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7 Children and Adolescents MAIN MESSAGES • EPFAR has positively affected the lives of children and adolescents P living with or affected by HIV. PEPFAR has contributed to major scale- up of services (orphans and vulnerable children [OVC], pediatric care and support, pediatric treatment, and prevention of mother-to-child transmission [PMTCT]) across delivery settings (facility-based, home- based, community-based, and family support). With its explicit focus on orphans and vulnerable children, PEPFAR has elevated attention to and investment in meeting the needs of this population through programs and services that are informed by evidence. PEPFAR has also been instrumental in facilitating partner country consideration and adoption of policies, laws, and guidelines on behalf of children and adolescents, including OVC policies and frameworks, policies for pediatric testing and treatment, and efforts to strengthen legislation and enforcement for child protection. • espite progress, there remain insufficiently met needs relating to D the health and well-being of children and adolescents. Although it is not realistic to expect PEPFAR to meet all the need of children and adolescents in partner countries, there are particular areas where PEPFAR could strive to address these needs more fully. In particular, there remain gaps in coverage for PMTCT relative to PEPFAR’s 85 per- cent goal; the coverage of pediatric HIV care and treatment remains proportionally much lower than the coverage for adults, despite the goal in the reauthorization legislation to provide care and treatment services in partner countries to children in proportion to their percent- age within the HIV-positive population; and OVC programs struggle to adequately meet the needs of children, and adolescents in particular. Across program areas, there is also a need to plan for long-term sus- tainability of services and to build the capability of partner countries to continue the successes they have realized in addressing the needs of children and adolescents living with or affected by HIV. • he ability to assess the impact of PEPFAR-supported programs for T children and adolescents is restricted by limitations in the available data. There are data insufficiencies in three key areas directly related to PEPFAR programs: disaggregation both by sex and by age sub- groups (e.g., less than 1 year, 1 to 5 years, and 6 to 17 years) to better understand what populations are receiving what services; baseline 343
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344 EVALUATION OF PEPFAR and longitudinal data to follow children and families and the effects of the services they receive over time; and data on effectiveness and outcomes to help identify the most effective PEPFAR OVC programs and models. In addition, there is a lack of data about the total popu- lation of children “in need,” in part because of a lack of clarity and consistency both across countries and across programs within coun- tries in how the population eligible for PEPFAR-supported services is defined (i.e., which children are defined as “vulnerable” or “affected by HIV”). Recommendation Presented in This Chapter Recommendation 7-1: To improve the implementation and assessment of nonclinical care and support programs for adults1 and children, in- cluding programs for orphans and vulnerable children, the Office of the U.S. Global AIDS Coordinator should shift its guidance from specifying allowable activities to instead specifying a limited number of key out- comes. The guidance should permit country programs to select priori- tized outcomes to inform the selection, design, and implementation of their activities. The guidance should also specify how to measure and monitor the key outcomes. Further considerations for implementing this recommendation: • or orphans and vulnerable children, the new OVC guidance and the F ongoing developments for program evaluation already represent ad- vances in addressing some of the challenges identified in this evalua- tion; this recommendation and the further considerations are intended to reinforce and further inform and support progress in achieving PEPFAR’s goals for children and adolescents. • utcomes for consideration should be linked to the aims of OVC O programs and therefore could include, for example, increased rates of staying in school, decreased excessive labor, reduced rates of ex- posure to further traumas, increased immunization completion, and increased coverage of HIV testing and treatment. With a continued focus on supporting developmentally informed programs, consider- ation should be given to identifying appropriate core outcomes for different age groups and for achieving developmental milestones. The program evaluation indicators currently being developed already offer a reasonable opportunity to link measures to core target outcomes for OVC programs. • he core key outcomes should also include quality of services and T measures to reflect the potential sustainability of programs. • shift to a more outcomes-oriented implementation model will re- A 1 The discussion of nonclinical care and support for adults leading to this aspect of this recommendation can be found in Chapter 6.
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CHILDREN AND ADOLESCENTS 345 quire that partner countries receive support to define their prioritized outcomes and their target population and then to conduct baseline assessments so that progress toward outcomes can be measured. • EPFAR U.S. mission teams should work with partner country stake- P holders and implementers to assess country-specific needs and to select a subset of the core key outcomes to focus on when planning, selecting, and developing evidence-informed activities and programs for implementation. • rioritization is critical in the presence of great need and finite re- P sources. When planning with partner countries, PEPFAR should im- prove targeted coverage and the quality of supported services for affected children and adolescents not only by prioritizing outcomes and activities but also by more explicitly, clearly, and narrowly defin- ing the eligibility for PEPFAR-supported services. This prioritization should be based on an assessment of country-specific needs with a process that consistently applies considerations and criteria across countries and programs. This prioritization should be done in coordi- nation across program areas that address the needs and vulnerabili- ties of children and adolescents. These areas, which may target and serve a broader eligible population of children and adolescents than is determined for specific OVC programs, include care and treatment, PMTCT, other prevention services, and gender programs. • o improve the targeted coverage and sustainability for children and T adolescents, PEPFAR and its implementing partners should continue to enhance services through existing systems and infrastructure and to support national governments in expanding social support services and the workforce to meet the health, education, and psychosocial needs of affected children and adolescents. • he Office of the U.S. Global AIDS Coordinator (OGAC) should pro- T vide general guidance for country programs on continuous program evaluation and quality improvement in order to measure and monitor the achievement of key outcomes. This may include, for example, template evaluation plans and methodological guidance. To allow for comparability across countries and programs, evaluation plans should include (but not be limited to) the defined indicators or other measures of the core key outcomes. Evaluations should emphasize the use of in-country local expertise (e.g., local implementing partners and sub-partners as well as local academic institutions) to enhance capacity building and contribute to country ownership. (See also rec- ommendations for PEPFAR’s knowledge management in Chapter 11.) • EPFAR should develop a system for the active dissemination and P sharing of evaluation outcomes and best practices both within and across countries that is driven as much by country-identified needs for information as by opportunities for exchange of information identi- fied by headquarters-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)
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