Memorandum submitted by UNICEF
UNICEF'S PROGRAMME
APPROACH TO
HIV/AIDS
I. Statement of the Problem
HIV/AIDS continues to wreak a path of devastation
through sub-Saharan Africa and other developing regions, with
nearly 34 million people now living with the virus and more than
half a million children infected last year alone.
Some 14.8 million women and 1.2 million children
under the age of 15 are living with the nightmare of HIV/AIDS,
almost all of them in sub-Saharan Africa and other parts of the
developing world. These figures evoke a vast scale of death and
destruction and tempt us to throw up our hands in despair. But
we must resist that temptation. There is hope, and the fight against
the HIV/AIDS pandemic in the developing world is just beginning.
II. UNICEF's priority programme areas
UNICEFs concern about the impact of HIV/AIDS
on vulnerable women and children dates back to the mid-1980s.
Following extensive consultation among UNICEF field offices in
countries then experiencing the initial explosive trajectory of
the disease, a report was presented to the Executive Board to
advise the membership regarding the potential impact of the pandemic
and the importance of ensuring appropriate sterilisation of all
equipment used in immunisation programmes. In 1988, a report to
the Executive Board analysed the impact of HIV/AIDS on women and
children and outlined an HIV/AIDS policy and programme approach
for children. These initial years were marked by limited but ground-breaking
work, focused mainly on AIDS orphans and developing AIDS curriculum
and life skills education programmes for schools as we have seen
in Uganda and Zimbabwe.
By the close of 1995, virtually all of UNICEF's
125 principal country offices works have HIV/AIDS-specific programmes.
As bleak as the picture may be in some countries where the rate
of HIV infection exceeds 20 per cent of the population, UNICEF's
message is that in all areas of AIDS activity, there is hope so
long as there is knowledge and accompanying change in behaviour.
For those of us working among women and children
whose lives are threatened by the prospect of HIV infection, we
now know about affordable drug treatments to reduce mother-to-child
transmission. There are also effective prevention programmes under
way for young people. There are exemplary pilot voluntary testing
and counselling centres for women. And there are projects that
are beginning to address the immense needs of children orphaned
by AIDS.
A. Breaking the conspiracy of silence
At the national level in all countries affected
by HIV/AIDS, there must be political commitment at all levels,
involving a variety of partners in coordinated public and private
action to address the disease. This includes breaking the "conspiracy
of silence" that in too many countries continues to hide
the dimensions of the HIV/AIDS crisis from the very people most
affected by it.
In the south, breaking the conspiracy of silence
means acknowledgement of the problem at the highest levels of
government; broad national engagement leading to the development
of prevention and treatment policies and strategies; the building
of HIV/AIDS partnerships with international organizations, and
international and local non-governmental organizations; and, a
willingness to mobilise both internal and external resources.
Nations that have taken these steps deserve the support of the
donor community, whether in the form of direct aid and/or through
debt relief.
B. Prevention of Mother to Child HIV Transmission
In 1999 alone, an estimated 570,000 children
were infected with the virus that causes AIDS, the large majority
through mother-to-child transmission. For this reason, UNICEF
and its partners have assigned top priority to supporting the
efforts of national governments in many of the most severely affected
countries of sub-Saharan Africa to help reduce the transmission
of HIV from mother to child.
The principal aim of UNICEF's partnership with
national governments and NGOs is to provide voluntary HIV testing
and counselling for pregnant women. Pregnant women who test HIV-positive
are provided with one of the recently developed anti-retroviral
drug regimens; counselling on infant feeding options; and support
for the feeding method of their choice. These interventions can
reduce transmission rates by half.
UNICEF is continuously encouraged by the news
of promising and dramatically more affordable drug regimens to
prevent mother-to-child transmission. A relatively new drug, nevirapine,
can reduce HIV transmission by 50 per cent with a single dose
to the mother and infant—at a per-treatment cost of about
$4.
More recently, we welcome the consensus reached
by experts to recommend the prophylactic use in Africa of cotrimoxazole,
a drug that wards off some of the opportunistic infections to
which HIV-infected people are prone. This is particularly good
news for women, who can live longer, healthier and more productive
lives.
C. Primary prevention among young people
One of the most encouraging developments regarding
actions to prevent the spread of the HIV/AIDS is the drive and
energy of young people who are becoming principal actors in national
efforts to address the pandemic. UNICEF has learned that young
people understand even better than many adults that, through prevention,
they can slow the rate of infection—and eventually stop
the spread of infection. This is already beginning to happen.
There are indications of a decrease in the spread of HIV in Zambia,
particularly among young people between 15 and 19. And there are
encouraging trends in Uganda, Senegal, and Thailand.
UNICEF has stressed the importance of focusing
on young people (a) because they are at the centre of the pandemic,
(b) because they are often more open than adults to do things
differently and (c) because they are a force for change among
their peers and in society generally.
D. Access to HIV voluntary testing and counselling
It has been estimated that up to 90 per cent
of HIV-positive people in Africa are unaware of their infection.
There is increasing evidence that awareness of one's HIV status
can be a powerful motivating force for behavioural change.
However, providing people with information about
how to protect against infection is not enough. UNICEF believes
that we must help create the right conditions and circumstances
for people to be able to act on the basis of the information we
make available to them. Such conditions can include a supportive
social environment; access to condoms; clean needles and syringes;
and access to appropriate health and other services such as HIV
counselling and testing.
E. Children and families affected by HIV/AIDS
Half of those infected in 1999 were people under
the age of 25. They will probably die before they turn 35. They
will leave behind children who face a future as orphans and often
the added burdens of poverty and stigma. The scale of the orphan
crisis is almost unimaginable. By the end of 1999, there were
approximately 11.2 million children who lost one or both parents
to HIV/AIDS. In many cases, a remaining parent is found to be
quite ill and dependent on the child for assistance.
Before AIDS, about 2 per cent of all children
in developing countries were orphans. By 1997, the figure had
jumped to 7 per cent in many African countries—in some countries
the figures run as high as 11 per cent.
In developing countries, AIDS orphans face extreme
economic uncertainty and are at higher risk of malnutrition, illness,
abuse and sexual exploitation than children orphaned by other
causes.
In response to the crisis, some African communities
have developed innovative care and support programmes. While communities
are clearly still in the forefront of the response, the sheer
numbers of orphans threaten to overwhelm their efforts. The response
of the donor community to the AIDS pandemic must include support
to communities that seek to address the physical and emotional
needs of the millions of children whose parents have been taken
from them by this disease.
III. What are the Challenges?
Early in the 21st century, we still have no
cure for AIDS. Nor do we have a vaccine to prevent the spread
of HIV. We have seen a growing number of successes in the global
fight against the epidemic, but they are not nearly numerous nor
widespread enough.
But there is hope. The future course of the
HIV/AIDS pandemic lies in the hands of young people. It is absolutely
vital that we do everything necessary to arm them with the knowledge
they need to protect themselves and their communities.
UNICEF has moved to redouble our efforts to
mobilise and support programmes to address the rights of young
people to development and to participation. While young people
are constantly receiving information about HIV/AIDS, consultations
with them and existing data show that they do not have all the
information they need and furthermore, information does not necessarily
translate into knowledge and skills.
We urgently need to address this knowledge gap,
using language and formats that young people can appreciate. For
example, in many sub-Saharan African countries, it has been found
that more than 25 per cent of women aged 15 to 19 are unaware
of even one effective way of avoiding HIV infection (see graph).
And in recent representative surveys, over 30
per cent of young women in many sub-Saharan African countries
expressed the view that a healthy looking person could not possibly
be infected with the AIDS virus (see graph).
What began nearly two decades ago as a mysterious
ailment that seemed confined to specific groups has now shown
itself for what it really is: a plague that is systematically
devastating entire societies, reducing life expectancy at an uncontrollable
rate in many developing countries. Life expectancy at birth in
southern Africa rose by a full 15 years from 44 years in the early
1950s to 59 in the early 1990s. However, because of AIDS life
expectancy is set to recede to just 45 years between 2005 and
2010. This decline has enormous impact on national economies.
In South Africa where the infection rate exceeds 20 per cent of
the young population, continual loss of trained workers to illness
and death has become a major problem for business. AIDS also has
had a great impact on certain sectors such as education. In numerous
sub-Saharan countries, teachers are dying at a rate faster than
new ones can be trained.
By comparison, life expectancy in South Asia,
another of the world's poorest regions, is evolving very differently.
While South Asians born in 1950 on average could survive barely
to their 40th birthday, by 2005 they can expect to live 22 years
longer than their counterparts in the AIDS-ravaged southern African
region. However, there are concerns that South Asia, and the former
Soviet Union as well, could see the trajectory of HIV/AIDS growth
in these regions if national governments do not acknowledge the
problem already in existence and take action to address it.
IV. Resources Needed
To capitalise on the hope provided by those
in developing countries, already working to prevent HIV/AIDS infection,
will require far more commitment and resources than we have yet
seen—from governments, donors, and civil society at every
level, including non-governmental groups, communities, families,
and the private sector. The success stories cited above must be
brought up to scale in country after country. UNICEF estimates
that an additional US$ 2-4 billion per year for 10-15 years will
be needed to control the epidemic. Much of these resources will
come from within affected countries. However, as HIV/AIDS is a
global problem, its response demands global action.
V. Special Regional Focus: Sub-Saharan Africa
Currently, two complex emergencies and catastrophes
threaten sub-Saharan Africa. Approximately 200,000 people die
annually due to armed conflicts in this region; the lives of millions
more are severely disrupted and their food, security, access to
adequate health, nutrition and education is reduced. The resumption
earlier this week of full-scale war between Ethiopia and Eritrea
is but one example of the growing crisis of war on the continent.
It is a conflict like this that will capture the attention of
the media.
However, somewhat more quietly a silent, almost
invisible, though massively larger tragedy has devastated sub-Saharan
Africa. HIV/AIDS is the greatest undeclared war with nearly 2
million deaths last year and a budget of less than two 747 aircraft
last year alone.
In Eastern and Southern Africa UNICEF has declared
HIV/AIDS as a number one priority. All offices have been requested
to convey to their government partners that UNICEF has taken an
agency-wide decision to put HIV/AIDS programmes and advocacy on
a much more urgent footing in the light of the devastating consequences
of the pandemic on the well-being of children and their families.
They have been urged to discuss with government partners the possible
reorientation of the existing programme of co-operation to make
HIV/AIDS the central element of the programme, including the reallocation
of resources earmarked for other components of the programme and
the possibilities for mobilising new resources locally or internationally.
Positive outcomes will require political commitment
at all levels. We cannot give in to a pervasive mood of writing
off whole generations in sub-Saharan Africa and Asia. We know
how to start tackling the HIV/AIDS pandemic. We must be willing
to pay what it costs to turn that knowledge into the lifeline
that it could be for millions of people. And we must ensure that
what works in one place is transported to another until the pandemic
is in full retreat.
UNICEF
May 2000
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