 | Prof. Linda Richter delivering her plenary presentation |
Children have been short-changed in the response to AIDS. They are visible in the photo opportunities and headlines, but mostly invisible in the response to HIV,' Prof. Linda Richter of the HSRC told the XVIIth International AIDS Conference in a plenary address entitled No Small Issue: Children and Families in the first plenary address to be devoted to the wellbeing of children affected by HIV and AIDS in the conference's 23-year history. UNAIDS estimates that two million children aged 0-14 were living with HIV in 2007 - an eight-fold increase since 1990 - while both new infections and deaths among children have grown threefold in the same period. Some 370 000 children became newly infected with HIV last year and about 270 000 children died. About 90% of these children live in sub-Saharan Africa, where an estimated 12.1 million children have also lost one or both parents to AIDS-related illnesses. While the global response to AIDS has accelerated, prevention, treatment and care for children continue to lag behind: HIV prevention is failing children. The overwhelming majority of children who are HIV-positive are infected through motherto- child transmission. Despite recent progress, services to prevent mother-to-child transmission (PMTCT) in low- and middle-income countries - the effectiveness of which has been established for over 10 years - reach only a third of those that need them. Children living with HIV have far less access to treatment than do adults in the same settings. Only about 10% of children living with HIV are receiving ART worldwide. Last year, fewer than 8% of infants in low- and middle-income countries were tested within two months of their birth, and only 1 in 25 babies exposed to HIV received the antibiotic co-trimoxazole, which is essential to prevention. There are serious gaps in the data on children and HIV, and the evidence that does exist is often overlooked. For example, very little is known about infections among children between infancy and 15 years of age, despite household surveys in countries showing significant levels of HIV prevalence in this age group. Conversely, population-based surveys in many African countries identify a relatively low number of childheaded or skip-generation households (with only elderly people and children) - yet very large amounts of money and attention are focused on these tragic but relatively rare situations. Current approaches to children affected by HIV/AIDS too often focus only on "AIDS orphans", to the detriment of other needy children and families. Targeting interventions specifically to orphans or AIDS-affected children is neither helpful nor efficient in hard-hit communities where there is widespread poverty and destitution. In these circumstances, orphans are seldom worse off than other vulnerable children. Singling out specific group of children can even result in undesirable effects, such as stigmatisation and abuse of those in need of help. All children in communities severely affected by HIV require support.
‘Children orphaned by AIDS are, sadly, only the tip of the iceberg of HIV-affected children,' said Prof. Richter. ‘Our primary focus in designing and implementing policies must be the actual needs of all children affected by HIV/AIDS, not whether they meet an agency's definition of "orphan".' Larger-scale support is urgently needed Prof. Richter said families, broadly defined, care best for children. Yet many efforts to assist children affected by HIV and AIDS have ignored the clear benefits of supporting families, many of which live in extreme poverty and receive little or no assistance from governments. ‘The poorest families face the worst effects of the epidemic, financing the health care of those who are sick, and absorbing kith and kin - largely by eating less and spending less on education and health care. This critically affects the wellbeing of children,' remarked Prof. Richter. In several southern African countries, more than 30% of families have an adult member living with HIV or have experienced a recent AIDS-related death. In addition, over 60% of children live below the poverty line - in countries that are themselves already very poor. In such situations, support to individual children by local community members and organisations has been critical, but falls woefully short of meeting children's needs. To date, however, few interventions for children have been formulated, resourced or implemented on a scale that matches the epidemic's impact on children and their families. The current response for children is largely composed of ad hoc projects with limited outreach that are often imperfectly designed and underfunded. 
In the most severely affected regions, families and communities are left to bear the overwhelming burden of the epidemic, including approximately 90% of the financial cost. Indeed, only about 15% of households supporting vulnerable children globally receive any support from community-based or public sector programmes. ‘Civil society organisations and faith groups provide most of the available support," Richter said. "But small, localised projects can only take us so far. To have a bigger impact requires larger and more systemic responses - responses which support families and address the pervasive poverty in which so many of them live.' A new action agenda for children In her plenary remarks, Prof. Richter laid out a new action agenda to provide the poorest families in poor countries with social protection and universal access to services, key steps toward addressing the needs of children affected by HIV/AIDS. This new agenda includes: Redirecting support for children to and through their families. Families are the most influential force in the lives of children and adolescents. Strengthening the capacity of families through systematic, public sector initiatives has been identified globally as one of the most important strategies in building an effective response for children. Institutional, orphanage and other forms of non-family care have well-documented problems and cost up to ten times more than family care. Providing integrated, family-centred services. By targeting only individuals, many HIV interventions and services - such as PMTCT, the home care of a very ill person or starting a family member on antiretroviral treatment - are missing critical opportunities to reach out to family and community members as well. Action for children's wellbeing must address not only their health but also their basic material needs, psychosocial wellbeing and cognitive development. These comprehensive approaches provide crucial opportunities to reinforce key components of primary health care delivery for all, integrate health sector action with child-focused work in other sectors, and leverage broader advances in social development. Providing social protection for poor families. HIV-affected households typically experience a worsening of their socioeconomic status, which greatly affects children in their care. Reducing the impact of extreme poverty through social protection efforts is the crucial missing ingredient in responses to children affected by HIV/AIDS.
‘Every developing country, no matter how poor, can afford a social protection package for children affected by HIV and extreme poverty,' Prof. Richter remarked. The International Labour Organisation estimates the cost of a small universal old age pension, universal primary education, free primary health and a child benefit of US$0.25 per day at between 1.5 to 4.5% of GDP in low-income African countries. ‘Putting needed resources into the hands of affected families should be urgently considered as a solid foundation for small scale programmes currently reaching very small numbers of children,' she added. Richter also noted the success of income transfer programmes, especially for the poorest families affected by HIV/AIDS who are often too incapacitated to take advantage of micro-lending or skills training programmes. Income transfer programmes can include social security entitlements such as old-age pensions and child support grants; programmatic interventions targeted to vulnerable communities and households; treatment allowances; or small amounts of money to cover the transport and opportunity costs of accessing HIV/AIDS prevention and care services. ‘Whatever approaches are taken, some form of income assistance for the neediest households is critical," Richter said. "In many high-prevalence countries in Africa, poverty is arguably the single biggest barrier to the scale-up of HIV treatment and prevention. Further expansion of these services may not be possible without addressing individual and household incapacity, including financial incapacity, to access them.' In conclusion, Prof. Richter noted that the spotlight is finally moving to children, as a result of projects such as the Joint Leaning Initiative on Children and HIV/AIDS (JLICA) and vigorous advocacy by a number of child-oriented agencies.
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