House of Commons - International Development

Select Committee on International Development Written Evidence

1. Memorandum submitted by the Department for International Development

ORPHANS AND CHILDREN MADE VULNERABLE BY HIV AND AIDS

SUMMARY

The impact of HIV and AIDS on children, especially in high HIV prevalence countries of sub-Saharan Africa presents a growing and serious challenge to families, communities and societies and to the achievement of the majority of the Millennium Development Goals. The direct impacts on children include higher infant and child morbidity and mortality rates, lower life expectancy and higher rates of orphaning[1] The problems faced by children living in households affected by HIV/AIDS are often common to those experienced by poor children. To these can be added stigmatisation and discrimination, the psychological, financial and practical impacts of caring for sick parents and relatives and the experience of deaths in the family and community. To these should be added the frequent loss of assets and hope for the future by children orphaned by AIDS. HIV/AIDS poses a unique set of challenges for children, their wellbeing and their development.

The most evident impact of HIV and AIDS on children is the generation of large numbers of orphans. The majority of these are currently being absorbed by the extended family structure, but some 10% fall outside this safety net. A concern must be the capacity of traditional safety nets to cope with increasing numbers of orphans as HIV progresses to AIDS in the absence of comprehensive treatment in high prevalence countries. Orphans, however, need to be considered together with children made vulnerable by AIDS and not considered in isolation.

The Convention on the Rights of the Child and the UNGASS Declaration of Commitment on HIV/AIDS[2] (articles 67-69 specifically concern orphans and vulnerable children) provide the framework for the international response. The Strategic Framework for the Protection, Care and Support of Orphans and Children Made Vulnerable by HIV/AIDS developed by UNICEF and partners provides specific guidance on the global response. DFID endorses this and encourages responses within this framework. Additional guidance is being developed on access to education for orphans and children made vulnerable by HIV and AIDS.

The challenges are enormous and worse impacts on children are yet to come. To date, the response to OVCs at international and national levels has been inadequate[3] UNAIDS (2003) reports that more than a third of countries with generalised epidemics have no national policy to provide essential support to OVCS[4] However, we are now know which interventions are likely to work. Increased commitment by the international community and national governments is required to close the gap between need and response.

The most significant challenges for national OVC responses include:

— Ensuring comprehensive responses to the needs of orphans and vulnerable children (OVCs) issues are in national poverty reduction strategies (PRSPs) and National AIDS Strategies.

— National policy development and legislation to define the standards of protection and care for all orphans and vulnerable children (OVCs).

— Strengthening the capacity of family and community structures to absorb and care for the rising numbers of OVCs.

— Ensuring the access of all children to quality services, especially nutrition, health and education.

— Scaling up and sustaining support for communities responses, ensuring resources reach the grassroots;

— Addressing stigma and discrimination affecting OVCs;

— Expanding voluntary counselling and testing (VCT) services and access to treatment for parents to reduce and delay orphaning.

DFID's response to orphans and children made vulnerable by HIV/AIDS (OVCs) is being stepped up. We are working with partners at the global level on advocacy and developing evidence based best practice. At the national level, ensuring effective policy and programme responses to the needs of children affected by HIV/AIDS is a high priority for us and for the achievement of the Millennium Development Goals (MDGs). We are currently preparing a new UK HIV/AIDS Strategy and we will use the outcomes of this session to inform the approach to OVCs.

DFID'S RESPONSE TO ORPHANS AND VULNERABLE CHILDREN

Responding to HIV/AIDS is a high priority for DFID. This is reflected in the publication of UK's Call to Action on HIV/AIDS[6] in December 2003 and the lead role given to DFID in taking this forward. Currently we are preparing a new UK strategy for HIV/AIDS to be published later in the year. This will in turn help shape our plans for the UK G8 and EU Presidencies.

In order to take the new strategy forward, we have prepared a document for consultation[7] We have recently convened consultations with representatives of NGOs, universities, business and other government departments. Currently, we are taking on board the feedback received.

We recognise the urgent need for the international community and affected countries to accelerate support for children affected by HIV/AIDS. The new UK strategy on HIV/AIDS will present a clear position on orphans and vulnerable children, which we expect to be a key priority. This session is therefore timely, as it will help contribute to developing the details of our response. DFID's new policy of HIV/AIDS Treatment and Care will also have strong implications for the response to OVCs through the prolongation of life for parents, guardians and for children.

THE DFID RESPONSE TO DATE

The current DFID HIV/AIDS Strategy[8] published in 2001, recognises the need for responding to the needs of orphans through strategies to reduce the impact of the epidemic. The UNGASS Declaration of Commitment published subsequently has helped to provide stronger direction to the international response. This has recently been strengthened by the guidance contained in Strategic Framework for the Protection, Care and Support of Children Orphaned and Made Vulnerable by HIV/AIDS.

DFID has been increasingly incorporating OVC perspectives into country programming. For example, we have supported government responses to OVCs in Malawi and Zimbabwe. In the former, we have been working to ensure that social protection measures for families affected by HIV/AIDS are integrated into the PRSP. These measures included targeted nutrition and cash transfers, legislation on inheritance and the introduction of less intensive crops to affected households.

In Uganda, we have been supporting the AIDS Support Organisation (TASO) to provide comprehensive services at family and community levels.

In Zimbabwe, DFID has been providing support for OVCs and child-headed households though the NGO administered feeding programme. Several of the NGOs target child-headed households. In addition, a bilateral programme with the Zimbabwe Red Cross and John Snow International is providing food to households affected by HIV/AIDS including child-headed households and some orphanages.

In South Africa, DFID is working closely with the Department of Social Development to ensure that children and parents can access the grants they are entitled to. We are also starting to work with the Church of the Province of Southern Africa to reduce stigma, improve home-based care and care for OVCs.

We are mainstreaming OVC perspectives across our programmes. For example in education, DFID is a key partner in the UNAIDS Inter-Agency Task Team (IATT) on Education and HIV/AIDS initiative "Accelerating the Education Response to HIV/AIDS in Africa". This is led by the World Bank and involves the participation of other UNAIDS cosponsors such as UNESCO, UNICEF and ILO as well as bilateral agencies such as USAID and DFID. The initiative is rolling out a programme of workshops at sub-regional and country level to assist national HIV/AIDS responses in the education sector. A key theme of these workshops is responding to the needs of OVCs. This ongoing programme has so far included regional seminars for countries in East and Central Africa with particular country-based workshops in Mozambique, Nigeria and Ethiopia.

THE WAY FORWARD

In developing the new HIV/AIDS strategy, we recognise the need to intensify, co-ordinate and harmonise efforts to develop and implement comprehensive national OVC responses within the framework of the "Three-Ones" (one national strategy, one national AIDS commission and one way to report progress). Governments need to ensure that assessments of the situation of OVCs including the national response are adequately reflected in PRSPs. This would be reflected in DFID's Country Assistance Plans. In Ethiopia, for example, it has recently been agreed that in the HIV/AIDS section of the final PRS matrix there will be action to strengthen support provided for orphans and vulnerable children. We will continue to work with development partners to ensure that PRSPs adequately address the commitments made in the Declaration of Commitment on HIV/AIDS, including specific attention to the situation of OVCs and their various protection, care and support needs.

We fully endorse the "Strategic Framework for the Protection, Care and Support of Orphans and Children made Vulnerable by HIV/AIDS". We will be working closely with development partners at country level to help operationalise the approaches recommended. In preparing our new HIV/AIDS strategy we will be considering ways in which we can better work with partners to support governments in their efforts to develop national policies, legislation, planning and programmes for OVCs and their care givers. We shall be advocating with governments that they appropriately prioritise the allocation of resources for OVCs. We are also considering how we can best assist governments in improving the monitoring the results of OVC interventions.

We recognise the need to mainstream an OVC perspective within our support for basic services in country programmes, especially health and education. We will advocate for free universal primary education, the removal of cost barriers to education and interventions to assist keeping children productively in school. Education personnel and in particular, teachers need to be trained to respond appropriately to the psychosocial needs of OVCs. We will continue to promote girls' education. DFID is implementing recently developed guidance notes for education advisers on gender equality and which includes analysis of HIV/AIDS issues[9]

At country level, we will work with development partners to ensure strengthened and sustained support for community based responses to care and support of OVCs. We see this as a key element in the national HIV/AIDS response. We have already signalled in the UK Call for Action that we will be working closely with the United States in countries in Africa starting with Ethiopia, Kenya, Nigeria, Uganda and Zambia[10] This will provide opportunities to collaborate in improving support for OVCs in those countries.

At the global level we will continue to participate in the Global Partners Forum for Children Orphaned and Made Vulnerable by HIV/AIDS, which is convened by UNICEF. This has enabled the development of the strategic framework, the sharing of information, better coordination of global efforts and strengthening of advocacy. In addition, we will advocate for effective strategic action for children infected and affected by HIV/AIDS through existing international development processes such as Education for All (EFA), the EFA Fast Track Initiative and the WHO/UNAIDS 3X5 Initiative.

We are working with the UNAIDS IATT on education and HIV/AIDS to finalise international guidance on the role of education and caring for orphans and other children made vulnerable by HIV/AIDS.

The Global Fund to Fight AIDS, Tuberculosis and Malaria has set a target for reaching over 1 million orphans through medical services, education and community care after five years (for Rounds 1, 2 and 3)[11] DFID has pledged $138 million to the Global Fund through to 2005 and $40 million in each of years 2006-07 and 2007-08. This money is not earmarked, but clearly this will contribute to OVC work.

Finally, we are calling for stronger political direction in the fight against HIV/AIDS[12] We will make HIV/AIDS a centrepiece of our Presidencies of the G8 and EU in 2005. We anticipate that this will include opportunities for championing issues concerning children affected and infected by HIV/AIDS and ensuring that these get addressed. We see the need for better funding, including raising our own commitments. We will make HIV/AIDS a priority for the extra £320 million the UK will be devoting to Africa by 2006 and the new UK government strategy will set out clear policy guidance.

ORPHANS. THE SCALE OF THE PROBLEM

This impact of HIV/AIDS on children presents a significant challenge to international development and is most evident in the growing number of orphans. By the end of 2001 in a survey of 88 countries, 13.4 million children currently under the age of 15 had lost a mother, father or both parents to AIDS. This number is projected to rise to 25 million by 2010. The age of orphans is quite constant across countries. More than 50% are orphaned before they reach the age of 10.

Sub-Saharan Africa is by far the most seriously affected region. It has the greatest proportion of children who are orphans. In 2001, 12% of all children were orphans, almost double the proportion in Asia and more than double that in Latin America. This is largely attributable to HIV/AIDS.

An estimated 34 million children in Africa are orphans[13] An estimated 11 million of these are as a result of AIDS and projected to rise to 20 million by 2010[14] Conflict, accidents, crime and disease take their toll. However, UNICEF[15] argues that the number of orphans in Africa would now be in decline if there were no HIV/AIDS.

With HIV/AIDS epidemics increasing their impacts the number of orphans is rising sharply on an unprecedented scale. Already, in the worst affected countries in sub-Saharan Africa, more than one in five children is an orphan. These countries need to respond urgently to the current situation and also plan for further impacts. It is to be predicted that the largest increase in the numbers of orphans will occur in countries with the highest HIV prevalence rates (such as Botswana, Swaziland and Lesotho).

But even where the HIV prevalence has stabilised or declined the number of orphans will continue to climb. This reflects the long time lag between HIV infection and death. The problem is therefore one of long term duration and worsening in scale and depth over time. The impact of expanded access to treatment through the 3X5 initiative will take time to have a population level impact, depending on the speed and effectiveness of its introduction. But an effective expansion of access to comprehensive treatment and care, because of its life extending and enhancing effects, will have a beneficial effect in reducing and delaying orphaning. Keeping mothers and fathers alive is a compelling rationale for rapidly expanding access to antiretroviral therapy[16]

HIV/AIDS is exceptional in terms of orphaning since if one parent is infected with HIV, it is likely that the other will become infected. This can result in children losing both their parents within a relatively short time span and becoming "double orphans". UNICEF[17] estimates that the number of double orphans will nearly triple in Africa by 2010, reaching a total of some 7 million due to AIDS.

The distribution of orphans within countries varies considerably. In some, such as Ethiopia, Malawi and Uganda, there is a high concentration in urban areas; in others, such as Namibia, Ghana and Zimbabwe a higher proportion is to be found in rural areas. These tendencies are influenced by higher rates of HIV prevalence in urban areas and migration to the village home as a result of sickness.

THE IMPACTS OF HIV/AIDS ON THE FAMILY

HIV/AIDS, especially in the most affected countries, is putting the extended family, arguably the most important social institution, under considerable and increasing stress. While the impacts of HIV/AIDS on household economies are becoming better understood, it is often hard to differentiate between the effects of HIV/AIDS and those of chronic poverty. Communities are often unwilling or unable to identify AIDS as major problem due to persistent stigma and discrimination.

The economic impacts of AIDS can be severe and particularly acute on rural households. A major factor is the loss of adult male labour. The high costs of health care for people living with AIDS coupled with the loss of income arising from their sickness causes a dramatic decline in household income. These economic problems result in significant stress within the household, which can lead to children being exposed to harsh treatment. A large and increasing number of families are impoverished to the extent that they have difficulties in meeting basic needs such as food, clothes, medical care and education.

The psychosocial impacts on children of the effects of the prolonged sickness and death of parents and family members are not yet adequately recognised. For children emotional suffering is perhaps the most acute effect of AIDS[18] and remains under-addressed. The knowledge of a parent's HIV status can result in shock and shame. The distancing of parents with HIV from their children can lead to stress depression and a feeling of being unloved. These problems are compounded with stresses associated with declining household income, hunger and health status. The emotional needs of children vary according to age and to the age when the parent or parents became sick or died, while the psychosocial impacts of the death of parents are similar across different contexts. The stigma of parental death from AIDS can result in "incomplete mourning".

The impacts on the family affect education opportunities for children. Poverty is a key factor. Financial pressures on the family reduce the ability to pay for school fees, shoes, uniforms, books etc. There is a lower expected return on the investment in education of children; while in the household there is increased demand for child work in the home or local economy. The psychosocial effects of AIDS in the family can strongly affect child performance at school[19]

HIV/AIDS affects both the supply of and demand for health services. The greatest impact is faced by the poorest who cannot afford to pay for or access private health care. Children in affected families are less likely to be immunised or be able to visit health clinics. They are also exposed to increased health risks such as infections associated with AIDS such as tuberculosis, pneumonia, respiratory infections and diarrhoeal diseases. Children with AIDS have had extremely limited access to treatment and care and anti retro-viral therapy (ART) for children has lagged behind the development of adult treatment formulations.

Children in AIDS affected households often receive inadequate nutrition due to a reduction in household income and expenditure on food and decline in household capacity to nurture a child properly. Patterns of malnutrition and health status are different among rural and urban children with the former suffering the most frequent ill health. There is alarming evidence that child survival is also strongly affected by orphaning. A recent study indicates that an infant in Southern Zambia who mother has died faces odds of dying 34 times greater than a similar infant whose mother is alive; while in north east South Africa the odds are 23 times greater[20]

Adult ill health and death can increase a child's vulnerability to HIV infection. This can be due to child abuse, especially in the case of orphans or street children or the sexual abuse of young girls, because they are thought to be uninfected. Highly vulnerable children may engage in survival sex for food or money.

Gender is a key factor. Adverse impacts on girls' education have been well documented[21] Girls are often the first to be taken out of school to provide care for sick family members or to take responsibility for siblings[22] In the worst cases girls may resort to transactional sex to provide for themselves and the family. It appears that HIV is putting new barriers in the way of girls' ability to access and complete their education. These need to be assessed and addressed in national education plans[23] However, the influences of gender are quite varied from context to context; UNAIDS reports that analysis of orphan school attendance does not seem to indicate any consistent pattern of sex-based discrimination[24] Lower orphan attendance seems to be associated with general low school attendance. Gender analysis needs therefore to be undertaken at national level, both quantitative and qualitative, needed to inform strategic responses to the impacts of HIV and AIDS on children.

Orphans generally seem to be at greater risk of exploitation. In Zambia, the majority of children in prostitution are orphans[25] as are the majority of street children in Lusaka[26] In Addis Ababa, Ethiopia, child domestic work draws heavily on orphans[27]

The phenomenon of property dispossession has been well documented[28] Because of the problems that poor people have in claiming their property rights, there is the risk that the assets of the deceased will be grabbed either by other family members or by members of the community. In Uganda, widows are most at risk of property seizure. Succession planning has been shown to be a promising intervention for AIDS affected families and children, although significant challenges remain to be faced due to traditional beliefs and practices, gender and age-related power inequalities, low literacy rates and poor legal literacy.

The extended family in high HIV prevalence contexts is coming under unprecedented pressure, frequently over-stressed, impoverished and at risk of being overwhelmed as burdens of care and dependency ratios increase. However, the extended family will continue to be the main social welfare mechanism in most of Africa, largely responsible for the care of orphans and vulnerable children. Responses must therefore recognise this and seek to strengthen the capacity of family structures to meet their basic needs and especially those of affected and infected children.

CARE OF ORPHANS

Although under massive stress from HIV/AIDS, the extended family is fundamentally important in providing for the needs of affected children. In sub-Saharan Africa, an estimated 90% of orphaned children live with the extended family. Patterns of care vary within and between countries. However a substantial responsibility for orphan care is falling on older and younger family members and governments need to recognise the impacts on these populations. In the worst affected countries, children often have elderly grandparents as their only form of care and support. The number of grandparent-headed and child-headed households is growing. In severely affected communities in Swaziland, about 10% of homesteads are headed by children. In some of the worst affected contexts in sub-Saharan Africa, traditional safety nets are at risk of being overwhelmed as the number of dependants in affected households increases. One consequence is the traumatic separation of siblings, with orphaned siblings put out into different homes as a way of managing the burden of care.

The burden of care and support falls particularly heavily on the female-headed household[29] Women have less access to employment and property, probably in all situations, and this is exacerbated by their caring for OVCs[30] It is therefore important for means to be found to strengthen the capacity of families to protect and care for the children in their charge through targeted support including for example, food, cash transfers and livelihoods training together with community mobilisation. It is also essential to provide support and protection to those children such as street children who have fallen outside the safety net.

The needs of older carers also require special attention. The capacity of older people to provide adequate care is frequently compromised by their poverty which is in turn exacerbated by HIV/AIDS. To meet the financial burden of caring for children they are often forced to sell their assets or borrow money. They need support including income, pyschosocial services and training on HIV/AIDS[31]

ORPHANS AND VULNERABLE CHILDREN

The problem extends beyond those who are orphaned. It affects those whose parents and family are sick with AIDS. HIV/AIDS impacts more generally on the well-being of children. AIDS worsens poverty. It increases the vulnerability of those children who live in poverty and face social exclusion or discrimination. Children made vulnerable by HIV/AIDS include children living with HIV/AIDS, children whose parents are living with HIV/AIDS and children in households that have taken on the care of orphans[32] Therefore we need to advocate that policy frameworks take a broader perspective and focus on both orphans and vulnerable children.

The number of children living with HIV/AIDS is significant. Of the 14,000 new HIV infections a day, almost 2,000 are in children under 15 years of age. Some 3 million children are currently living with HIV/AIDS. This constitutes an especially neglected population in national HIVAIDS responses. Paediatric treatment has been given a significantly lower priority than adult treatment. There are few children with HIV born in rich countries and consequently a limited range of formulations and treatments for children with HIV, the majority of whom are in poor countries.

The availability, cost and storage of paediatric formulations are major research issues. We have insufficient knowledge about how to provide treatment for children infected with HIV. Key questions include the appropriate time to commence treatment, dosage to give and how to combat resistance, whether drugs can be given in liquid form instead of tablet form and how liquids should be stored. It is unclear what drugs formulations for children are likely to cost, but it will be important to make them affordable in poor countries. The success of strategies to establish national coverage of programmes to prevent mother to child transmission of HIV is therefore of significant importance.

RIGHTS

In national HIV/AIDS responses, particular attention needs to be given to the rights of children infected and affected[33] Guiding human rights principles are provided by the Convention on the Rights of the Child. The Convention affirms that governments have the principal responsibility to ensure that children's rights are met and protected. It also specifies the responsibility of States to provide special protection for a child who is deprived of his or her family environment.

Birth registration is important to enable people to claim their identity and their rights as well as access to basic services. Poor children whose births are not registered are put at particular risk of being denied their rights. In sub-Saharan Africa, more than two thirds of births went unregistered in 2000[34] The levels of birth registration for Zambia, Tanzania and Uganda were 10%, 6% and 4% respectively. These are among the countries which are particularly badly affected by HIV/AIDS.

The legal system has a key role in helping protect the rights of children and to prevent abuse, discrimination and property grabbing. This includes raising awareness in the system about the issues that face orphans and vulnerable children. Moreover existing legislation needs to be reviewed and revised to address the challenges and effective structures put in place for national implementation.

THE INTERNATIONAL RESPONSE

In Africa, in particular, the gap between need and effective action is substantial. The UNGASS Declaration of Commitment on HIV/AIDS35 (article 65) requires that countries develop by 2003 and by 2005 implement national policies and strategies to build a supporting enabling environment for orphans and girls and boys affected by HIV/AIDS by providing:[35]

— appropriate counselling and psychosocial support;

— ensuring enrolment in school;

— access to shelter;

— good nutrition, health and social services on an equal basis with other children; and

— to protect orphans and vulnerable children from all forms of abuse, violence, exploitation, discrimination, trafficking and loss of inheritance.

The response to date has been slow and falls short of what is required to meet these targets.

UNICEF, in concert with UNAIDS and bilateral partners such as USAID and DFID, has prepared the "Strategic Framework for the Protection, Care and Support of Orphans and Children made Vulnerable by HIV/AIDS." This provides a global framework for action, a tool for catalysing an accelerated response at country level.

The Strategic Framework highlights the need for strong action on five fronts:

— Strengthening the capacity of families to protect and care for orphans and other children made vulnerable by HIV/AIDS.

— Mobilizing and strengthening community-based responses.

— Ensuring access to essential services for orphans and vulnerable children.

— Ensuring that governments protect the most vulnerable children.

— Raising awareness to create a supportive environment for children affected by HIV/AIDS.

The UNAIDS Monitoring and Evaluation Reference Group (MERG) is taking the lead on co-ordinating efforts to strengthen the ability of countries to monitor and evaluate progress in responding to the situation of orphans and vulnerable children. This includes the development of a set of indicators.

The new US Five year Global HIV/AIDS strategy[36] sets the goal of providing care to 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children. A Bill has been launched in Congress to amend the Foreign Assistance Act of 1961 in order to provide assistance to orphans and other vulnerable children in developing countries.[37] The McCollum amendment in Congress ensures that OVCs will receive not less than 10% of amounts appropriated for HIV/AIDS for financial years 2006-08, of which, not less than 50% shall be channelled through non-government organisations at community level.[38]

NATIONAL RESPONSES

As yet fully comprehensive data on progress to achieve the 2005 UNGASS target (article 65) are unavailable. UNICEF[39] however, records an inadequate response by national governments in Africa. Less than half the countries had completed a national situation analysis. Only six had developed national orphan and vulnerable children policy and four had developed appropriate protective legislation. More than a third of countries with generalised epidemics have no national policy to provide essential support to OVCs[40]

A key challenge for governments is to include effective strategies to combat HIV/AIDS within the instrument of Poverty Reduction Strategy Papers (PRSPs). A study by World Vision[41] illustrates the difficulties that countries such as Mozambique, Rwanda and Zambia have experienced in this regard.

A second challenge is to ensure that there is effective coordination of the large number of local and international organisations involved in the national response to OVCs. The framework that is being called the "Three Ones" provides a solution for this. This involves one national HIV/AIDS strategy, one national AIDS commission and one way to monitor in every country.

UNICEF, within the Strategic Framework, recommends the following key intervention areas[42]

— strengthening health services to prolong the lives of parents and carers, including clinic and home-based care; access to ART; nutritional support; treatment of opportunistic infections;

— strengthening the economic capacity of the household through micro-finance, income generating activities; improved livelihoods;

— providing psychosocial support to children and caregivers;

— strengthening early child development capacities and services;

— supporting succession planning for children.

These measures need to be included within a national strategic framework for orphans and vulnerable children. South Africa, for example, has a National Integrated Plan for Children Infected and Affected by HIV/AIDS. Consideration needs to be given as to how these services may be optimally provided. There is a role for both governments and civil society organisations. National policy frameworks need to establish the mechanisms and normative guidance for decentralised responses which would involve local government. At grass roots level these should involve civil society organisations including faith-based organisations. Experience has shown that a family and community-based approach provides many advantages over more centralised approaches in delivering benefits effectively and inexpensively[43] External support is needed to strengthen community initiatives and motivation, involving for example, psychosocial support, early childhood programmes and succession planning. International NGOs and HIV/AIDS networks are likely to have an important role in developing the capacity and strengthening the programming of community based organisations and local NGOs[44]

In responding to the needs of OVCs, the involvement of people living with HIV/AIDS is essential. The AIDS Support Organisation (TASO) in Uganda reports[45] that the biggest worries of PLWHA relate to their children. Assurance of support lifts a heavy load off their minds. TASO has gained significant experience in providing comprehensive services in this regard at family and community levels.

Mobilising and strengthening community responses are key to widening and strengthening social safety nets. These responses need to be expanded and taken to scale nationally[46] Good examples of promising practice can be found in Malawi[47] Tanzania[48] Swaziland[49] Uganda[50] and in Thailand[51] Elements of effective community responses include:

— mobilising and sensitising local leaders;

— opening community dialogue on HIV/AIDS;

— the organisation of community support activities;

— promoting and supporting community care for children without family support.

The majority of OVC households at present receive no support beyond that which is provided by communities themselves[52] However within community-level responses, faith-based responses are proliferating. These are generally well organised, but currently have limited long term impact and require financial support[53] UNAIDS data on orphan school attendance in Africa suggest strong commitment on the part of some countries to assist vulnerable children[54]

It is the responsibility of governments to ensure that orphans and vulnerable children are able to benefit from essential services such as education and health. Orphans are less likely to attend school[55] and to be at their proper education level.[56] Education has a fundamental role in child development and in building resilience to meet the challenges imposed by the epidemic. It is essential, therefore, that all children are enrolled, attend, progress and are retained at school. To achieve this, policies need to be put in place to eliminate cost and social barriers to education for orphans and vulnerable children. Abolishing school fees is an effective way of increasing access to school for all children as exemplified by Uganda (1996) and Kenya (2003).

In addition to promoting access for all, Ministries of Education need to manage the impacts of AIDS on the sector, particularly on teacher supply and productivity, which if unmanaged can undermine the quality of education on offer[57] Education stakeholders need to be trained in understanding OVC issues and developing long-term solutions[58] The role of schools to provide care and support to children in the community needs to be expanded. This may include the provision of school meals and counselling. Schools need also to ensure the protection of orphans and vulnerable children in school settings from stigma and discrimination, violence and sexual abuse—the latter a significant problem for girls[59] in some African schools[60] Schools should enable them and indeed all children to protect themselves through the acquisition of life skills[61] The promotion of health, psychosocial development and resilience through "child friendly" schools appears to be a promising approach.[62] Schools need to be made more responsive to the needs of OVCs including through the development of innovative responses such as complementary learning opportunities for those who have difficulty in attending regularly[63] Strengthening provision of early childhood development and education is also important[64]

Schools, however, cannot do everything. Available resources in many contexts will be very constrained in taking on additional resources in support of OVCs[65] and responses will need to work within these.

Children who are not in school, who are the most vulnerable and at risk, require specially targeted efforts for protection[66] There are examples of promising practices which need to inform policy and strategy development. Mwanza in Tanzania, for example, provides an integrated programme for street children involving community awareness, health, education, counselling and income generation[67] Special protection measures are needed for young persons living on the streets. They are at higher risk of HIV infection because of their involvement in prostitution, lack of adult protection and socialisation and the inherent risks of street life[68] Measures need to be developed to strengthen their connections with family, school and community[69]

Essential health and nutritional services include immunisation, vitamin A supplementation, de-worming and the integrated management of childhood illnesses. Psychosocial support should also be included. Nutrition services are important. Orphans are more likely to be malnourished where food insecurity exists[70]

Governments need to enhance the protection of vulnerable children as a result of HIV/AIDS. This should involve the review of existing legislation, policies and strategies relating to the rights, protection, care and support of children. Policy areas would include child labour, child abuse, foster care, inheritance rights and discrimination. Governments need to consider prioritising financial, human and institutional resources for strengthening social protection[71] through responses such as food, cash transfers, appropriate micro-credit and insurance schemes and early childhood development and education programmes. In some countries, such as Namibia and South Africa pensions schemes have proved effective.

Businesses have a role as employers in countries affected by HIV primarily in relation to their provision of treatment and care to their employees. Providing antiretroviral treatment and treatment for opportunistic infections through work place policies means that people with HIV can continue to live productive lives. If they have children, this will lead to a reduction in the number of orphans. Pharmaceutical companies also have a role to play in terms of treatment and care for children and young people with HIV by conducting further research into paediatric formulations and treatments.

The setting up of orphanages as a response is not to be encouraged as such settings often fail to meet the developmental needs of children. Children once institutionalised often have difficulties later in reintegrating into society. Moreover orphanages are high cost in relation to other care options such as fostering. They are not a sustainable solution[72] and should best be considered as a last resort[73]

Awareness of the impacts of HIV/AIDS on children needs to be raised at all levels in society to help build an enabling environment for action. This needs to engage leadership and civil society at all levels.

Measuring the impact of HIV/AIDS on children is a new challenge for governments. The silences, denial and shame surrounding AIDS render this task all the more difficult. UNAIDS and USAID are working on developing means of strengthening the ability of countries to monitor and evaluate progress in responding to the needs of orphans and vulnerable children through developing indicators and tools for programmatic use. DFID will work closely with them in this endeavour, especially at country level.

April 2004

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2 United Nations. 2001.Declaration of Commitment on HIV/AIDS. Back

3 House of Commons. International Development Committee. 2001. HIV/AIDS: The Impact on Social and Economic Development. Back

4 UNAIDS. 2003. Progress Report on the Global Response to the HIV/AIDS Epidemic. Back

5 UNICEF. 2003. Fighting HIV/AIDS Strategies for Success. 2002-05. Back

6 DFID. 2003. UK's Call for Action on HIV/AIDS. Back

7 DFID. 2004. Consultation Document on the UK Governments New Strategy on HIV/AIDS in the Developing World. Back

8 DFID. 2001. HIV/AIDS Strategy. Paragraph 3.6.1. Back

9 DFID. 2003. Achieving the Public Service Agreement (PSA) Gender Equality Targets. Back

10 Ibid. Page 20. Back

11 The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2004. Progress Report. April 2004. Back