Memorandum submitted by World Vision
INTRODUCTION
1. World Vision is a Christian relief, development
and advocacy organisation, dedicated to working with children,
families and communities to overcome poverty and injustice. Motivated
by our Christian faith, World Vision is dedicated to working with
the world's most vulnerable people. World Vision serves all people,
regardless of religion, race, ethnicity or gender.
SPECIFIC COMMENTS
ON THE
IDC QUESTION 1: "THE
EXTENT TO
WHICH DFID'S
STRATEGY WILL
BE EFFECTIVE
IN TACKLING
THE DISPROPORTIONATE
IMPACT OF
HIV AND AIDS ON
WOMEN AND
CHILDREN"
2. Considerable progress has been made in
recent years towards achieving universal access to prevention,
treatment care and support for adults and children living with
and affected by HIV and AIDS.[81]
With greater political and financial attention, advances have
been made on providing antiretroviral therapy for adults and children,
preventing mother-to-child transmission of HIV and reducing the
rate of new infections in a number of countries.
3. However, children are not benefiting
equally from all of the recent advances that have been made, especially
in terms of access to treatment for HIV. A recent report from
UNAIDS states that in sub-Saharan Africa, children living with
HIV are only one third as likely as adults to receive antiretroviral
therapy.[82]
4. Sub-Saharan Africa remains the region
where AIDS continues to have the most impact on the health, education,
protection and survival of millions of children. Approximately
1.8 million children are living with HIV in the region and about
12 million children under 18 have lost one or both parents to
AIDS.[83]
HIV has contributed to increased child mortality rates across
the region and has been the leading cause of death among children
younger than five years of age in six countries, all in East and
Southern Africa.[84]
5. Urgent and sustained action is needed
by governments and the international community[85]
to protect the rights and needs of all children living with and
affected by HIV and AIDS to reach the goal of universal access.
This must include enabling children to participate themselves
according to their evolving capacities in all policies and programmes
concerning them.
CARE AND
SUPPORT FOR
ORPHANS AND
VULNERABLE CHILDREN
6. Taking Action, the UK Government's previous
strategy to tackle HIV and AIDS, demonstrated the UK Government's
commitment to children by including an earmark of 10% of all HIV
and AIDS spending for orphans and vulnerable children (OVC). The
earmark was an important statement of the UK's global leadership
role and through this DFID encouraged other donors to follow their
example and make children affected by AIDS a clear priority. As
other donors, primarily PEPFAR, have pledged increases in funding
for OVC, DFID's response in their new AIDS strategy is to move
away from earmarked funding and take a multi-sectoral approach,
with the aim of integrating National Plans of Action for OVC into
national health, education and social protection plans.
7. The assumption that there will now be
sufficient funding from other donors to provide essential care
and support for OVC is not supported by recent information released
by the UN. A report from the Secretary General on the UN High
Level Meeting on AIDS in June this year highlighted a concern
that many of the policies to address the needs of children orphaned
or made vulnerable by HIV in high prevalence countries were not
being implemented. Information from 11 high prevalence countries
showed that only 15% of orphans were living in households receiving
some form of assistance, representing only a modest increase from
the 10% reported in 2005.[86]
8. DFID have restated their commitment to
meet the needs of OVC within the new AIDS Strategy and announced
the allocation of £200 million to develop social protection
policies and programmes in at least eight African countries. This
is welcomed by World Vision, especially as it is intended to ensure
that orphans and vulnerable children should have access to education,
health care and nutrition.
9. However there are two main concerns regarding
this commitment:
— That there will be many competing
demands for this money. Vulnerable households with children will
be just one group, though money given to grandparents (as a pension)
has been found to be an effective means of benefiting vulnerable
children.
— There is a danger that funding for
social protection will be regarded as limited to providing cash
transfers, which whilst important, are only one part of the required
package of policies and services needed to care and protect vulnerable
children affected by HIV & AIDS (others include: child and
legal protection services, psycho-social support, and strengthened
community support). There is also evidence that social transfers
do not necessarily benefit vulnerable children living outside
family settings and in households where there is poor intra-household
distribution.
Recommendations:
10. It is essential that DFID supports holistic
social protection which is well integrated and multi-sectoral,
focusing on (i) social transfers (eg social transfers eg cash,
vouchers and in-kind); (ii) support services (eg family support
services, psycho-social support, child protection services, legal
assistance) and (iii) social policies (eg legislation, policies
and regulations).
11. It will be crucial for DFID to monitor
the targets and indicators for the £200 million commitment
to social protection, especially regarding the 8 African countries,
to ensure that they support this comprehensive package. (See Annex
1 for more details on monitoring DFID's new AIDS Strategy).
12. DFID should support further efforts
to disaggregate all data collected in relation to HIV and AIDS
by age, to ensure that a clear picture of the status of children
is available and is subsequently used to inform a more effective
response.
PROVIDE PAEDIATRIC
TREATMENT
13. There are 2 million children under the
age of 15 living with HIV world-wide, nearly nine out of 10 of
them in sub-Saharan Africa. While rapid developments have been
made over the last two years in the number of adults accessing
anti-retroviral therapy, treatment for children has not kept pace.
This was highlighted recently by the UN Secretary General who
said that "Children living with HIV are significantly less
likely to receive anti-retrovirals than HIV positive adults in
sub-Saharan Africa".[87]
14. There are now a number of fixed-dose
combinations for children, and the price of these first-line drugs
has reduced dramatically, with the aid of negotiating power from
the Clinton Foundation and UNITAID. But many ARVs simply do not
exist in the easier to administer, child-adapted tablet formulation,
and children continue to endure sub-standard treatment. Second-line
regimens for children are expensive and complex, and more research
and development is urgently needed in this area.
15. Early treatment within the first few
months of life can dramatically improve the survival rates of
children with HIV. A recent study in South Africa found that mortality
was reduced by 75% in HIV-infected infants who were treated before
they reached 12 weeks of age.[88]
Diagnosis by clinical symptoms or by CD4 testing is not reliable
and obviously delays the delivery of paediatric treatment, contributing
to the low survival rates of HIV-infected infants. Most infants
with HIV die under the age of two years and about one third will
not live to see their first birthday.
16. The new DFID AIDS Strategy recognises
the situation, stating that "Access to treatment for children
remains inadequate. This is due in part to poor capacity to diagnose
HIV infection in infants and the difficulty in tailoring dosage
and formulations to meet their specific needs". (Page 19)
Current diagnostics capable of detecting the HIV virus in infants
are very costly and not quick, leading to difficulties in diagnosis
and an increased risk of losing children to follow-up where services
are available.
17. There have been some promising developments
in diagnostics but they urgently need to be made affordable, adaptable
and appropriate for resource-poor settings for infants below 18
months old, in whom antibody testing is unreliable. A recent report
stated that only 8% of infants born to HIV positive pregnant women
in 2007 were tested for HIV within two months of birth, further
highlighting the need for urgent action.[89]
It is also necessary to recognise the specific treatment needs
of adolescents.
18. But despite reference to, and recognition
of, the need to provide better diagnostics for children infected
with HIV and greater access to paediatric treatment within the
new AIDS Strategy, these crucial areas are not reflected in DFID's
priority actions. Instead there seems to be an assumption that
providing funding to UNITAID alone will ensure greater access
to paediatric treatment. But DFID need to do much more to ensure
that children living with HIV benefit from equal access as adults
to HIV treatment, unlike the current situation in so many countries.
19. There is an announcement in the new
AIDS Strategy of a new DFID Southern African regional programme
on Access to Medicines in 2008 with £10 million to be spent
in the first three year phase on quality essential medicines and
diagnostics. (Page 45) Given that 90% of all children living with
HIV are in sub-Saharan Africa, DFID should ensure that infant
diagnostics and paediatric HIV treatment feature prominently in
this programme and that real progress is made within the region
in children's access to these life-saving services.
Recommendation:
20. DFID must do more to scale up research
and development, as well as access to infant diagnostics and paediatric
antiretroviral therapy, through exisiting and new initiatives.
SCALE UP
ACCESS TO
COTRIMOXAZOLE
21. The new DFID AIDS strategy repeats findings
highlighted in the previous AIDS strategy, from DFID funded research
in Zambia in 2004 on cotrimoxazole, a cheap antibiotic, which
when given to children exposed to HIV, gives a 43% reduction in
mortality from opportunistic infections such as pnuemonia. (Page
20) However, a recent World Health Organisation report released
this year, shows that four years on, globally only 4% of children
born to women living with HIV received the drug.[90]
A plan is urgently required to translate these DFID research findings
into action so that the deaths of thousands of children can be
prevented.
Recommendation:
22. DFID should commission research to identify
key barriers at country level that prevent children accessing
cotrimoxazole and subsequently provide support to countries to
implement the recommendations of this research. The urgent scale
up of cotrimoxazole should be a priority action for DFID.
PREVENT MOTHER
TO CHILD
TRANSMISSION OF
HIV (PMTCT)
23. One of DFID's priorities for action
in the new AIDS strategy is the urgent improvement of services
to prevent mother to child transmission of HIV. This is a key
area for reducing new infections in children as the transmission
of HIV from mother to child during pregnancy, childbirth and breast-feeding
accounts for 90% of all HIV-positive children. Without access
to services to prevent transmission, about 35% of infants born
to HIV-positive mothers will acquire the virus during pregnancy,
labour, delivery or breast-feeding.[91]
Yet providing a mother with a full range of PMTCT services, including
anti-retrovirals (ARVs), can reduce the risk of transmission to
less than 2%.
24. In sub-Saharan Africa, young women between
the ages of 15-24 are three to four times more likely than young
men to contract HIV, and consequently their yet-to-be born babies
are also at significant risk of being born with HIV.[92]
There is an urgent need to scale up PMTCT services and pioneer
comprehensive and accessible family-centred and child-friendly
approaches in countries with generalised epidemics.
25. It is critical that the effectiveness
of PMTCT services are measured to ensure that evidence-informed
and well-targeted scale-up can take place. The potential of PMTCT
programmes for targeting vulnerable mothers and children for additional
assistance, including food, social protection and welfare is vastly
under exploited. Family-centred approaches urgently need to be
strengthened to provide comprehensive and integrated packages
of treatment, care and support.
26. Substantial progress has been made over
the past few years towards preventing mother-to-child transmission.
In sub-Saharan Africa, the proportion of HIV-positive pregnant
women receiving antiretroviral prophylaxis to reduce the risk
of transmission in 2007 was 34%.[93]
But despite recent scale up of PMTCT services, Africa, and the
world, remain far short of the target of 80% coverage by 2010.
27. DFID's commitment on PMTCT in the new
AIDS Strategy is directly linked to this international target,
seen in the pledge that the UK will "Work with others to
intensify international efforts to increase to 80% by 2010 the
percentage of HIV-infected pregnant women who receive anti-retroviral
treatments to reduce the risk of mother to child transmission".
(Page 62)
Recommendation:
28. DFID should outline what the specific
contribution they will make to meeting the international target
of 80% coverage for PMTCT will be, and how it will be measured.
SPECIFIC COMMENTS
ON THE
IDC QUESTION 3: "HOW
THE NEW
AIDS STRATEGY WILL
BE INCORPORATED
INTO DFID'S
COUNTRY PROGRAMMES"
29. It is critical for the successful implementation
of DFID's AIDS Strategy that it is incorporated and implemented
within DFID's Country Programmes. Specific indicators related
to the new AIDS Strategy must feature in Country Assistance Plans
as they are updated, and in the Director's Delivery Plans or other
strategic documents, to ensure that DFID's response to HIV and
AIDS can be monitored.
Recommendation:
30. DFID should include indicators related
to country level implementation within the Monitoring and Evaluation
Framework currently in development. (See Annex 1 for more details
on monitoring DFID's new AIDS Strategy).
SPECIFIC COMMENTS
ON THE
IDC QUESTION 5: "THE
LIKELY EFFECTIVENESS
OF MONITORING
SYSTEMS IN
ENSURING THAT
THE FUNDING
ANNOUNCED IN
THE STRATEGY
REACHES LOCAL
LEVEL"
31. One of the "Key Messages"
of DFID's new AIDS Strategy is that resources need to be channelled
to where they are most needed—including to communities and
community-based organisations. In the response to HIV and AIDS
it is essential that the value of providing funding to civil society
and community-based organisations be recognised. The AIDS Strategy
goes on to say "Money and opportunities must be made available
to community-based organisations and networks of those most affected
by AIDS to maximise their contribution" which should include:
"delivering services and creating demand, challenging inequality,
advocacy and strengthening accountability". (Page 47) It
is essential that community structures are strengthened in order
to play a vital role in providing the care and child protection
services, which must be provided alongside cash transfers. However,
the strategy does not say what DFID will do to support this.
Recommendation:
32. DFID should outline how they will support
community-based organisations to ensure that they have the capacity
to strengthen community structures.
MONITORING AND
EVALUATION
33. The effectiveness of monitoring the
commitments made by DFID in the new AIDS Strategy relies mainly
on the Monitoring and Evaluation Framework, which is currently
being developed. Detailed recommendations of specific indicators
to monitor issues related to children affected by AIDS in the
Strategy are included in Annex 1 of this submission. These indicators
represent the work of the Children Affected by AIDS Working Group
of the UK Consortium on AIDS and International Development, of
which World Vision is an active member.
Annex 1
CHILDREN AFFECTED BY HIV AND AIDS (CABA)
WORKING GROUP[94]
IDC Question 1—The extent to which DFID's
strategy will be effective in tackling the disproportionate impact
of HIV and AIDS on women and children
INDICATORS FOR
MONITORING ISSUES
RELATED TO
CHILDREN AFFECTED
BY HIV AND
AIDS IN DFID'S
AIDS STRATEGY
The Children Affected by HIV and AIDS Working
Group has been advocating for targets and indicators related to
children affected by HIV and AIDS to be included in DFID's AIDS
Strategy and Monitoring & Evaluation Framework.
The indicators below relate to issues outlined
in the Strategy as priority actions and other issues that are
mentioned as requiring attention.
The indicators are those which are internationally
recognised and most are being collected by governments either
for reporting progress on the UNGASS Declaration of Commitment
or as part of national monitoring systems.
The main recommendation of the CABA Working
Group is that DFID agree to take the following steps:
1. Indicate what specific actions DFID will be
taking to contribute towards the accomplishment of the international
targets listed in the M&E Framework.
2. Require DFID Field Offices in each PSA country
to report annually on what activities they have supported against
each agreed indicator.
3. Strengthen the national M&E systems in
PSA countries to enable them collect the data required for comprehensive
reporting.
DFID PRIORITY 1:
INCREASE EFFORT
ON HIV PREVENTION;
SUSTAIN MOMENTUM
FOR TREATMENT;
INCREASE EFFORT
ON CARE
AND SUPPORT
Top line UK priorities
— Work with others to intensify international
efforts to increase to 80% by 2010 the percentage of HIV-positive
pregnant women who receive anti-retroviral treatments (ARVs) to
reduce the risk of mother to child transmission, both in low income
and high prevalence countries. (P62)
Indicator:
— Number and percentage of HIV-infected
pregnant women who received antiretrovirals to reduce the risk
of mother-to-child-transmission. (UNGASS, 2008)
Other issues related to children highlighted by DFID
— Provide support to ensure that cotrimoxazole
is better utilised as a paediatric prophylaxis. (P20)
Indicator:
— Number of infants born to women living
with HIV receiving cotrimoxazole within two months of birth. (WHO
& UNICEF for IATT, Report Card on PMTCT, 2008)
DFID PRIORITY 2:
RESPOND TO
THE NEEDS
AND PROTECT
THE RIGHTS
OF THOSE
MOST AFFECTED
Other issues related to children highlighted by DFID
— National plans of action for OVC
should be supported in a long-term, predictable manner. (P27)
Indicator:
— Increasing score from 59% (2007 baseline)
of the OVC Policy & Planning Effort Index in sub-Saharan Africa.
(UNICEF, 2008)
DFID PRIORITY 3:
SUPPORT MORE
EFFECTIVE AND
INTEGRATED SERVICE
DELIVERY
Top line UK priorities
— Spend over £200 million to support
social protection programmes over the next three years. Work with
governments and civil society in eight African countries to develop
social protection policies and programmes that will provide effective
and predictable support for the most vulnerable households, including
those with children affected by AIDS. (P64)
Indicators:
— Percentage of orphaned and vulnerable
children aged 0-17 whose households received free basic external
support in caring for the child. (UNGASS, 2008)
— Current school attendance among orphans
and among non-orphans aged 10-14. (UNGASS, 2008)
— Proposed—DFID Field Offices
in the eight countries provide annual progress reports on social
protection programme.
— Proposed—DFID undertake evaluation
of eight-country social protection programme in two to three years,
which will include analysis of impact of cash transfers and appropriate
social protection policies and services on children.
— Proposed—DFID Field Offices
report annually on activities related to especially vulnerable
children eg street children and disabled children.
Other issues related to children highlighted by DFID
1. We also need to ensure that| provide better
diagnostics of children infected with HIV and greater access to
paediatric treatment. (P39)
2. Regularly review our approach (on vulnerable
children), including publishing a report following the biennial
Global partners Forum on Children Affected by HIV & AIDS to
ensure that the approach outlined here supports the most effective
ways of meeting the needs and rights of OVCs. (P40)
3. Supporting the development, implementation
and review of credible, comprehensive and costed national AIDS
plans, which are linked to national health and other sector delivery
plans. (P64)
4. Cash transfers must be part of a comprehensive
system of care and support that includes family support services,
accessible and affordable healthcare and education, psychosocial
support, and broad livelihood support. (P39)
5. A new DFID Southern African regional programme
on Access to Medicines will start in 2008. This will spend over
£10 million (in the first three year phase) to improve availability
and affordability of quality essential medicines and diagnostics
in Southern Africa Development Community (SADC) Member States.
(P45)
6. Promoting the implementation of education
programmes that help young people, both those in and out of school,
to have safe and healthy sexual relationships, free from stereotyping,
violence and exploitation.
Indicators (numbers relate to issues above):
1a. Total number of HIV-infected children (<15
years of age) receiving ART.
1b. Proposed—Provide progress report on
DFID support for UNITAID including activities on paediatric diagnostics
and paediatric treatment.
2. Proposed—Produce report analysing DFID
approach for effectively supporting OVCs, following Global Partners
Forum.
3. Increasing score from 59% (2007 baseline)
of the OVC Policy & Planning Effort Index in sub-Saharan Africa
(UNICEF, 2007).
4. Proposed—DFID undertake evaluation of
eight-country social protection programme in two to three years,
which will include analysis of impact of cash transfers and appropriate
social protection policies and services on children.
5. Proposed—DFID Southern Africa to produce
annual report on progress of Southern African regional programme
on Access to Medicines and include analysis of support for paediatric
diagnostics and paediatric treatment.
6a. Percentage of schools that provided life
skills-based HIV education in the last academic year. (UNGASS,
2008)
6b. Number of national governments that have
put in place national HIV prevention programmes for out of school
youth in most or all districts in need. (UNGASS, 2008)
DFID PRIORITY 4:
MAKING MONEY
WORK HARDER
THROUGH AN
EFFECTIVE AND
CO-ORDINATED
RESPONSE
Other issues related to children highlighted by DFID
— Promoting efforts to track the flow
of funds from national to community level and alleviate bottlenecks.(P65)
Indicators:
— Total number of HIV-infected children
(<15 years of age) receiving ART.
— Proposed—DFID supporting research
on resource tracking and activities to alleviate bottlenecks (DFID
Field Office Annual HIV & AIDS Activity reports.
September 2008
81 UNAIDS, August 2008 Report on the Global AIDS Epidemic
2008. Back
82
ibid. Back
83
ibid. Back
84
WHO, UNAIDS and UNICEF, 2008, Towards Universal Access: Scaling
up priority HIV/AIDS interventions in the health sector. Back
85
The international community includes: international non-governmental
organisations, civil society organisations, UN agencies and international
donors. Back
86
UN General Assembly, Report of the Secretary General, April 2008,
Declaration of Commitment on HIV/AIDS and Political Declaration
on HIV/AIDS: midway to the Millennium Development Goals. Back
87
United Nations General Assembly, April 2008, Declaration of Commitment
on HIV/AIDS and Political Declaration on HIV/AIDS: midway to the
Millennium Development Goals-Report of the Secretary General. Back
88
UNAIDS, UNICEF and WHO, 2008, Children and AIDS: Second stocktaking
report: Actions and Progress. Back
89
WHO, UNAIDS and UNICEF, 2008, Towards Universal Access: Scaling
up priority HIV/AIDS interventions in the health sector. Back
90
ibid. Back
91
UNAIDS, 2005, AIDS epidemic update: December 2005. Back
92
UNICEF, PMTCT Report Card 2005, Monitoring Progress on the Implementation
of Programs to Prevent Mother to Child Transmission of HIV. Back
93
UNAIDS, UNICEF and WHO, 2008, Children and AIDS: Second stocktaking
report: Actions and Progress. Back
94
Members of The Working Group on Children Affected by HIV and AIDS:
AVERT, British Red Cross, Cafod, Care International, ChildHope,
Christian Aid, Consortium for Street Children, Egmont Trust, Healthlink
Worldwide, HelpAge International, Hope HIV, International HIV/AIDS
Alliance, Learning for Life, Mildmay International, Partnership
for Child Development, Plan UK, Religions for Peace UK, Samaritan's
Purse International Relief, SOS Children's Villages, Street Child
Africa, Tearfund, Uganda AIDS Action Fund, UNICEF UK, VSO and
World Vision UK. Back
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