is also supported by a study which revealed daily co-trimoxazole lays the groundwork for medication adherence by the patient and the establishment of reliable drug distribution systems [42]. Nutrition interventions can help to optimize the benefits of ARVs and may increase compliance with treatment regimens, both of which are essential to prolonging the Lives of People Living with HIV (PLHIV) and preventing the MTCT [43]. However; in our study receiving nutritional support from the clinic had an inverse relationship with adherence to ART therapy. In contrast to our finding, it is reported that one of the significant barriers to adherence was insufficient food and patients reported that lack of food prevented or delayed them taking their medication [44]. Provision of food and micronutrients has been shown to improve outcomes [45-47]. In a South African study, many families spend more than 50% of their household income on food and food production and wage earnings were adversely affected when an adult has AIDS [48]. In the same line, poverty factors such as food insecurity and user fees for medical care, posed more significant barriers to adhering to long-term therapy than a patient's individual behavior. In a pilot program in Zambia on nutritional supplementation for food insecure patients on ART, it was shown that patients receiving food were on average 2.4 days late for their pharmacy appointments, whereas patients not receiving food were on average 3.4 days late each month. Patients receiving food were significantly adhered to pharmacy visits than patients not receiving food [49]. Surprisingly, in our study, adherence rates were significantly lower in those who received nutritional support than in those who did not. The inverse relationship between adherence to HAART and nutritional support is somewhat worrisome and needs to be investigated further in order to plan interventions in HIV infected children.