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Evaluation of PEPFAR (2013)

Chapter: 7 Children and Adolescents

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Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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7

Children and Adolescents

The congressional charge for this study, as laid out in the Lantos-Hyde Act of 2008,1 requested an “evaluation of the impact on child health and welfare of interventions authorized under the Act on behalf of orphans and vulnerable children” and “an evaluation of the impact of programs and activities authorized in the Act on child mortality.”2 In addition, the request for an assessment in other areas, especially prevention, treatment, and care programs and gender-specific aspects of HIV/AIDS, implicitly included considerations for children and adolescents as well as for adult populations.

After a brief background on the effects of the HIV pandemic on children and adolescents and on the needs of this population, this chapter presents the committee’s assessment, in response to this congressional charge, of PEPFAR’s efforts aimed at the needs of children and adolescents3 living with

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1 Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, P.L. 110-293, 110th Cong., 2nd sess. (July 30, 2008).

2Ibid., at img101(c), 22 U.S.C. 7611(c)(2)(B)(vi-vii).

3 The term “children and adolescents” is used throughout this report as a general term without a specific age definition, recognizing that the ages used to categorize children and adolescents vary by data source and organization. The age categories vary in particular for terms like adolescents, youth, and young people. For example, the World Health Organization (WHO) defines adolescents as men and women 10 to 19 years of age and young people refers to men and women 10 to 24 years of age (WHO, 1999, 2006). The United Nations defines youth as men and women 15 to 24 years of age and refers to young people as men and women 10 to 24 years of age (WHO, 1999, 2006). Defined age ranges for children and adolescents also vary by programmatic area within PEPFAR, which uses ages 0 to 17 years for orphans and

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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and affected by HIV/AIDS. This chapter includes the primary presentation of the committee’s assessment of PEPFAR’s activities that fall under the specific category of programming for orphans and vulnerable children (OVC), following the program impact pathway framework of assessing inputs, activities, and, to the extent possible, outcomes and impact. PEPFAR also supports services for children and adolescents through prevention, treatment, and care programs, and although findings about these programmatic areas are covered in more detail in other chapters, the major conclusions that are specific to children and adolescents are summarized at the end of this chapter in order to bring together a comprehensive picture of PEPFAR’s efforts to improve the health and well-being of children and adolescents.

To meet its charge, the IOM committee assessed PEPFAR’s investment in programming for children and adolescents, including its progress in meeting fiscal targets; reviewed PEPFAR’s guidance and the activities it has supported for these populations; and examined PEPFAR’s progress toward programmatic targets and goals for children and adolescents, specifically its efforts to increase the number of HIV-positive children receiving treatment (discussed in Chapter 6) and to increase the number of orphans and vulnerable children receiving care and support services. To the extent possible, the committee also reviewed the available evidence to assess the effects of services provided to children and adolescents, efforts to support family-centered programs and community-led initiatives, and efforts to support countries to strengthen country policies and systems for supporting this population. The presentation of the committee’s assessment in these areas is followed by a discussion of the future directions most recently articulated by PEPFAR in new guidance. This chapter also includes some discussion of child survival in PEPFAR partner countries, including the limitations on directly evaluating the effect of PEPFAR on child mortality.

BACKGROUND

The HIV pandemic has severely affected the lives of millions of children and adolescents across the globe, endangering their health, well-being, and development. The population of children and adolescents affected by HIV varies by geographic, demographic, social, and cultural factors, and their needs and the responses to these needs vary according to these factors as well as to their developmental stage and gender. Globally, approximately 3.3 million children younger than 15 years of age were living with HIV in 2011, and 330,000 children acquired new HIV infections that year

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vulnerable children (OVC) programs and 0 to 14 years for pediatric HIV care and treatment. Throughout this report, the specific age ranges used by PEPFAR or by the cited data source are indicated whenever feasible.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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(UNICEF, 2012). By affecting parents and other caregivers who are HIV-positive, the HIV pandemic also adversely affects infants, children, and adolescents who are not HIV-positive themselves by affecting their families and depriving them of parental care and protection. As of 2011 an estimated 17.3 million children and adolescents up to 17 years old had lost at least one parent to the HIV pandemic4 (Luo, 2012). HIV can also indirectly harm children and adolescents by weakening communities and social support networks, welfare systems, and economies.

The health and psychosocial well-being of children and adolescents affected by HIV are influenced by a range of critical factors. Mediators of adverse effects include trauma, relocation, residence in poorer households, and residence with more distantly related caregivers, which can lead to inadequate access to nutrition, shelter, and health care, lack of educational support, lack of legal and other forms of protection, and other effects (UNICEF, 2007). When a parent dies, the grieving process, the deprivation of emotional and material support, and other life changes that occur because of this loss can affect a child’s health and well-being (Cluver and Orkin, 2009; Nyamukapa et al., 2008; Whetten et al., 2011a). Depending on the economic status of their available caregiver, children often enter into excessive labor and stop attending school (Whetten et al., 2011b). In some cases, children and adolescents with sick and dying parents end up becoming the primary caregivers and financial and emotional supporters of their households, essentially losing the opportunity of being children (UNICEF, 2007). In settings where stigmatization is high, children and adolescents who lose parents because of HIV/AIDS are faced with more psychosocial stressors than do non-orphans and children orphaned by other causes (Cluver and Gardner, 2007; Cluver and Orkin, 2009; Cluver et al., 2007). Children and adolescents living within communities that experience a high HIV burden are also at a greater risk of homelessness, of exposure to HIV, and of physical and sexual abuse and exploitation (UNAIDS et al., 2002, 2004). Orphans and abandoned children in these communities, both boys and girls, are at high risk of experiencing additional traumatic events of this kind (Whetten et al., 2011a).

In addition to the vulnerabilities of younger children, the international community has also recognized the vulnerabilities of adolescents between the ages of 15 and 24 years along with the opportunities for interventions during this important developmental transition period (UN, 2001; World

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4 In 2001, a consensus was reached among members of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Reference Group on Estimates Modelling and Projection and international researchers on the definition of HIV/AIDS orphans. An AIDS orphan was defined as “a child who has at least one parent who has died due to AIDS” and a double (or dual) AIDS orphan as “a child whose mother and father have both died, at least one due to AIDS” (UNAIDS Reference Group on Estimates Modelling and Projections, 2002, p. W9).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Bank, 2006). An estimated 5 million people aged 15 to 24 years were living with HIV in 2009 (UNICEF, 2011). In 2011 an estimated 40 percent of HIV incidence in people aged 15 years and older was among those aged 15 to 24 years (UNAIDS, 2012b). Adolescents are vulnerable because of age-specific physical, psychological, and social changes (e.g., their relationships and roles, expectations, and economic security) (Call et al., 2002). These transitions affect the ways in which adolescents understand information, how they are influenced, their abilities to make decisions in the present and to plan for the future, and their perceptions of risk (FHI, 2010). The majority of the people in this age group living with HIV are in sub-Saharan Africa, where young women in particular are more vulnerable and at greater risk of HIV infection (Gouws et al., 2008; Napierala Mavedzenge et al., 2011; UNICEF, 2011). There are many socio-cultural factors that increase the vulnerability of young women to sexually transmitted HIV infection. These include deep-rooted gender roles, uneven power relations, sexual violence (including rape), intergenerational sex, and a lack of skills and information that would enable them to access services and better protect themselves (UNAIDS, 2009). Issues related to women and girls as well as gender norms are discussed in more depth in Chapter 8.

The United Nations Convention on the Rights of the Child guides the efforts of the international community to protect the rights of children to survival, healthy development, and access to health services. The convention’s guidelines stress the importance of reversing the HIV epidemic in children and using the Millennium Development Goals, the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS, and the UNGASS on Children as platforms through which to mitigate the negative effects of HIV on children’s health and well-being (UNICEF, 2007). The Committee on the Rights of the Child monitors the progress of countries in achieving standards and goals.5 Multilateral and bilateral stakeholders who support efforts and policies for OVC affected by HIV/AIDS have developed the Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS. This framework includes five strategies for improving the well-being of children: “(1) Strengthen the capacity of families to protect and care for orphans and vulnerable children by pro-

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5 The Convention on the Rights of the Child, which the United States has not ratified, is the first legally binding international instrument that addresses the complete range of civil, cultural, economic, political, and social rights of children. Through the convention, the United Nations Children’s Fund (UNICEF) assumes the responsibility of promoting the rights of children by supporting the Committee on the Rights of the Child. UNICEF provides governments with technical assistance on implementation of the Convention and the development of implementing reports, which must be submitted every 5 years (OHCHR, 2007; UN, 1990; United Nations Treaty Collection, 2010).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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longing the lives of parents and providing economic, psychosocial and other support; (2) Mobilize and support community-based responses; (3) Ensure access for orphans and vulnerable children to essential services, including education, health care, birth registration and others; (4) Ensure that governments protect the most vulnerable children through improved policy and legislation and by channeling resources to families and communities; (5) Raise awareness at all levels through advocacy and social mobilization to create a supportive environment for children and families affected by HIV/AIDS” (UNICEF, 2004).

Given the range and scope of the adverse effects of HIV/AIDS on children and adolescents, addressing their needs is vital to the response to the epidemic. Programs and services for this population, from infancy through adolescence, provide the opportunity to mitigate these effects and promote positive outcomes with a long-term trajectory for accrual of benefits from early intervention. Early intervention of this kind lays the groundwork for supporting healthy and productive lives and promoting HIV prevention throughout the life course. As part of its contribution to the HIV response in partner countries, PEPFAR supports services for children and adolescents affected by HIV in all of its three main programmatic areas—prevention, care, and treatment (OGAC, 2006a, 2011a,b). PEPFAR also supports programs specifically for orphans and vulnerable children and adolescents, in keeping with the framework described above (hereinafter referred to as OVC programs or programming6) (OGAC, 2006a, 2012). The Lantos-Hyde Act of 2008 underscored the needs of children and adolescents as part of the U.S. government (USG) commitment to prevent 12 million new HIV infections worldwide and to increase the number of individuals with HIV/AIDS who are receiving antiretroviral therapy. It also stated that PEPFAR-supported programs need to “provide care and treatment services to children with HIV in proportion to their percentage within the HIV-infected population of a given partner country.”7 Additionally, PEPFAR II performance targets for the care and support of people living with HIV include the specific target of providing care and support for 5 million children and adolescents orphaned or made otherwise vulnerable by HIV/AIDS.8

The committee’s assessment of prevention, care, and treatment, including for children and adolescents, were covered in more detail in Chapters 5 and 6. In brief, PEPFAR support has made a major contribution to meeting the need in partner countries for prevention of mother-to-child transmission

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6 For the purpose of brevity, the acronym OVC will be used to describe programs or programming targeting eligible children and adolescents under PEPFAR’s programs for orphan and vulnerable children.

7Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(4)(E).

8Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(4)(C).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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(PMTCT) services that reduce the transmission of HIV to infants. PEPFAR has also contributed to increasing pediatric treatment, but the coverage of pediatric HIV remains proportionally much lower than 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 percentage within the HIV-infected population. Treatment of infants and children remains a persistent challenge across the continuum of care. The main barriers, especially for infants, come at the stages of testing and diagnosis, linkages to care and treatment, and timely initiation of therapy.

After a brief summary of PEPFAR’s funding over time across all services for children and adolescents, this chapter provides the primary presentation of the committee’s assessment of PEPFAR’s activities that fall under the specific category of programming for OVC.

FUNDING HISTORY FOR PEPFAR SUPPORT FOR CHILDREN AND ADOLESCENTS

There is no single reporting mechanism that captures all of the financial investment that has supported services for children and adolescents through PEPFAR. Activities that support children and adolescents are implemented with funding captured within several budget codes: Pediatric Care and Support, Pediatric Treatment, and OVC (OGAC, 2010a). Figure 7-1 shows the funding over time in these budget codes in both the dollar amount and as a proportion of all PEPFAR funding. The total across these budget codes has increased since the beginning of PEPFAR, reaching by fiscal year (FY) 2009 a peak of about $500 million dollars per year and more than 12 percent of all PEPFAR funding, then declining slightly in 2010 and 2011. The total planned/approved funding that can be documented from these budget codes as explicit support for services for children and adolescents includes a total from FY 2005 to FY 2011 of $2.3 billion, including $1.7 billion for OVC programs, as well as at least $160 million for pediatric HIV care and $405 million for pediatric treatment.

Although these data give a general sense of the funding history and provide an approximation of PEPFAR’s overall investment in children and adolescents, it is important to note that it is difficult to compile an entirely accurate accounting over time of the total investment that has gone to serve this population of beneficiaries. There are several reasons for this. First, the services captured by these budget codes have changed over time. In particular, funding for pediatric treatment was not reported in FY 2005 and FY 2008 (OGAC, 2005a, 2008c), and the separate budget code for pediatric HIV care was not introduced until FY 2009 (OGAC, 2008a, 2010b). Second, the age ranges covered by the services documented in these budget codes vary. The programs captured as OVC programs extend through the

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

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FIGURE 7-1 Planned/approved funding over time for services for children and adolescents.
NOTES: This figure represents funding for all PEPFAR countries as planned/approved through PEPFAR’s budget codes. The budget codes are the only available source of funding information disaggregated by type of activity and are therefore used in this report as the most reasonable and reliable approximation of PEPFAR investment by programmatic area. Data are presented in constant 2010 USD for comparison over time. See Chapter 4 for a more detailed discussion of PEPFAR’s budget codes and the available data for tracking PEPFAR funding.
SOURCES: OGAC, 2005a, 2006f, 2007c, 2008c, 2010b, 2011c,d.

age of 17 years, while pediatric HIV clinical care and treatment services encompass children less than 15 years of age (OGAC, 2009c,d). In addition, individuals receiving services who are older than the upper limit of these age ranges yet might still be considered adolescents are included within adult budget codes and are not reflected in these data. Finally, some PEPFAR-supported services for this population are not included in these codes but instead are in budget codes that are not tracked separately by age, such as prevention services for youth when not explicitly a part of OVC programs (OGAC, 2011b). Most notably absent from the totals shown in Figure 7-1 in terms of representing investments in interventions that benefit children is PMTCT, which is a prevention intervention to reduce HIV infection in infants, yet is not tracked in a pediatric budget code but rather in its own prevention budget code (OGAC, 2010a). In FY 2011, $396 million was planned/approved for PMTCT services, which is more than three-quarters of the total funding for all other documentable pediatric services (OGAC, 2005a, 2006f, 2007c, 2008c, 2010b, 2011c,d). See Chapter 5 for a discussion of PEPFAR’s support for PMTCT.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Legislative Budgetary Allocation Requirement for OVC Funding

The original legislation authorizing PEPFAR mandated that, starting in FY 2006, “not less than 10 percent of the amounts appropriated . . . for HIV/AIDS assistance for each such fiscal year shall be expended for assistance for orphans and vulnerable children.”9 This earmark was preserved when the Lantos-Hyde Act of 2008 reauthorized PEPFAR.10 PEPFAR’s policy for implementing this budgetary requirement is provided in the instructions to country programs on planning and budgeting for OVC programming through Country Operational Plan (COP) guidance, and compliance with the requirement is monitored by PEPFAR on a country-by-country basis through the COP review process. As established in the 2006 COP guidance, countries are instructed that in order to comply with the requirement, 10 percent of program resources for prevention, care, and treatment should go to OVC programs. Countries that are unable to meet the budgetary requirement must provide a justification (OGAC, 2005b). Over time it was clarified in the COP guidance that the expectation for meeting the 10 percent budgetary requirement was for countries with generalized epidemics and that it was less applicable for countries with smaller OVC populations or concentrated epidemics (OGAC, 2008a, 2009b). Ultimately it was explicitly stated that all former focus countries, except Vietnam and Guyana, are required to comply with the OVC budgetary requirement and that a justification for spending less would not be considered for these countries. For other countries submitting COPs, while OVC programming is still considered essential, those with smaller OVC populations or concentrated epidemics can submit justifications for spending less than 10 percent (OGAC, 2010a, 2011a).

Tracking PEPFAR’s compliance with the proportional budgetary requirement over time and across countries is complicated because the guidance on what funding and activities were to be counted toward the allocation changed over time and varied somewhat by country. One major variation is that for FY 2006 and FY 2007 countries could choose to attribute activities for pediatric HIV to either the OVC budgetary requirements or the treatment budgetary requirements that were in place at that time (OGAC, 2005b, 2006e). In both years the COP guidance encouraged countries to prioritize non-treatment OVC activities in a balance with pediatric treatment activities (OGAC, 2005b, 2006e), and the 2007 guidance specifically encouraged countries to “strive to fund OVC programs at, or as close as possible, the 10% level prior to including funding for pediatric treatment” to ensure the provision of a comprehensive OVC program

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9 United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, P.L. 108-25, 108th Cong., 1st sess. (May 27, 2003), img403(b).

10Supra, note 1 at img402, 22 U.S.C. 7672(b) and img403(2), 22 U.S.C. 7673(b).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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(OGAC, 2006e, p. 5). Since FY 2008 the COP guidance has changed to specify that pediatric treatment could no longer be counted toward the 10 percent OVC budgetary requirement. Each year the guidance has emphasized that this change was not intended to lessen the importance of a focus on pediatric treatment as a priority, but rather to establish that the 10 percent requirement should include only OVC programs and that funds for pediatric treatment should be attributed separately as dedicated funds in the pediatric treatment budget code (OGAC, 2007a, 2008a, 2009b, 2010a, 2011a). Another complication in tracking the proportion of OVC funds is that the activities funded that contributed to the denominator of total prevention, care, and treatment resources changed, with activities in the laboratory infrastructure budget code no longer included within treatment beginning in FY 2010 and therefore no longer included as part of the total denominator (OGAC, 2008a, 2009b).

Given these complications, in order to reasonably and comparably approximate the compliance with the legislative earmark across PEPFAR partner countries and over time, the committee chose to assess the available planned/approved funding data reported through the OVC budget code, compiling the totals for prevention, care, and treatment program resources as the denominator using the FY 2011 definition retrospectively for all years (therefore excluding the laboratory infrastructure budget code). As shown in Table 7-1, even using the planned/approved funding across all countries, including those with concentrated epidemics and small OVC populations, PEPFAR has maintained or exceeded the budgetary requirement since FY 2007, with total planned/approved funds of $1.7 billion dollars for OVC programs over those 7 years.

The original legislation also prescribed that “at least 50 percent” of the 10 percent earmark “shall be provided through non-profit, nongovernmental organizations including faith-based organizations that implement programs at the community level,”11 and this requirement was retained in the reauthorizing legislation.12 COPs and interview data collected by this committee indicate that PEPFAR’s OVC activities are widely implemented by the kinds of organizations described in the legislation. However, because there is no central reporting of funding both by implementing partners and subpartners and by budget code (see Chapter 4), the committee was not able to access a comprehensive PEPFAR-wide documentation of funding to determine whether the 50 percent mandate has been met.

In summary, although there are complications in definitively and comprehensively tracking PEPFAR’s total investment over time in children and adolescents, the available data on planned/approved funding show that

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11Supra, note 9 at img403(b).

12Supra, note 1 at img403(2), 22 U.S.C. 7673(b).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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TABLE 7-1 Tracking the Legislative Budgetary Requirement for OVC Programming (in USD Millions)

  FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 Total
OVC $74.3 $111.6 $202.9 $305.1 $350.6 $327.9 $336.0 $1,708.4
Total Program Resources (prevention, care, and treatment) $946.2 $1,238.9 $2,120.2 $2,962.2 $3,165.9 $3,119.3 $3,269.1 $16,821.8
OVC as % of Total Program Resources 8% 9% 10% 10% 11% 11% 10% 10%

NOTES: This table represents funding for all PEPFAR countries as planned/approved through PEPFAR’s budget codes. The budget codes are the only available source of funding information disaggregated by type of activity and are therefore used in this report as the most reasonable and reliable approximation of PEPFAR investment by programmatic area. Data are presented in constant 2010 USD for comparison over time. See Chapter 4 fora more detailed discussion of PEPFAR’s budget codes and the available data for tracking PEPFAR funding. OVC = orphans and vulnerable children.
SOURCES: OGAC, 2005a, 2006f, 2007c, 2008b, 2010b, 2011c,d.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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PEPFAR has complied with its policy for implementing the legislative budgetary requirement by spending at least 10 percent of program resources for prevention, care, and treatment on OVC programs. The guidance for complying with this requirement evolved over time to become more clearly focused on support for OVC programs, with separate tracking of investments in pediatric HIV treatment and care. The total planned/approved funding that can be documented as explicit support for services for children and adolescents includes a total from FY 2005 to FY 2011 of $1.7 billion for OVC programs as well as at least $160 million for pediatric HIV care, $405 million for pediatric treatment, and $1.43 billion for PMTCT (OGAC, 2005a, 2006f, 2007c, 2008a, 2010b, 2011c,d).

PEPFAR’S PROGRAMS AND SERVICES FOR ORPHANS AND VULNERABLE CHILDREN

OVC Program Guidance and Supported Activities

PEPFAR provides guidance for programs aimed at meeting the needs of children and adolescents living with and affected by HIV through programming guidance documents, “Technical Considerations” provided by headquarters-level technical working groups, and the COP guidance, which is released annually at the beginning of the country planning process. The primary relevant programming guidance for OVC programs is Orphans and Other Vulnerable Children Programming Guidance for United States Government In-Country Staff and Implementing Partners (OGAC, 2006a). PEPFAR updated its guidance on OVC programming in July 2012; however, because the program operated under the earlier guidance during the timeframe of this evaluation, the committee’s assessment is made primarily in the context of the prior guidance, which is reflected in this section. The recently updated guidance is discussed in more detail in the section below on the future directions of the program. Guidance related to services for children and adolescents other than specific OVC programming are discussed in Chapter 5 on prevention and Chapter 6 on care and treatment.

The 2006 guidance document described those who were potentially eligible for PEPFAR-supported OVC services as children aged 0 to 17 years who are “either orphaned or made more vulnerable because of HIV/AIDS.” An orphan was defined as a child who “has lost one or both parents to HIV/AIDS” (OGAC, 2006b, p. 2). Children were described as being more vulnerable “because of any or all of the following factors that result from HIV/AIDS: is HIV-positive; lives without adequate adult support (e.g., in a household with chronically ill parents, a household that has experienced a recent death from chronic illness, a household headed by a grandparent, and/or a household headed by a child); lives outside of family care (e.g., in

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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TABLE 7-2 PEPFAR Age Categories for Programs for Orphans and Vulnerable Children


Age (years) Stage

<2 Infancy
2-4 Early Childhood/Toddler
5-11 Middle Childhood
12-17 Late Childhood/Adolescence

SOURCE: OGAC, 2006b.

residential care or on the streets); or is marginalized, stigmatized, or discriminated against” (OGAC, 2006b, p. 2). Among this potentially eligible population, the guidance did not establish priorities defining those in most need. Although PEPFAR guidance provides this operational definition for OVC and guiding principles for OVC programming decisions, the guidance states that “each community will need to prioritize those children most vulnerable and in need of further care” (OGAC, 2006b, p. 2).

To facilitate age-appropriate development and to meet age-specific needs, PEPFAR guidance recommends that OVC programs target different age categories within ages 0 to 17 years (see Table 7-2) (OGAC, 2006b). The Lantos-Hyde Act of 2008 also offered a new emphasis on the vulnerabilities and needs of adolescents and young people.13 In its second Five-Year Strategy, PEPFAR articulated goals for programming for adolescents and young people such as supporting countries in “developing a case management capability to assist the transition of young adults from OVC services into society and careers” and helping to ensure that policies for populations at elevated risk include coverage and referrals for youth subpopulations (OGAC, 2009f, p. 23). The expanded program goals under the new Five-Year Strategy also highlight the importance of coordinating OVC programs with other efforts to address the needs of other age subset populations such as newborns, infants, and toddlers and school-age children (OGAC, 2009f).

PEPFAR’s OVC programming guidance (OGAC, 2006b) identifies important elements of child and adolescent well-being in seven core areas that are based on the principles of the Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS (UNICEF, 2004). These core areas of intervention, described in more detail below, include food and nutritional support, shelter and care, protection, health care, psychosocial support, education and vocational training, and economic opportunity or strengthening. PEPFAR also supports linkages of OVC programs and the children and families

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13Supra, note 1 at img301(e)(2)(B), 22 U.S.C. 104A(f)(2)(D)(ix)(III).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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they serve with PMTCT, palliative care, and treatment (OGAC, 2009b). Further, PEPFAR-supported activities under OVC programs include not only services that directly support orphans and vulnerable children and adolescents but also those that support their caregivers, families, and community structures (OGAC, 2009b). In addition, PEPFAR supports activities at the systems level. The first Five-Year Strategy emphasized not only rapid scale of services for OVC but also building capacity for long-term sustainability of these services, advancing policy initiatives that support OVC, and monitoring and evaluating progress (OGAC, 2004). As emphasized again in the second Five-Year Strategy, system-wide OVC program activities aim to build local, regional, and national capacity to strengthen the structures and networks that support healthy development of children. PEPFAR does this in part by helping countries to coordinate among ministries that oversee education, social welfare, and health, thus facilitating the development of policy and program responses that are comprehensive and effective in addressing the needs of orphans and vulnerable children and adolescents (OGAC, 2009f).

Core Areas of OVC Programming

Food and nutritional support OVC programs include nutritional assessments and counseling as well as the provision of therapeutic or supplementary feeding and micronutrients for children infected with HIV that are based on national and international guidelines (OGAC, 2006b). PEPFAR’s policy guidance on addressing food and nutrition needs identifies OVC, especially children under the age of 2 years born to HIV-positive mothers, as a priority group for food and nutrition interventions (OGAC, 2006c). PEPFAR provides food and nutritional support by linking with partners that are not specifically focused on HIV, such as the Food for Peace program of the U.S. Agency for International Development (USAID),14 the United Nations World Food Program, and programs in partner countries (OGAC, 2006d). To capture information on activities that relate to this cross-cutting issue, PEPFAR’s FY 2010 COP guidance introduced new budget codes for food and nutrition commodities, policy, tools, and service delivery (OGAC, 2009a,b). Currently, however, the Office of the U.S. Global AIDS Coordinator (OGAC) requires only one indicator specifically related to food and

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14 The Food for Peace program (P.L. 480, also renamed Food for Peace Act of 2008) is the primary mechanism through which the USG provides international food assistance. Title II of the Food for Peace Act, which authorizes most of the international food assistance given by the United States, is managed by the USAID Office of Food for Peace. Implementing partners who work with USAID Peace include private voluntary organizations registered with USAID, local and international nongovernmental organizations, and the United Nations World Food Program (USAID, 2009).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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nutrition for OVC, which captures the number of eligible individuals under 18 years old who received food and nutrition services (OGAC, 2009c,d).

Shelter and care As the number of orphans and vulnerable children and adolescents increases globally, it is becoming increasingly necessary to enhance the capacity of the families and communities that are caring for these children. PEPFAR funds can be put toward shelter and care activities such as identifying potential caregivers prior to the death of a guardian’s, tracing families, fostering, providing transitioning children with access to temporary shelter, helping child- or adolescent-headed households, increasing access to programs that incentivize adoption or the provision of foster care, and strengthening community- and family-based models of caring for children (OGAC, 2006b).

Protection PEPFAR OVC programs that address the protection of orphans and vulnerable children and adolescents may focus on interventions such as health care and social services that facilitate birth registration and identification, community-based assistance to orphans and vulnerable children who need to make inheritance claims, the removal of children from abusive situations and their placement in safe temporary or permanent living situations, and the strengthening of community structures that are responsible for monitoring and protecting orphans and vulnerable children (OGAC, 2006b).

Health care Core health care services for orphans and vulnerable children focus on the general health needs of this population and also address the health needs of HIV-positive children and promote HIV prevention activities. OVC programs should facilitate access to primary health care for orphans and vulnerable children and are required to use age-specific health requirements and interventions (OGAC, 2006b). Health interventions for OVC include referrals to child health care, the provision of support for abuse survivors, caregiver training on monitoring children’s health, and building the capacity of public and private health providers (OGAC, 2006b). PEPFAR OVC programs provide health care to HIV-positive children and HIV-exposed children by providing direct access to health providers or referrals to prevention and treatment services.

Psychosocial support Children and adolescents suffer anxiety, fear, grief, and trauma with the illness or death of a parent, and PEPFAR programs include activities that are intended to address their psychosocial and life-skills needs. PEPFAR activities to support the psychosocial well-being of orphans and vulnerable children include the provision of gender-sensitive life skills and experiential learning opportunities; the strengthening of connections

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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between children affected by HIV/AIDS and their communities; rehabilitation for children who do not live with their families; and referral to counseling, particularly for HIV-positive children and adolescents (OGAC, 2006b).

Education and vocational training PEPFAR funding supports activities for OVC that aim to ensure attendance at school; improve access to early childhood development programs; strengthen opportunities for vocational training; integrate children into the social life of the community; provide life skills training and HIV prevention messages; and reduce stigma (OGAC, 2006b). Partnerships with the education sector on national and local levels, as well as with other external donor efforts, are important for ensuring that children and adolescents affected by HIV have access to education. PEPFAR’s efforts in this core area include linkages with other USG development programs and involvement in interagency activities, such as an Interagency Education Steering Committee and other strategic planning activities that work toward the expansion of education programs to reach children and adolescents who are living with or made vulnerable by HIV/AIDS (OGAC, 2006b, 2009a).

Economic opportunity and strengthening PEPFAR programs fund economic strengthening services so that caregivers are able to tend to ill family members or receive orphaned children into the household. These activities include microfinance programs for the caregivers of orphans and vulnerable children, small business development, and community-based asset building. Programs also provide orphans and vulnerable children and adolescents with training and other skills that can improve their economic opportunities in the future (OGAC, 2006b).

Effects of PEPFAR’s OVC Programs

PEPFAR Indicator Data: Targets and Results

PEPFAR has few centrally reported indicators to reflect the performance of its OVC programs. There is one output indicator, which captures the number of children served by OVC programs; this was reported through 2009 as the number of eligible OVC served by OVC programs (OGAC, 2007b). In the Next Generation Indicators this was revised to be reported as the age-disaggregated subset (less than 18 years old) of the number of eligible individuals provided with a minimum of one care service (OGAC, 2009c,d). This indicator serves to track the overall legislative target of reaching 5 million children who have been orphaned or made vulnerable due to HIV (see Table 7-3).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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TABLE 7-3 OVC Indicator Targets and Results (in Millions)

Number of OVC Served by OVC Programsa Number of Eligible Children (Age <18 Yrs) Provided with a Minimum of One Care Serviceb
FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY 10
Actual 0.6 0.8 1.5 2.2 2.9 3.6 3.8
Target 0.8 1.3 1.9 2.7 3.3 3.6
% of Target 91 117 117 107 111 104

NOTE: This table represents data for the 31 countries identified as the focus of this evaluation (see Chapter 2). OVC = orphans and vulnerable children
a Results and targets for FY 2004-FY 2009 correspond to OGAC indicator 8.1 (direct). This indicator counts OVC who are monitored periodically in all six of PEPFAR’s core OVC service areas and who receive support “appropriate for that child’s needs and context” in either three or more of the areas (primary direct support) or in one or two of the areas (supplemental direct support) (OGAC, 2007b, p. 71).
b Results and targets for FY 2010 correspond to OGAC indicator C1.1.D. This indicator counts children (<18 years old) who received at least one care service, including support, preventative, and clinical services, from facilities and/or community/home-based organizations (OGAC, 2009c).

SOURCE: Program monitoring indicators provided by OGAC.

In the Next Generation Indicators the number of eligible clients who received food or other nutrition services is currently centrally reported, with some age disaggregation (OGAC, 2009c,d). According to the program monitoring data provided by OGAC, in FY 2010 in the 31 countries that were the focus of this evaluation PEPFAR provided these food/nutrition services to less than 800,000 children under 18 years of age as well as to more than 180,000 pregnant or lactating women.

Many country programs and partners also collect additional indicators on intervention areas within OVC programs that are not routinely reported centrally. However, even with the additional data that may be available at the country and program levels, there are limitations to the usefulness of the program monitoring data in fully understanding the effects of PEPFAR’s programs. The lack of unique identifiers for each participant in most PEPFAR activities constitutes a major methodological challenge. OVC programs are often offered within different settings in which eligible children and adolescents may receive multiple services. Therefore, there is a risk of a single child being counted several times by different implementing partners, thus potentially over-representing the number of children receiving services. (Double counting is discussed further in the section on data quality in Chapter 11 on knowledge management.) This also makes it difficult to track the scope of services received by an individual child and to track that child through programs and services over time. As with the care and treatment indicators described in Chapter 6, the lack of age disaggregation by more age range subgroups within children and adolescents also makes it difficult to assess how services are distributed across the identified

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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target age groups and developmental stages. Finally, these indicators do not reflect outcomes for the children who received services and therefore do not inform an assessment of the effectiveness or quality of PEPFAR-supported OVC programs.

PEPFAR has supported the development of tools for more in-depth assessment of children and programming for children, most notably the Child Status Index (MEASURE Evaluation, 2009, 2012a). PEPFAR has also supported the Care That Counts initiative to develop, disseminate, and implement tools to assess and improve the quality of OVC services (USAID, 2008). In some countries, PEPFAR has contributed to national or community tools or indices to assess vulnerability or to directories of available services (461-19-USG; 116-5-USNGO; 116-24-USNGO; 272-9-USG).15 However, these existing tools are not designed for systematic program evaluation or for data collection across countries. To date, there has not been a routine application of tools that would generate readily accessible data to assess PEPFAR’s OVC programs systematically across programs and countries. However, there has been considerable recent progress in this area as PEPFAR, through an effort commissioned by the headquarters interagency OVC technical working group and implemented by the MEASURE Evaluation Project, is currently in the process of developing, piloting, and disseminating new outcome measurement tools, including manuals, protocols, templates, and training materials. These focus on 10 to 15 indicators for outcome and impact evaluation and are intended to standardize baseline and endpoints for more comparative assessments of child well-being and the effectiveness of PEPFAR-supported programs across programs and countries (MEASURE Evaluation, 2012b).

Achievements of PEPFAR’s OVC Programs

Across countries visited for this evaluation, a review of Country Operational Plans and the information gathered from interviewees reflected PEPFAR’s support for a wide range of OVC programs and activities that spanned the core programming areas described in the OVC guidance. Interviewees noted that with its explicit focus on OVC, PEPFAR has elevated at-

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15 Country Visit Exit Synthesis Key: Country # + ES Country Visit Interview Citation Key: Country # + Interview # + Organization Type Non-Country Visit Interview Citation Key: “NCV” + Interview # + Organization Type Organization Types: United States: USG = U.S. Government; USNGO = U.S. Nongovernmental Organization; USPS = U.S. Private Sector; USACA = U.S. Academia; Partner Country: PCGOV = Partner Country Government; PCNGO = Partner Country NGO; PCPS = Partner Country Private Sector; PCACA = Partner Country Academia; Other: CCM = Country Coordinating Mechanism; ML = Multilateral Organization; OBL = Other (non-U.S. and non-Partner Country) Bilateral; OGOV = Other Government; ONGO = Other Country NGO.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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tention to and investment in meeting the needs of OVC. The initiatives that PEPFAR has supported in collaboration with partner countries on behalf of children and adolescents living with and affected by HIV have resulted in substantive improvements in the lives of OVC (240-12-USG; 461-4-USG; 272-15-PCNGO; 240-5-PCGOV), and even in ‘saving children’s lives(461-4-USG).16 As described by an interviewee in one country,

Support for orphans and vulnerable children has [positively] impacted the lives of many families and children.’ (240-5-PCGOV)

Policy and systems-level effects In addition to PEPFAR’s support of OVC programs, PEPFAR has supported and guided the implementation of programs in countries that had previously lacked an infrastructure to assist children and adolescents living with or made vulnerable by HIV (461-4-USG). Partner country support of children and adolescents who are living with or affected by HIV is reflected by their inclusion as a targeted population in partner country strategic plans and policies and also in the specific duties of the relevant ministries (166-19-PCGOV; 396-21-USNGO; 116-20-USNGO; 272-9-USG). Partner country interviewees described alignment of PEPFAR-supported child- and adolescent-directed HIV efforts with national government-sponsored strategic plans (166-19-PCGOV; 116-20-USNGO). In addition, PEPFAR team members or implementing partners actively participated in national technical working groups related to children and adolescents living with or affected by HIV (166-8-USG; 116-20-USNGO).

In addition to supporting the overall inclusion of OVC in national strategic planning for the response to HIV, interviewees described PEPFAR’s contributions in the area of policies, laws, and legal support. These contributions included, for example, supporting efforts to legislate minimum standards for orphanages, to provide support and acquire necessary documentation to ensure the inheritance rights of and access to social security by orphaned children, and to develop policies to facilitate the provision of care and services for orphans in households and the community (587-13-USG; 166-23-USG; 272-11-PCNGO; 240-3-USG).

Child protection is another area that was frequently mentioned by interviewees. PEPFAR was acknowledged for contributing to the enactment of legislation to criminalize sexual offenses; establishing personnel with responsibility for child protection; and addressing issues related to child custody and guardianship, foster parenting, and institutional care (587-13-USG). In one country PEPFAR supported a project to define minimum standards

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16 Single quotations denote an interviewee’s perspective with wording extracted from transcribed notes written during the interview. Double quotations denote an exact quote from an interviewee either confirmed by listening to the audio-recording of the interview or extracted from a full transcript of the audio-recording.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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for child protection (166-19-PCGOV). In another, a PEPFAR-supported partner country nongovernmental organization designed a model to keep children from going into residential care by strategically building capacity and integrating early intervention, prevention, and child protection (272-11-PCNGO; 116-15-USNGO). Other partner programs incorporated strategies for children to enact their own protection or for communities to build capacity to address child abuse (272-18-PCNGO; 116-15-USNGO). Another effort involved supporting faith-based organizations to provide support in child protection where the government’s child welfare officers were underfunded and cases were not receiving follow-up (461-17-PCNGO).

PEPFAR has also contributed to the training of providers for child services, including, for example, efforts to develop accreditation systems for child care workers as a cadre and contributing to their adoption by national governments (272-2-USG; 272-11-PCNGO). Also at the systems level, despite some challenges with PEPFAR’s monitoring and evaluation of OVC, several interviewees described PEPFAR as contributing to a stronger approach, more informed by evidence, to OVC programs as well as to greater capacity for the measurement of programs. PEPFAR was also acknowledged for enhancing both programmatic and financial accountability and management among partner country organizations and providers for OVC programs, as well as at the level of national systems (272-ES; 272-15-PCNGO; 272-26-PCNGO; NCV-30; NCV-29).

Effects on child and adolescent well-being Interviewees in partner countries, including representatives of U.S. mission teams and local governmental and nongovernmental implementing partners, described various achievements of PEPFAR-supported OVC programs and the resulting improvements in the lives of children. These included, for example, successfully keeping OVC in the community; improving psychosocial well-being, especially for HIV-positive children, through clubs and psychosocial support; improving enrollment, attendance, and performance in school; increasing applications for social services and foster care grants; assisting with bereavement after the loss of a parent; improving understanding and hope, leading to better treatment adherence; children becoming a voice to advocate for and educate other children and even achieving the training and education to come back and work on OVC projects; supporting education and referral of children to therapy for substance abuse; supporting education and counseling for extended family caregivers after orphanhoood; and providing treatment and grant support for HIV-positive parents (272-14-PCNGO; 240-1-USG; 636-17-PCGOV; 272-18-PCNGO; 272-15-PCNGO; 272-32/35-PCNGO). In one country, local implementing partners stated that ‘children now have dreams—before they were hopeless with no reason to live(272-14-PCNGO); now the children are ‘lightening up and their smiles are coming back(272-18-PCNGO).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Challenges for PEPFAR’s OVC Programs

Gaps in services Despite PEPFAR’s achievements in increasing the attention to, investment in, and implementation of OVC programs, interviewees identified a number of areas where there remain gaps in needed services or where the needs of children and adolescents are not sufficiently met.

Food and nutrition HIV-positive children have special nutritional needs, particularly those undergoing pharmacotherapy for HIV. Dietary needs are frequently unmet due to an impaired ability to procure nutritional foods caused by the poverty that some children and their family members experience (461-17-PCNGO). Organizations and agencies tend to struggle in addressing the problem of food security (272-11-PCNGO) because of funding issues and the challenges presented by widespread nutritional need. Although PEPFAR does not fund food provision (272-11-PCNGO), other implementing partners that receive Food for Peace support can and sometimes do make an effort to meet this need (331-14-USG; 331-19-USNGO; 331-23-USNGO; 116-24-USNGO). In one partner country, PEPFAR added resources to work with OVC by using Title 2 for food commodities to buy food for HIV-positive families (240-3-USG). In others, PEPFAR OVC programs have supported household or community food generation, but in some cases the yields have been low (461-19-USG; 116-20-USNGO).

Psychological counseling and psychosocial support Across countries, interviewees identified psychosocial services as an area in which services are provided but are insufficient to meet the need (116-20-USNGO; 272-15-PCNGO; 272-16-PCNGO; 935-11-PCNGO; 272-22-USG). When psychological support is offered, such care sometimes is provided in association with large, full-service OVC programs. In one country, for example, a large national program run by a faith-based organization that supports multiple OVC sites has offered comprehensive OVC care and support that included psychological care provided by professionals. These psychological services included bereavement support, as well as individual and group counseling (272-32/35-PCNGO). Another program described providing or referring for professional psychological services as a challenge due to a shortage of qualified social workers (272-15-PCNGO). In another country a faith-based organization program similarly offered psychological support for OVC as one of four primary program areas (461-17-PCNGO). In another example, a home-based care project, with the support of religious leaders and volunteers, provided psychological and social support to children who had lost one or both parents. The project also addressed personal hygiene needs and provided nutritional support, educational support, life skills training, and economic support for OVC guardians (240-26-PCNGO).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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School support and services for out-of-school OVC Discrimination against children and adolescents living with and affected by HIV can be significant. Children who are HIV positive or have an HIV-positive parent face the possibility of stigma or rejection from school in some settings (196-20-PCNGO; 116-15-USNGO), and OVC face other school challenges (331-10-PCGOV), not the least of which are poverty and social support issues, particularly for those living on their own. In order to remain in school, children incur costs related to tuition, uniforms, books, and school fees as well as to transportation to and from school. OVC-directed programs supported by PEPFAR may subsidize or seek to reduce these, but the support is sometimes not sufficient (116-29-USNGO; 116-24-USNGO; 116-20-USNGO). Out-of-school children and adolescents in particular face many challenges. One interviewee noted that ‘there are lots of dropouts, both females and males, but there are not enough structured interventions to address out-of-school youth(272-12-USNGO). Another interviewee reported alarmingly high unemployment that ‘leads to increased crime, drug and alcohol use, unintended pregnancy and gender-based violence(272-25-USG).

Adolescents in transition Adolescents affected by HIV face many challenges as they navigate this developmental stage and, later, as they face aging out of the services directed toward orphans and vulnerable children, despite their continuing need for support. Interviewees in partner countries provided some examples of efforts and programs to support adolescents, such as high school and university-based prevention programs (240-9-USG; 240-35-PCNGO), facilitating alternate child care arrangements for children born to adolescent parents (240-35-PCNGO), programs for rural at-risk girls and boys (240-35-PCNGO), and special youth or adolescent services at care and treatment centers (935-13-PCGOV; 935-19-PCGOV; 461-13-USACA). Nonetheless, despite some positive examples, interviewees across countries consistently identified this population as an area in need of more concerted attention. In particular, adolescents are faced with a dearth of age-appropriate psychological care services; a need for support for the continuation of schooling, vocational training, and services for those who are out of school; a need for reproductive health information and services; and, for those who are living with HIV, a need for support in transitioning to adult care and treatment systems as well as knowledge and skills-building related to disclosure.

Interviewees reported that many adolescent OVC would benefit from opportunities to participate in training programs for job skills and other skills related to economic self-sufficiency. One interviewee commented that even affected adolescents who were able to complete their schooling still needed ‘training in simple skills to at least qualify them to obtain a job(272-15-PCNGO). After successfully pilot-testing a vocational training program with vulnerable children, a faith-based organization in one country de-

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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clared that vocational training should be a future priority because program participants had been able to ‘transform themselves to be able to generate income(461-17-PCNGO). However, countries often lack the resources, personnel, and facilities to offer enough accessible vocational training programs to children and adolescents who might benefit from them.

Adolescents who are HIV-positive have specific needs within care and treatment programs. There are some PEPFAR-supported programs in a few countries that have developed strong adolescent components, including, for example, adolescent-specific care and support programs, bi-monthly provider forums to discuss challenges in the adolescent population, and facilitation of referrals between clinics and community services (Sharer and Fullem, 2012). However, interviewees across countries pointed to comprehensive services that focus specifically on the unique needs of adolescents living with HIV as a remaining gap (272-22-USG; 396-43-ML; 396-42-PCGOV; 935-13-PCGOV; 935-19-PCGOV). One specific issue for these adolescents is the transition to adult services. Adult care and treatment programs often are not geared to meet adolescents’ needs. As one interviewee stated, ‘The system is not designed for HIV-positive kids growing up,’ and ‘children will not do well at adult outpatient clinics(396-42-PCGOV). This may be particularly true in specialized settings such as those in concentrated epidemics where those who have been living with HIV since infancy or childhood are now surviving into adulthood, but adult care focuses on specific populations, such as people who inject drugs. Preparing adolescents for this transition to adult HIV services is difficult, as is ‘trying to decide when to transition . . . 16 is too young, 19 is too late(396-42-PCGOV). Another challenge is that developmentally informed psychosocial support is not generally available or accessible to adolescents, and adolescents who are HIV-positive are in particular need of help to address HIV disclosure issues and to develop life skills (396-43-ML; 396-42-PCGOV).

Access to reproductive health services is another need faced in particular by adolescents. According to interviewees, adolescent OVC face issues such as pregnancy, relationships that involve multiple concurrent partners, intergenerational or transactional sex, safe sex concerns, and a gap in school-based prevention programs (272-17-USG; 240-9-USG; 240-35-PCNGO). Adolescents in general, including those who are living with or affected by HIV, were described as lacking the reproductive health information and skills to effectively reduce their risks. For example, adolescents may not have developed life skills relating to interpersonal communication with sexual partners, including HIV-related disclosure (240-35-PCNGO; 396-42-PCGOV). Adolescent girls in particular need reproductive health services (461-19-USG), and parents may not provide girls with information about reproductive health (240-35-PCNGO). As one interviewee observed, ‘Teenage pregnancy rates are high, which leads to more vulnerable children(272-32/35-PCNGO). Children and adolescents who

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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become adults living with HIV may experience a cycle of effects with their own children. As one interviewee noted,

‘Sometimes achievements can be a challenge for the future. With a successful comprehensive package of services, patients are living longer, may get married and have children and their children may be infected or orphaned so even children of children may be affected.’ (396-44-PCGOV)

Finally, aging out of OVC services was raised as a challenge that poses several issues for adolescents. Interviewees indicated that the imposition of an age limit of 18 years to qualify for PEPFAR-funded OVC services poses a barrier to those who may be in need of such support for several years beyond their 18th birthday (272-9-USG; 272-18-PCNGO; 272-15-PCNGO; 331-14-USG). Exiting OVC programs poses issues for the many OVC who remain in school beyond age 18; according to one interviewee, ‘There are no proper plans in place for those who exit at age 18. Most are still at school, and there are no resources for them(272-32/35-NGO). An interviewee affiliated with a partner country nongovernmental organization indicated a desire to continue to care for children who were no longer eligible for services because of PEPFAR-imposed age limits (272-18-PCNGO). This was echoed by another interviewee:

[We] assist [OVC] officially until [they] turn 18. After that, they are still in the community and we look after them. [. . .] Perhaps they have brothers and sisters in the program and inevitably you still try to assist them as well. Some are still in school as well. We just can’t spend PEPFAR money on that. [We] try and obtain other funding and try and help them to get a job, link them to government vocational training, but it is extremely difficult.’ (272-15-PCNGO)

Other gaps in services Interviewees identified several other insufficiently met needs in services for OVC, including support for income-generating activities and adequate access to care for children and adolescents, particularly for those living in poverty and those in rural areas. As described previously, interviewees across several countries emphasized that PEPFAR has made a positive contribution in the area of child protection. However, a number of interviewees also saw this as an area of major unmet need, seeing child protection as an under-resourced activity in the face of child rape, abuse, and neglect (272-15-PCNGO; 272-11-PCNGO; 461-17-PCNGO). Interviewees also identified concerns related to the early detection of HIV in both infants and children, which was seen as a key component to providing services through OVC programs to meet the needs of HIV-positive children. (HIV testing for children is discussed in depth in Chapter 6.) Another gap identified by

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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interviewees was addressing the needs of children with disabilities, who represent a particularly vulnerable population because of issues related to access, transportation, medical needs, availability of assistive devices, and skills building (116-24-USNGO; 272-11-PCNGO). Finally, an area identified as receiving insufficient attention is the chronic nature of the health care needs of children and adolescents living with HIV. As one interviewee stated,

There are a growing number of HIV-positive children in school who have to take drugs on a daily basis and there are side effects of the drugs and there are nutritional needs. This is a key gap, not doing enough to address dealing with chronic treatment. PEPFAR could take a stronger look at children living with HIV as a core program with special needs that are now not being addressed.’ (461-17-PCNGO)

Linkages among services and settings PEPFAR guidance recommends having comprehensive services designed for individual children, but not necessarily all of them provided by a single PEPFAR program. PEPFAR also emphasizes household-centered approaches that link families to other services (PMTCT, clinical care and treatment, etc.) (OGAC, 2006b, 2009e). The reliance on a functioning referral system poses an ongoing logistical and implementation challenge to effectively achieving comprehensive services. Some examples exist of explicit efforts to improve integration and linkages, such as integration of care for orphans and vulnerable children with treatment programs, adult clinics, family clinics, and maternal and child health programs (116-7-USG; 396-21-USG; 240-24-USG), integration of HIV education into the school curriculum (587-6-CCM; 196-20-PCNGO; 331-24-PCGOV; 587-10-USG), linkages to social welfare services (396-21-USG; 272-15-PCNGO), and efforts to better link the OVC and home-based care programs, which were described as having previously been ‘separate, requiring lots of effort, especially with staff recruitment, and lots of staff making different visits for different purposes(587-13-USG). There is also increasing recognition in PEPFAR of the need to establish and support a continuum of services beginning with pregnant women and following mother–infant pairs from the cascade of PMTCT and maternal and child health care through to ensuring that the child is ready for school (NCV-18-USG).

Stigma and discrimination HIV-related stigma and discrimination against children and adolescents persists and remains a continuing focus of the HIV response (166-19-PCGOV; 196-20-USNGO; 461-17-PCNGO; 116-15-USNGO). As one interviewee observed, ‘vulnerable children are very poor and stigmatized(461-17-PCNGO). Interviewees suggested that the problem of stigma and discrimination has improved to some degree over time (196-20-USNGO), but,

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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despite improvements, stigma and discrimination remain a problem of such magnitude that disclosure of one’s HIV-positive status continues to pose significant issues for children and adolescents as well as for adults. To reduce the problem of stigma, in some cases PEPFAR has changed its service delivery focus from child-specific delivery, which could be stigmatizing to individual children, to a service delivery approach that is household-focused or community-focused (272-9-USG; 461-19-USG). In some circumstances, governments and programs reportedly avoided referring to HIV/AIDS or identifying HIV-positive children in an effort to avoid stigma and discrimination (116-15-USNGO; 166-19-PCGOV).

Defining eligibility for funded services One persistent challenge associated with addressing the needs of children and adolescents living with and affected by HIV has been defining eligibility and criteria for inclusion in service provision. As interviewees in one country observed,

Trying to qualify children as OVC is a challenge. When you look at it, every child in [this country] counts as a “V” (vulnerable child). It is not a science and OGAC is trying to make it into a science. How do we know that the needs of HIV-positive children or exposed children are being met?(461-3-USG)There are many more vulnerable children than they are able to reach, and so the concern is that the programs might not be reaching the most critically vulnerable children.’ (461-19-USG)

Another challenge arises when different implementing partners in a country use different models to identify children as “vulnerable,” thus using different standards to determine eligibility for services (461-19-USG). In response to data in one country indicating that only a small percentage of orphans were being reached, PEPFAR partnered with the United Nations Children’s Fund (UNICEF) and a partner country ministry to develop systematic criteria to identify children eligible for services (461-19-USG).

Other challenges for determining eligibility, setting priorities, and monitoring how well the identified need is being met are a lack of population size estimates or registries of children and adolescents living with or affected by HIV and a lack of information about the geographical locations and the specific programs currently supporting OVC (116-15-USNGO; 396-39-USG; 166-19-PCGOV). A related issue raised by one interviewee was the inability of the partner country government to track OVC-directed funding; in this case the government was aware that funds were disbursed to national and international nongovernmental organizations working with OVC but had received no information to facilitate the monitoring of these activities (166-19-PCGOV).

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Meeting PEPFAR targets Interviewees raised several issues related to PEPFAR OVC targets, including, as mentioned above in the discussion on eligibility, the need for clear criteria associated with the designation of “OVC,” how to resolve the trade-off between target attainment and service quality, and the services provided to OVC that can be “counted” toward PEPFAR targets.

In some cases, interviewees described ‘a little bit for everyone approach’ in which three services must be provided before the effort can be counted as an OVC contribution (461-3-USG). While this may help ensure more comprehensive services for OVC, there was concern that requiring a minimum number of services may also mean that partners are providing services beyond their scope of capability (272-15-PCNGO). According to one interviewee:

We are chasing the numbers. We have to find a balance of achieving the target but also rendering a quality service to the OVC. Sometimes it is just the figures that make a difference. If you do not achieve the target you get ‘rapped on the knuckles,’ but if you achieve the target nobody ever asks [if] you can ensure the quality of the services. We try and render quality services and also meet the targets.’ (272-15-PCNGO)

Interviewees also raised questions about what services a partner must provide to constitute support for OVC. One interviewee described the following interpretation issue for PEPFAR indicators to track targets for OVC care and support:

In the current generation of PEPFAR indicators, there are still areas that people still do not actually understand [. . .] to be receiving a particular care service, the expectation is that even assessment, assessing the individual to see whether they need a particular service is now counted as receiving a service. So many people see that as a loophole because some of the project can take an easier route of doing assessment that this child needs to go to school, needs nutrition, needs immunization and so on, and so those are probably three services, but the child has not actually received the service. There is potential you know for communities to come up and say well this project we cannot see what these projects are doing, because there’s potential for reporting high numbers but on the ground the children were only visited [. . .]. So without [. . .] stricter guidelines on how to assess and probably offer something then the indicators and expectations from the community may collide.” (331-34-USNGO)

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Another interviewee perceived that support for children and adolescents living with and affected by HIV had amounted only to ‘lip service’ with a small disbursement of money (331-11-PCNGO). Another reported that community-based OVC care efforts had been undertaken but observed that such efforts were ‘not well structured’ and that PEPFAR had not met expectations regarding community-based care (331-10-PCGOV).

Capacity to sustain and expand programs to meet the needs of OVC Sustainability as an overarching issue for PEPFAR is discussed in more detail in Chapter 10, but it is worth noting here that interviewees were deeply concerned about sustainability specifically for OVC programs, viewing it as a serious challenge. As one interviewee stated,

OVC-PEPFAR has done a good job of saving lives for children. With the emergency response there was no strategy for sustainability and continuing the successes is a challenge.’ (461-04-USG)

An interviewee from another country stated,

It is going to be very difficult for OVC sites to continue providing services once PEPFAR pulls out. Some will manage but probably two-thirds will not be able to continue.’ (272-32/35-PCNGO)

The ability of partner countries to continue the successes they have realized in addressing the needs of OVC, to sustain existing programs over time, and to meet the remaining gaps in coverage and in needed services, as described in the preceding section, remains a continuing challenge and an unanswered question in the face of expected future reductions or cessation of donor support (272-32/35-PCNGO; 461-4-USG). From the perspective of interviewees, a need exists to ‘increase attention on the younger age group and move towards an AIDS free generation(934-7-PCGOV) and concentrating on children ‘needs to be a priority for PEPFAR(272-32/35-PCNGO).

Funding for OVC programs remains a challenge. Although it is ‘difficult to turn a child away that needs OVC support because there is not enough funding(331-19-USNGO), the large magnitude of need for children and adolescents often outstrips the available financial resources (461-19-USG; 934-5-USG). One interviewee described that in a country with a “very old, mature epidemic [. . .] what we are doing, is literally a drop in a very large population” of OVC (934-5-USG). Limited resources have led some programs to focus on a limited cohort of OVC or to reduce program eligibility by narrowing their inclusion criteria for OVC services (934-5-USG; 396-39-USG). In addition to insufficient funding, delays in funding can have negative consequences for affected children and adolescents. A consequence of funding delays for

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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educational support, for instance, is that children and adolescents must remain home from school and thus risk getting behind in their schoolwork (331-19-USNGO).

Interviewees also voiced great concern about the continuing need to support not only children and adolescents living with and affected by HIV but also their caregivers and families. The toll that HIV has taken on families in some partner countries will be magnified with the eventual loss of grandparent caregivers:

There is going to be a big gap when an older generation dies, because there are places where the middle generation (30- to 50-year-olds) doesn’t exist anymore or have HIV and will not be there to care for their children. This will lead to child-headed households. They need to concentrate on children. This needs to be a priority for PEPFAR.’ (272-32/35-PCNGO)

The situation in terms of supporting the caregivers of children is already a difficult one, and it will likely get worse if the resources are reduced. For instance, one interviewee described success with the training of OVC caregivers in income generation that enabled them to build skills and knowledge about starting and managing a small business. An absence of startup funds after the training, however, derailed their chances to start their own business (467-17-PCNGO).

To address the fundamental problem of funding, sources have yet to be identified if PEPFAR, its implementing partners, and other donors reduce their support. A need exists for ‘creative ways to address this issue(934-7-PCGOV). Some programs will continue to be supported by the faith-based organizations with which they are presently affiliated, though they will need ‘a sustainable structure to hold them together and good leadership(272-32/35-PCNGO). One strategy suggested by an interviewee to sustainably ensure the ongoing care of children and adolescents living with and affected by HIV entailed continuing efforts to build the capacity of local organizations, especially ‘the best organizations or community-based organizations, so that they can take care of the families, continue providing services to these children(934-5-USG). Another suggestion was to do ‘more economic empowerment’ so that families will be able to sustain their efforts (461-19-USG). Yet another was sustaining services to this population by bridging to the welfare system and supporting the government (396-39-USG; 461-19-USG). One interviewee emphasized the time and process needed for these solutions:

Transitioning to sustainability of the response is just at the “take-off point”; it needs time. The United States needs to talk explicitly

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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with the [partner country] government about an exit strategy so the government will know its responsibility; this has to start now.’ (461-19-USG)

Effectiveness of PEPFAR’s OVC Programs: Reviews of Existing Evaluations

Three recent reviews of PEPFAR OVC program evaluations have used available data to determine which activities and services are the most effective in improving the well-being of children affected by HIV/AIDS. In 2011 (Sherr and Zoll, 2011) synthesized the findings of 18 evaluations that surveyed a total of 22 OVC programs in 9 countries (Kenya, Tanzania, Uganda, Mozambique, Rwanda, Namibia, Zambia, South Africa, and Haiti). In 2012 (Bryant et al., 2012) reviewed findings from five studies—four effectiveness studies of OVC programs in Zambia, Namibia, South Africa, Tanzania, and Kenya and one baseline data collection study for new OVC programs in Mozambique. A third review of existing program evaluations was part of a multi-faceted USAID review of the PEPFAR OVC portfolio that included background data and literature review, an analysis of data from surveys received from USG staff in 17 partner countries and OVC Task Force staff in 3 countries, and interviews with various stakeholders in 3 countries (Malawi, Tanzania, and South Africa) (Yates et al., 2011).

These three reviews make it clear that the available pool of program evaluations is not comprehensive enough to lead to strong conclusions about the effectiveness of PEPFAR OVC programs. In the Sherr et al. review, only eight evaluations used some form of comparison design. There was little, if any, baseline data to use to determine PEPFAR’s impact on OVC well-being, in part due to PEPFAR’s initial emergency response status with little focus on pre-trial data collection. There was also a lack of clear outcome and impact indicators, which hinders program evaluation. Nonetheless, despite these limitations, the three reviews taken together provide some consistent data across evaluations to indicate the effectiveness of several OVC program elements (Bryant et al., 2012; Sherr and Zoll, 2011; Yates et al., 2011).

The reviews of Bryant et al. and Sherr and Zoll both found positive effects on OVC well-being from at least three specific program elements: support for school fees, child-centered clubs for females, and savings and loans programs. Support for school fees was found to have a positive effect on educational outcomes, such as school attendance and children’s psychosocial outlook, although nonfinancial support such as books and supplies did not show any effects. The USAID review also concluded that keeping children in school is one measure clearly shown to have long-

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lasting positive effects on OVC well-being. However, the Bryant review indicated some concern that these outcomes will not be long-lasting and will not continue once external support stops. Government subsidization of school fees was noted as one way of continuing to support OVC educational outcomes as external donors cut back (Bryant et al., 2012; Sherr and Zoll, 2011).

Child-centered clubs were also found to have positive outcomes if they were well organized with frequent activities and meetings. The reviews concluded that club support had consistently positive impacts on the confidence and health attitudes of girls, while the impacts on boys were not clear. Clubs that were poorly organized with insufficiently trained staff did not have any measurable effect, and evaluations of activities focused on providing psychosocial support outside of children’s clubs found inconclusive results (Bryant et al., 2012; Sherr and Zoll, 2011).

Economic strengthening in the form of savings and loan programs was also the subject of several evaluations; these reviews concluded that such programs led to increased engagement in income-generating activities. The review by Sherr et al. found that caregiver access to local savings and loan schemes led to better outcomes for OVC by positively affecting health, nutrition, education, shelter, and psychosocial well-being. The evaluations in Bryant et al.’s (2012) review, however, did not show conclusive evidence for positive impact on broader development goals beyond increased engagement in economic strengthening activities. Bryant et al. suggested that this could be due in part to the fact that households with OVC are often very poor and thus often cannot invest enough to have substantial returns in the long run. Other avenues of economic support could thus supplement savings and loan programs for more effective results. The USAID review suggested that one way of strengthening families and supporting OVC well-being would be through such social services as free or subsidized schooling and health care, while Bryant et al. suggested cash transfers between the government and households for health, food, and nutrition (Bryant et al., 2012; Sherr and Zoll, 2011).

The evaluations reviewed by Sherr et al. also showed positive effects from other interventions: consistent food supplements were seen to have a positive impact on nutrition in OVC households; consistent home visits and health education led to increased HIV testing and better adherence to antiretroviral therapy; guardian group therapy reduced the reports of child abuse and helped family relations, as did legal help in the form of birth certificates and will preparation; and shelter improvement improved OVC standards of living. The evaluations reviewed by Bryant et al. (2012) had inconclusive findings in these areas. In addition to the interventions already described, the USAID review found that good maternal and young child health programs have had some of the most cost-effective and posi-

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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tive results, and it suggested that early childhood development should be a focus of future programming (Bryant et al., 2012; Sherr and Zoll, 2011).

Finally, from the USAID review of the PEPFAR OVC portfolio it can be concluded that PEPFAR has been in the forefront of OVC programming, leading the way in terms of financing, capacity building, and human resources development for OVC well-being (Yates et al., 2011).

Evolution of PEPFAR’s OVC Programs: Updated Programmatic Guidance

In July 2012 OGAC released new program guidance for OVC programs (OGAC, 2012). The new guidance was released too late for this committee to assess its implementation process or its effects, but a review of the guidance document does serve to indicate the intended future directions of PEPFAR-supported OVC programs. Many of the strategies and interventions recommended in the new guidance build on the 2006 guidance (OGAC, 2006b). However, the new guidance has a few key changes, which are summarized here.

The guidance defines eligibility for OVC programs by stating that “intended beneficiaries of PEPFAR programs include ‘Children who have lost a parent to HIV/AIDS, who are otherwise directly affected by the disease, or who live in areas of high HIV prevalence and may be vulnerable to the disease or its socioeconomic effects’” (OGAC, 2012, p. 20). The ages from 0 to 17 years old still constitute the de facto programmatic eligibility age range, but PEPFAR recognizes in the guidance that “the period of transition from adolescence to adulthood is critical” (OGAC, 2012, p. 21) and does not specify a timeline for transitioning children from OVC programs. Furthermore, it recommends that a “young person who turns 18 while receiving OVC assistance should not be terminated from receiving assistance; rather, from the outset, programs should plan for appropriate transition strategies and be prepared to cover a buffer period for seamless transition” (OGAC, 2012, p. 21).

The core areas of intervention recommended in the guidance are reorganized into the following technical sectors: education, psychosocial care and support, household economic strengthening, social protection, health and nutrition, child protection, legal protection, and capacity building. Further, the guidance emphasizes the need for a continuum of response to address the lifetime needs of OVC populations, and PEPFAR recommends the integration of OVC programs with HIV prevention, care, and treatment. The new guidance is based on the ecological model for child development, focusing on strengthening parents, caregivers, and families and on placing OVC programs within coordinated systems of community- and facility-based services and providers, rather than taking a child-focused approach.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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In the new guidance PEPFAR also specifies that it does not require that programs provide a minimum package of services. Many programs understood the prior guidance to require individual programs to provide a minimum package of services, which OGAC recognized may have led to implementing partners providing services that were not their strengths, leading in turn to challenges in delivering high-quality services.

The new guidance also emphasizes the need to prioritize interventions. PEPFAR cannot address all needs, so programs need to identify which activities and interventions are most urgent and will have the biggest impact. The guidance does not prescribe priorities, but it does provide illustrative guidance on the prioritization of interventions relative to different scenarios of the epidemic. The guidance also provides a compendium of best practices.

Country and community ownership is an important element in the new guidance, which pushes for local community-based organizations and nongovernmental organizations to take on the role of prime partners, while still recognizing the role of larger partner organizations in helping implement programs. Other models to support smaller local partners include umbrella organizations and the use of private firms for financial administration and oversight.

Finally, the new guidance recommends that 10 percent of the OVC portfolio budget at the country level be allocated for monitoring and evaluation, in a manner to be determined by the mission team. The guidance emphasizes the need to support innovation both in OVC programming and in the evaluation of OVC programs. As described previously, in addition to the new OVC programming guidance, PEPFAR has recently spearheaded an effort to develop, field test, and pilot program-evaluation methods that can be disseminated and implemented in OVC programs (MEASURE Evaluation, 2012b).

PEPFAR’S PROGRAMS AND CHILD SURVIVAL

HIV programs, such as those implemented through PEPFAR, have the potential to reduce under-5 mortality (Bourne et al., 2009; Ndirangu et al., 2010) and to contribute to Millennium Development Goal 4 (to reduce child mortality and, in particular, to achieve a two-thirds reduction in the under-5 mortality rate between 1990 and 2015). The programs that can be expected to affect child mortality most directly are those for the PMTCT and those for the successful identification and treatment of infected infants and children. In addition to PEPFAR-supported activities related to these pathways, which were discussed in more detail in Chapters 5 and 6, programs implemented through PEPFAR also plausibly contribute to child survival through the OVC programs described in this chapter when

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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they result in improved access to and increased quality of non-HIV health services (such as well-child visits, immunizations, and nutrition) and other nonclinical services. Finally, PEPFAR also conceivably contributes to child survival by averting orphanhood through reduced adult mortality and improved health of parents as a result of support for the availability and coverage of antiretroviral therapy and other care and support services; a positive effect on the health of caregivers is linked to the health and well-being of children (Mermin et al., 2008; Stover et al., 2008; UNAIDS, 2008; UNAIDS and WHO, 2009).

Although these are plausible pathways to reducing child mortality at the level of individual children, there are major limitations to directly assessing the effects of PEPFAR programs on the overall population mortality among children. Cause-specific mortality is often not well documented in children, but even the best estimates show that HIV/AIDS is only one of many contributors to child mortality, and in many countries it is not the leading cause of death in children. Even in countries where HIV is a leading cause, the rates of deaths due to HIV are often low enough that it would be unrealistic to expect to discern a substantial effect at the population level in many countries. Therefore, the committee was not able to draw definitive conclusions about the direct effects of PEPFAR on child mortality rates.

However, the committee did review trends in estimated child mortality due to all causes and due to AIDS using data on AIDS deaths from HIV prevalence and on prevention and treatment coverage (Liu et al., 2012). The committee selected the subset of the nine PEPFAR countries where 15 percent or more of the child deaths were attributed to AIDS in 2000 (before the initiation of PEPFAR) and in which it would therefore be more likely that the effects of PEPFAR’s efforts on AIDs deaths could be observed. Of these countries, five were original focus countries when PEPFAR was initiated (Botswana, South Africa, Namibia, Zambia, and Kenya), and four were not focus countries but did have some USG investment in HIV programs (Zimbabwe, Lesotho, Swaziland, and Malawi); these four have become COP countries since the reauthorization of PEPFAR in 2008.

The committee examined the trends in estimated child mortality in these nine countries from 2000 to 2010 using data from the Child Health Epidemiology Reference Group (CHERG), shown in Figure 7-2 (Liu et al., 2012). In all of these nine countries, the child mortality rates followed a downward trend in both all-cause and AIDS-specific deaths, with several showing relatively large declines during the time period after PEPFAR was initiated or scaled up. In most of these countries, the AIDS deaths and all-cause child deaths tracked downward in similar paths, suggesting that the declines in AIDS death were contributing to the decline in overall child mortality, although it was not feasible to draw a causal inference and AIDS is not likely to be the sole contributor to the decline. In some exceptions

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Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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there is less consistency between the two. In Malawi, for example, the all-cause deaths decreased more than the AIDS-specific deaths. In Zambia, after an initial decline in both AIDS deaths and all-cause deaths, the number of all-cause deaths has recently risen again, while AIDS deaths continued to decline. This suggests that the changes in overall child mortality may have been driven more by declines in causes of death other than AIDS, as is the case in most other countries examined in the CHERG analysis (Liu et al., 2012).

In all of these countries PEPFAR has supported the activities and interventions described previously that could reasonably be expected to have contributed to improving child survival during the time period in which, for most of the countries, both overall child mortality and AIDS-specific child morality have trended downward. However, it is not feasible to draw conclusions about causality for the mortality trends described here nor to determine the extent to which these trends can be attributed directly to PEPFAR investments in programs and services.

SUMMATION

Conclusion: PEPFAR has positively affected the lives of children and adolescents living with or affected by HIV. PEPFAR has contributed to major scale-up of services (OVC, pediatric care and support, pediatric treatment, and 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.

Conclusion: Despite progress, there remain insufficiently met needs relating to the health and well-being of children and adolescents. Although it is not realistic to expect PEPFAR to meet all the needs for 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 percent goal; the coverage of pediatric HIV care and treatment remains proportionally much lower than the coverage for adults, despite the goal in the reauthorization legisla-

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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tion to provide care and treatment services in partner countries to children in proportion to their percentage 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 the long-term sustainability 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.

Conclusion: The ability to assess the impact of PEPFAR-supported programs for 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 subgroups (e.g., less than 1 year, 1 to 5 years, and 6 to 17 years) to better understand which populations are receiving which services; baseline and longitudinal data to follow children and families and the effects of the services they receive over time; and data on effectiveness and outcomes that can be used to help identify the most effective PEPFAR OVC programs and models. In addition, there is a lack of data about the total population of children “in need,” in part due to a lack of clarity and consistency both across countries and across programs within countries about how the population eligible for PEPFAR-supported services is defined (i.e., which children are defined as “vulnerable” or “affected by HIV”).

Recommendation 7-1: To improve the implementation and assessment of nonclinical care and support programs for adults17 and children, including 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 outcomes. The guidance should permit country programs to select prioritized outcomes to inform the selection, design, and implementation of their activities. The guidance should also specify how to measure and monitor the key outcomes.

__________________

17 The discussion of nonclinical care and support for adults leading to this aspect of this recommendation can be found in Chapter 6.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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Further considerations for implementing this recommendation:

•   For orphans and vulnerable children, the new OVC guidance and the ongoing developments for program evaluation already represent advances in addressing some of the challenges identified in this evaluation; 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.

•   Outcomes for consideration should be linked to the aims of OVC programs and therefore could include, for example, increased rates of staying in school, decreased excessive labor, reduced rates of exposure to further traumas, increased immunization completion, and increased coverage of HIV testing and treatment. With a continued focus on supporting developmentally informed programs, consideration 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.

•   The core key outcomes should also include quality of services and measures to reflect the potential sustainability of programs.

•   A shift to a more outcomes-oriented implementation model will require 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.

•   PEPFAR U.S. mission teams should work with partner country stakeholders 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.

•   Prioritization is critical in the presence of great need and finite resources. When planning with partner countries, PEPFAR should improve 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 defining the eligibility for PEPFAR-

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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    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 coordination across program areas that address the needs and vulnerabilities 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.

•   To improve the targeted coverage and sustainability for children and 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.

•   OGAC should provide 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 subpartners as well as local academic institutions) to enhance capacity building and contribute to country ownership. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

•   PEPFAR should develop a system for the active dissemination and 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 identified by headquarters-level leadership and technical working groups. (See also recommendations for PEPFAR’s knowledge management in Chapter 11.)

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
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REFERENCES

Bourne, D. E., M. Thompson, L. L. Brody, M. Cotton, B. Draper, R. Laubscher, M. F. Abdullah, and J. E. Myers. 2009. Emergence of a peak in early infant mortality due to HIV/AIDS in South Africa. AIDS 23(1):101-106.

Bryant, M., J. Beard, L. Sabin, M. Brooks, N. Scott, B. Larson, G. Biemba, C. Miller, and J. Simon. 2012. PEPFAR’s support for orphans and vulnerable children: Some beneficial effects, but too little data, and programs spread thin. Health Affairs 31(7):11.

Call, K. T., A. A. Riedel, K. Hein, V. McLoyd, A. Petersen, and M. Kipke. 2002. Adolescent health and well-being in the twenty-first century: A global perspective. Journal of Research on Adolescence 12(1):69-98.

Cluver, L., and F. Gardner. 2007. Risk and protective factors for psychological well-being of children orphaned by AIDS in Cape Town: A qualitative study of children and caregivers’ perspectives. AIDS Care 19(3):318-325.

Cluver, L., and M. Orkin. 2009. Cumulative risk and AIDS-orphanhood: Interactions of stigma, bullying and poverty on child mental health in South Africa. Social Science &Medicine 69(8):1186-1193.

Cluver, L., F. Gardner, and D. Operario. 2007. Psychological distress amongst AIDS-orphaned children in urban South Africa. Journal of Child Psychology and Psychiatry 48(8):755-763.

FHI (Family Health International). 2010. Young people most at risk of HIV: A meeting report and discussion paper from the Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter-agency Task Team on HIV and Young People, and FHI. Research Triangle Park, NC: FHI.

Gouws, E., K. A. Stanecki, R. Lyerla, and P. D. Ghys. 2008. The epidemiology of HIV infection among young people aged 15-24 years in southern Africa. AIDS 22(Suppl 4):S5-S16.

Liu, L., H. L. Johnson, S. Cousens, J. Perin, S. Scott, J. E. Lawn, I. Rudan, H. Campbell, R. Cibulskis, M. Li, C. Mathers, and R. E. Black. 2012. Global, regional, and national causes of child mortality: An updated systematic analysis for 2010 with time trends since 2000. Lancet 379(9832):2151-2161.

Luo, C. M. M. P. 2012. Innovation for elimination of new HIV infections in children by 2015 and keeping mothers alive. Paper read at Joint UNICEF pharmaceutical supplier meeting & WHO prequalification of medicines programme, Copenhagen, Denmark.

MEASURE Evaluation. 2009. Child status index a tool for assessing the well-being of orphans and vulnerable children—manual. Chapel Hill, NC: MEASURE Evaluation.

MEASURE Evaluation. 2012a. Clarification regarding usage of the child status index. Chapel Hill, NC: MEASURE Evaluation.

MEASURE Evaluation. 2012b. Evaluating impact of OVC programs: Standardizing our methods. Paper read at International AIDS Conference, Washington, DC.

Mermin, J., W. Were, J. P. Ekwaru, D. Moore, R. Downing, P. Behumbiize, J. R. Lule, A. Coutinho, J. Tappero, and R. Bunnell. 2008. Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: A prospective cohort study. Lancet 371(9614):752-759.

Napierala Mavedzenge, S. M., A. M. Doyle, and D. A. Ross. 2011. HIV prevention in young people in sub-Saharan Africa: A systematic review. Journal of Adolescent Health 49(6):568-586.

Ndirangu, J., M. L. Newell, F. Tanser, A. J. Herbst, and R. Bland. 2010. Decline in early life mortality in a high HIV prevalence rural area of South Africa: Evidence of HIV prevention or treatment impact? AIDS 24(4):593-602.

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Nyamukapa, C. A., S. Gregson, B. Lopman, S. Saito, H. J. Watts, R. Monasch, and M. C. Jukes. 2008. HIV-associated orphanhood and children’s psychosocial distress: Theoretical framework tested with data from Zimbabwe. American Journal of Public Health 98(1):133-141.

OGAC (Office of the Global AIDS Coordinator). 2004. The President’s Emergency Plan for AIDS Relief: U.S. five-year global HIV/AIDS strategy. Washington, DC: OGAC.

OGAC. 2005a. Emergency plan for AIDS relief fiscal year 2005 operational plan: June 2005 update. Washington, DC: OGAC.

OGAC. 2005b. President’s Emergency Plan for AIDS Relief: FY06 country operational plan final guidance. Washington, DC: OGAC.

OGAC. 2006a. Guidance for United States government in-country staff and implementing partners for a preventive care package for children aged 0-14 years old born to HIV-infected mothers. Washington, DC: OGAC.

OGAC. 2006b. Orphans and other vulnerable children programming guidance for United States government in-country staff and implementing partners. Washington, DC: OGAC.

OGAC. 2006c. Policy guidance on the use of emergency plan funds to address food and nutrition needs. Washington, DC: OGAC.

OGAC. 2006d. The President’s Emergency Plan for AIDS Relief: Report on food and nutrition for people living with HIV/AIDS. Washington, DC: OGAC.

OGAC. 2006e. The President’s Emergency Plan for AIDS Relief: FY 2007 country operational plan guidance. Washington, DC: OGAC.

OGAC. 2006f. The U.S. President’s Emergency Plan for AIDS Relief fiscal year 2006: Operational plan. 2006 August update. Washington, DC: OGAC.

OGAC. 2007a. The President’s Emergency Plan for AIDS Relief: FY 2008 country operational plan guidance. Washington, DC: OGAC.

OGAC. 2007b. The President’s Emergency Plan for AIDS Relief: Indicators, reporting requirements, and guidelines. Indicators reference guide: FY 2007 reporting/FY 2008 planning. Washington, DC: OGAC.

OGAC. 2007c. The U.S. President’s Emergency Plan for AIDS Relief fiscal year 2007: Operational plan. 2007 June update. Washington, DC: OGAC.

OGAC. 2008a. The President’s Emergency Plan for AIDS Relief: FY 2009 country operational plan guidance. Washington, DC: OGAC.

OGAC. 2008b. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2008: PEPFAR operational plan. Washington, DC: OGAC.

OGAC. 2008c. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2008: PEPFAR operational plan. June 2008. Washington, DC: OGAC.

OGAC. 2009a. Celebrating life: The U.S. President’s Emergency Plan for AIDS Relief. 2009 annual report to congress. Washington, DC: OGAC.

OGAC. 2009b. The President’s Emergency Plan for AIDS Relief: FY 2010 country operational plan guidance: Programmatic considerations. Washington, DC: OGAC.

OGAC. 2009c. The President’s Emergency Plan for AIDS Relief: Next generation indicators reference guide. Version 1.0. Washington, DC: OGAC.

OGAC. 2009d. The President’s Emergency Plan for AIDS Relief: Next generation indicators reference guide. Version 1.1. Washington, DC: OGAC.

OGAC. 2009e. The U.S. President’s Emergency Plan for AIDS Relief: Five-year strategy. Washington, DC: OGAC.

OGAC. 2009f. The U.S. President’s Emergency Plan for AIDS Relief: Five-year strategy. Annex: PEPFAR and prevention, care and treatment. Washington, DC: OGAC.

OGAC. 2010a. The President’s Emergency Plan for AIDS Relief: FY 2011 country operational plan guidance and appendices. Washington, DC: OGAC.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

OGAC. 2010b. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2009: PEPFAR operational plan. November 2010. Washington, DC: OGAC.

OGAC. 2011a. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance and appendices. Washington, DC: OGAC.

OGAC. 2011b. The President’s Emergency Plan for AIDS Relief: FY 2012 country operational plan guidance technical considerations. Washington, DC: OGAC.

OGAC. 2011c. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2010: PEPFAR operational plan. Washington, DC: OGAC.

OGAC. 2011d. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fiscal year 2011: PEPFAR operational plan. Washington, DC: OGAC.

OGAC. 2012. Guidance for orphans and vulnerable children programming. Washington, DC: OGAC.

OHCHR (Office of the High Commissioner for Human Rights). 2007. Committee on the Rights of the Child: Sessions. http://www2.ohchr.org/english/bodies/crc/sessions.htm (accessed May 28, 2010).

Sharer, M., and A. Fullem. 2012. Transitioning of care and other services of adolescents living with HIV in sub-Saharan Africa. Arlington, VA: USAIDS’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order I.

Sherr, L., and M. Zoll. 2011. PEPFAR OVC evaluation: How good at doing good? Washington, DC: Global Health Technical Assistance Project, USAID.

Stover, J., B. Fidzani, B. C. Molomo, T. Moeti, and G. Musuka. 2008. Estimated HIV trends and program effects in Botswana. PLOS ONE 3(11):e3729.

UN (United Nations). 1990. Convention on the rights of the child. New York: United Nations.

UN. 2001. Declaration of Commitment on HIV/AIDS. Geneva: United Nations.

UN Treaty Collection. 2010. Convention on the rights of the child (status as of 14-04-2010). http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV-11&chapter=4&lang=en (accessed April 16, 2010).

UNAIDS (Joint United Nations Programme on HIV/AIDS). 2008. Report on the global AIDS epidemic. Geneva: UNAIDS.

UNAIDS. 2009. Operational plan for the UNAIDS action framework: Addressing women, girls, gender equality and HIV. Geneva: UNAIDS.

UNAIDS. 2012a. UNAIDS report on the global AIDS epidemic 2012. Geneva: UNAIDS.

UNAIDS. 2012b. World AIDS Day report. Geneva: UNAIDS.

UNAIDS Reference Group on Estimates, Modelling, and Projections. 2002. Improved methods and assumptions for estimation of the HIV/AIDS epidemic and its impact: Recommendations of the UNAIDS Reference Group on Estimations, Modelling, and Projections. AIDS 16:W1-W14.

UNAIDS, UNICEF (United Nations Children’s Fund), and USAID (U.S. Agency for International Development). 2002. Children on the brink 2002: A joint report on orphan estimates and program strategies. Washington, DC: UNAIDS, UNICEF, and USAID.

UNAIDS, UNICEF, and USAID. 2004. Children on the brink 2004: A joint report on new orphan estimates and a framework for action. Washington, DC: UNAIDS, UNICEF, and USAID.

UNAIDS and WHO (World Health Organization). 2009. AIDS epidemic update: December 2009. Geneva: UNAIDS and WHO.

UNICEF. 2004. The framework for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. New York: UNICEF.

UNICEF. 2007. Enhanced protection for children affected by AIDS. A companion paper to the framework for the protection, care and support of orphans and vulnerable children living in a world with HIV and AIDS. New York: UNICEF.

Suggested Citation:"7 Children and Adolescents." Institute of Medicine. 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. doi: 10.17226/18256.
×

UNICEF. 2011. Opportunity in crisis: Preventing HIV from early adolescence to young adulthood. New York: UNICEF.

UNICEF. 2012. HIV/AIDS statistics: Global and regional trends. http://www.childinfo.org/hiv_aids.html (accessed April 2, 2013).

USAID (U.S. Agency for International Development). 2008. Care that counts: Improving quality of services to reach the most children. Washington, DC: USAID.

USAID. 2009. Food for peace. http://www.usaid.gov/out_work/global_health/aids/Funding/index.html (accessed May 28, 2010).

Whetten, K., J. Ostermann, R. Whetten, K. O’Donnell, and N. Thielman. 2011a. More than the loss of a parent: Potentially traumatic events among orphaned and abandoned children. Journal of Traumatic Stress 24(2):174-182.

Whetten, R., L. Messer, J. Ostermann, K. Whetten, B. W. Pence, M. Buckner, N. Thielman, and K. O’Donnell. 2011b. Child work and labour among orphaned and abandoned children in five low and middle income countries. BMC International Health and Human Rights 11:1.

WHO (World Health Organization). 1999. Programming for adolescent health and development. Report of a WHO/UNFPA/UNICEF study group. Geneva: WHO.

WHO. 2006. Preventing HIV/AIDS in young people: A systematic review of the evidence from developing countries. Geneva: WHO.

World Bank. 2006. World development report 2007: Development and the next generation. Washington, DC: World Bank.

Yates, D., L. Richter, J. Zingu, R. Yates, and J. Wolfe. 2011. PEPFAR HKID portfolio review: Children in the HIV/AIDS epidemic. Washington, DC: USAID.

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The U.S. government supports programs to combat global HIV/AIDS through an initiative that is known as the President's Emergency Plan for AIDS Relief (PEPFAR). This initiative was originally authorized in the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 and focused on an emergency response to the HIV/AIDS pandemic to deliver lifesaving care and treatment in low- and middle-income countries (LMICs) with the highest burdens of disease. It was subsequently reauthorized in the Tom Lantos and Henry J. Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (the Lantos-Hyde Act).

Evaluation of PEPFAR makes recommendations for improving the U.S. government's bilateral programs as part of the U.S. response to global HIV/AIDS. The overall aim of this evaluation is a forward-looking approach to track and anticipate the evolution of the U.S. response to global HIV to be positioned to inform the ability of the U.S. government to address key issues under consideration at the time of the report release.

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