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PEPFAR Implementation: Progress and Promise (2007)

Chapter: 7 PEPFAR's Orphans and Other Vulnerable Children Category

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Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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7

PEPFAR’s Orphans and Other Vulnerable Children Category

Summary of Key Findings

  • As of September 30, 2006, PEPFAR had provided services to more than 2 million orphans and other vulnerable children in the focus countries. There is no specific performance target for the number of orphans and other vulnerable children to be served, instead they are counted toward the overall care target.

  • PEPFAR has adopted the international approach for core services for orphans and other vulnerable children and supported activities corresponding to those services. However, scale-up efforts for the provision of these services are hampered by several challenges, including a lack of social service systems to address the social and mental health support needs of children and a lack of systems with which countries can track and report vital statistics, such as birth registration, to facilitate determination of eligibility for both PEPFAR and non-PEPFAR services. PEPFAR is supporting efforts to develop such systems, and priority to social welfare and education workers in its workforce capacity-building efforts is greatly needed.

  • The Office of the U.S. Global AIDS Coordinator (OGAC) and the U.S. Agency for International Development are collaborating to strengthen the collection and validity of strategic information needed by policy makers and program managers by revising the program-level indicator used to report data; providing clear guidance on how and when a child can be counted as served; standardizing services; and conducting targeted evaluations of service-related issues, including cost and program effectiveness.

  • OGAC efforts to strengthen data could also include its adoption of some of the United Nations Children’s Fund (UNICEF) program and outcome indicators, such as the number of girls enrolled in school and the grade levels they attain, to better position PEPFAR to evaluate the responsiveness and impact of PEPFAR-supported services. Adoption of these indicators could be under taken with attention to continued harmony with one nationally integrated monitoring and evaluation system.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Recommendation Discussed in This Chapter


Recommendation 7-1: The needs of orphans and other children made vulnerable by AIDS cover a wide spectrum that cuts across all of PEPFAR’s categories of prevention, treatment, and care and extends well beyond the health sector. It is essential for an HIV/AIDS response to address these needs adequately—not only to support these children in living healthy and productive lives, but also to protect them from becoming the next wave of the pandemic. The U.S. Global AIDS Initiative should continue to support countries in the development of national plans that address the needs of orphans and other children made vulnerable by AIDS, as well as to support the priorities delineated in these plans. To ensure adequate focus on and accountability for addressing the needs of orphans and other vulnerable children, the U.S. Global AIDS Coordinator should work with Congress to set a distinct and meaningful performance target for this population. This target should be developed in a manner that both builds on the improvements PEPFAR has made in its indicator for children served and enhances its ability to support comprehensive and integrated HIV/AIDS programming.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

7
PEPFAR’s Orphans and Other Vulnerable Children Category

CATEGORY, TARGET, AND RESULTS

Category

The Leadership Act treats orphans and vulnerable children as a fourth category for purposes of the President’s Emergency Plan for AIDS Relief (PEPFAR) funding and reporting, although the services they receive—prevention, treatment, and care—cut across the other three categories. In PEPFAR’s indicator guidance, an orphan is defined as a child under 18 who has lost either a mother or a father (OGAC, 2005f); in its second annual report, however, PEPFAR defined an orphan as a child under age 15 who has lost a mother, a father, or both (OGAC, 2006a). The Office of the U.S. Global AIDS Coordinator (OGAC) has previously defined vulnerable children as “those affected by HIV though the illness of a parent or principal caretaker” (OGAC, 2005f). New programmatic guidance addresses the conflicts created by varying definitions of those served under this category, which are discussed in detail in the section on issues and opportunities for improvement later in the chapter.

PEPFAR’s activities targeting orphans and other vulnerable children fall into two subcategories: services to children and training for providers of those services.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
Target

There is no quantified target for the number of orphans and other vulnerable children to be served by a specific deadline, as with the 2010 target for prevention and the 2008 target for treatment (OGAC, 2005c, 2006e. f). However, the Leadership Act mandates that no less than 10 percent of total PEPFAR funding allocated for prevention, treatment, and care be used to provide services to address the needs of orphans and other vulnerable children. Furthermore, the legislation prescribes that of that 10 percent, “at least 50 percent shall be provided through non-profit, nongovernmental organizations including faith-based organizations that implement programs at the community level” (p. 746). However, Country Teams, in collaboration with country governments, do set specific country targets for the number of orphans and other vulnerable children to be served by the program that count towards the 10 million people target for care.

Similar to the indicators for the other PEPFAR categories, this indicator counts the number of children provided PEPFAR-supported services (food/nutrition, shelter and care, protection, health care, psychosocial support, and education/vocational training), but does not allow determination of the quality or impact of those services (see Chapter 8 for a discussion of this issue). However, the evolution of PEPFAR’s current indicator for the orphans and other vulnerable children category reflects one of OGAC’s best efforts to strengthen the data provided by care indicators—potentially improving the quality of services, utilizing an approach to meet the individualized needs of children, and at the very least ensuring that recipients are receiving appropriate and standardized services and are being tracked over time.

In August 2006, OGAC informed the Country Teams through its News to the Field that the orphans and other vulnerable children indicator had been revised. The revision changes which children can be counted as served by an orphans and other vulnerable children program and how. Many of the PEPFAR targets, other than training, were defined as direct support (downstream) and indirect support (upstream). The corresponding indicators were the number served directly and the number served indirectly, disaggregated by gender. Although targets for the total number of orphans and other vulnerable children served directly for Country Operational Plans for fiscal year 2007 will be set as in previous years, use of the revised reporting indicator will be effective as of the fiscal year 2007 mid and annual reporting periods, with allowance made if the country’s monitoring system is not yet able to provide the new breakdown (OGAC, 2006c,d). The new measure will be divided into two subcategories: orphans and other vulnerable children receiving primary direct support and those receiving supplemental direct support. Direct support is defined as follows: “direct recipients of support are orphans and vulnerable children who are regularly monitored

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

in the six core areas (food/nutrition, shelter and care, protection, health care, psychosocial support, and education) and whose individual needs are addressed accordingly. Economic strengthening should be evaluated according to its benefit to the six core areas” (OGAC, 2006i, p. 10). Indirect support for orphans and other vulnerable children support is defined as follows: “indirect recipients of support are orphans and vulnerable children who are NOT individually monitored but who collectively benefit in some way from system strengthening or other interventions. For example, estimated number of orphans and vulnerable children benefiting from a policy change or improved system (i.e., birth registration, inheritance laws, or educational system or the estimated number of orphans and vulnerable children benefiting from the training or support for caregivers)” (OGAC, 2006i, p. 11). Reporting of primary direct support is defined as follows: “count orphans and other vulnerable children who are periodically monitored in all six core areas and who are receiving PEPFAR funded or leveraged support in three or more areas, in the relevant reporting period, that are appropriate for that child’s needs and context” (OGAC, 2006i, p. 11). Reporting of supplemental direct support is defined as follows: “count orphans and other vulnerable children who are periodically monitored in all six core areas and who are receiving PEPFAR funded or leveraged support in one or two areas, in the relevant reporting period, that are appropriate for that child’s needs and context” (OGAC, 2006i, p. 11). Total direct support is the sum of primary and supplemental support (OGAC, 2006i). The indicator guidance also states that the impact of services on children is not to be measured by routinely collected program indicators and references plans to collect national-level outcome and impact indicators periodically through population-based surveys and special studies (OGAC, 2005f).

Additionally, the announcement to the Country Teams states that an orphan or otherwise vulnerable child can be counted under only one category (not both direct and indirect) and that program-level monitoring will need to be done by core service area to provide the national-level breakdown between primary and supplemental direct support. OGAC also suggests that tracking this indicator by age group could be helpful for developing appropriate service strategies. The Orphans and Other Vulnerable Children Technical Working Group is available to assist countries that need to develop appropriate and necessary monitoring systems to report on the new indicator. The new definitions and other revisions may cause the numbers of orphans and other vulnerable children served to decrease from their previous annual levels. However, the benefit of measuring impact, measuring longitudinal benefit to orphans and other vulnerable children, and standardizing services to this population will improve the quality of the services provided and yield valuable data to inform future service planning and policy development or reform.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
Results

Of the slightly more than 15 million children estimated to be orphaned or otherwise made vulnerable by HIV/AIDS, 7.4 million or 49 percent live in the focus countries (UNAIDS, 2006). Prior to fiscal year 2006, funding for services to orphans and other vulnerable children has been below the 10 percent required by the Leadership Act (see Chapter 3). According to OGAC’s third annual report to Congress, however, the amount for fiscal year 2006 is approximately 12 percent of prevention, treatment, and care resources, but drops to 9 percent if amounts for pediatric AIDS are excluded (OGAC, 2007).

By the end of fiscal year 2006, OGAC reported that services had been provided to more than 2 million orphans and other vulnerable children. This is more than triple the children served in fiscal year 2004 (see Table 7-1). As for training in the same time period, OGAC trained six times the number of people to provide services to this population since fiscal year 2004. The number of service outlets (“programs providing care and support for orphans and vulnerable children” [OGAC, 2005a, p. 48]) to which PEPFAR provided technical support for the provision of services to orphans and other vulnerable children was only reported for fiscal year 2004, though OGAC reports it continues to provide technical assistance to an undisclosed number of service outlets as part if its capacity-building efforts.

BACKGROUND

Estimates of Numbers of Orphans and Other Vulnerable Children

In its 2006 Report on the Global AIDS Epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated the numbers of children orphaned as a result of HIV/AIDS by region and country, using age 18 as the delimiter. Countries were ranked 1–37 (1 being the highest) by the number of such children out of the global estimate of 15.2 million.

TABLE 7-1 PEPFAR Orphans and Other Vulnerable Children Results by Fiscal Year, 2004–2006

Category

Fiscal Year 2004

Fiscal Year 2005

Fiscal Year 2006

Total orphans and vulnerable children served

630,200

1,222,100

2,000,700

Total people trained as providers

22,600

74,800

143,000

Service outlets

700

Not available

Not available

SOURCE: OGAC, 2005a, 2006a, 2007.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

TABLE 7-2 Estimates of Living Children Orphaned as a Result of HIV/AIDS in the PEPFAR Focus Countries and Country Population Totals, 2005–2006

Rank

Country

Number of Orphans due to AIDS (< 18 years)a

Percentage of Global Estimate

Country Total Population (2006)b

Number of Children in Country (0–14 yrs) (2005)b

Total OVC Index Score (0–100)b

 

Global

15,200,000

100.0

N/A

N/A

N/A

1

South Africa

1,200,000

7.9

47,432,000

15,500,000

69

2

Kenya

1,100,000

7.2

34,256,000

14,700,000

N/A

2

Tanzania

1,100,000

7.2

38,329,000

16,300,000

55

3

Uganda

1,000,000

6.6

28,816,000

14,500,000

65

4

Nigeria

930,000

6.1

131,530,000

58,200,000

46

5

Zambia

710,000

4.7

11,668,000

5,300,000

29

8

Mozambique

510,000

3.4

19,792,000

8,700,000

41

9

Côte d’Ivoire

450,000

3.0

18,154,000

7,600,000

68

11

Rwanda

210,000

1.4

9,038,000

3,900,000

79

15

Botswana

120,000

0.8

1,765,000

660,000

N/A

20

Namibia

85,000

0.6

2,031,000

840,000

73

37

Ethiopia

N/A

N/A

77,431,100

34,500,000

57

37

Guyana

N/A

N/A

751,000

N/A

N/A

37

Haiti

N/A

N/A

8,528,000

N/A

N/A

37

Vietnam

N/A

N/A

84,238,000

N/A

N/A

 

Total reported

7,415,000

48.9

513,759,100

180,700,000

 

NOTE: All data are estimates. UNAIDS indicates that data are still preliminary for Canada, Ethiopia, and the United Kingdom. A child orphaned by AIDS is defined as any living child under the age of 18 who has lost one or both parents as a result of HIV/AIDS. N/A = not available.

SOURCE: Compiled from aUNAIDS, 2006, and Kaiser Family Foundation, 2007; bUNICEF, 2006a.

The rankings of the focus countries are shown in Table 7-2. As of 2005, South Africa, Kenya, Uganda, and Tanzania had each reported orphan populations of just over 1,000,000. Zambia, Nigeria, Mozambique, Côte d’Ivoire, Rwanda, and Botswana had reported orphan populations in the range of 120,000–930,000, with Botswana at the lowest end of the range and Nigeria at the highest. The estimate for Namibia was 85,000 orphans. The UNAIDS report noted that the data for Ethiopia were preliminary and not included in the table, and no data were reported for Vietnam, Haiti, or Guyana. It is important to note that these estimates do not include other vulnerable children; thus they are underestimates of the numbers of children who should be counted in the category of orphans and other vulnerable children and are in urgent need of services. Though estimates may appear low for some countries, the context of the magnitude of the problem is best

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

understood by the proportion of the country’s total population and total population of children the estimates represent.

Standards of Care
Global Approach to Addressing Needs of Orphans and Other Vulnerable Children

International events and efforts by international organizations, governments, and the civil sector led to the development of a normative approach for addressing the needs of children orphaned and otherwise made vulnerable by HIV/AIDS. Box 7-1 presents a summary of these key events. The United Nations Children’s Fund (UNICEF) was instrumental in spearheading the formation of the Global Partners Forum for Children Affected by HIV/AIDS (GPFC) as a focal point for advocacy, dialogue, and prioritizing of action items. The result was a set of recommendations for global action in six key areas: (1) planning for national scale-up response; (2) ensuring that children have adequate legal protection; (3) expanding the role of community organizations in national responses; (4) improving access to education; (5) improving access to health care services for children and caregivers affected by HIV/AIDS, including pediatric treatment and prevention of mother-to-child transmission of HIV; and (6) supporting social welfare interventions.

The GPFC was initially convened in Geneva in 2003 by UNAIDS and UNICEF to mobilize action and monitor progress toward fulfilling the global commitments for children affected by HIV/AIDS set forth in the United Nations General Assembly’s 2001 Declaration of Commitment on HIV/AIDS and the Millennium Development Goals (MDGs) (UNICEF, 2006b). The first meeting resulted in endorsement of The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS (“The Framework”), which has become the normative approach for urgently addressing the needs of orphans and other vulnerable children (UNICEF, 2004). The GPFC’s second convention, held by UNICEF and the World Bank in December 2004, resulted in acceleration of the abolishment of school fees and removal of other barriers to education in a joint effort with the Education for All Fast Tract initiative; the initiation of a system for reporting on care, with indictors to track donor and national government actions and resource commitments to children affected by HIV/AIDS; and the establishment and strengthening of global treatment targets for children with HIV/AIDS. The GPFC’s third convention was held in England in 2006 by the Department for International Development (DFID), UNICEF, and UNAIDS with three major objectives: (1) to measure progress on the previous year’s commitments at the GPFC;

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

BOX 7-1

Selected Events Leading to the Development of The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS

1994: Lusaka Declaration adopted at a workshop in Zambia on support to children and families affected by HIV/AIDS. Issues reflected in the declaration include the need to assess the magnitude of the problem, the role of institutional care, the need for material and financial support for affected families, survival skills and vocational training for orphans and vulnerable children, and their right to basic education.

1998: United Nations held a General Discussion on “Children Living in a World with AIDS.” The discussion stressed the relevance of the rights contained in the Convention on the Rights of the Child to prevention and care efforts, noting that HIV/AIDS was often seen primarily as a medical problem, whereas the holistic, rights-centered approach required to implement the convention was more appropriate to the much broader range of issues that must be addressed.

1998: Regional Children in Distress conference held in Pietermaritzburg, South Africa. Country representatives committed to establishing Orphans and Vulnerable Children Task Teams in their countries.

2000: First East and Southern African regional meeting on orphans and vulnerable children held in Lusaka, Zambia. Countries made commitments and plans to address the issue of the growing numbers of orphans and vulnerable children in their countries.

2001: United Nations General Assembly Special Session (UNGASS) met to review and address the problem of HIV/AIDS in all its aspects, as well as to secure a global commitment to enhancing coordination and intensifying efforts. The resulting Declaration of Commitment on HIV/AIDS includes a specific section and set of policy and strategy actions addressing orphans and other vulnerable children for signatory states.

2002: United Nations Special Session on Children resulted in the “World Fit for Children” declaration. This declaration reaffirmed the goals set by UNGASS in 2001.

2002: Regional workshop on orphans and other vulnerable children held in Yamoussoukro, Côte d’Ivoire, with representatives from 21 Central and West African countries, in the spirit of the Pietermaritzburg and Lusaka meetings. Country representatives committed to setting up task teams in their countries to develop action plans for ensuring achievement of the targets pertaining to orphans and other vulnerable children set forth in the 2001 UNGASS declaration.

2002: Africa Leadership Consultation entitled “Urgent Action for Children on the Brink” aimed at developing consensus on priorities for a scaled-up response to the orphans and vulnerable children crisis. Actions were proposed to mobilize the leadership, partnerships, and resources required to deliver on the UNGASS goals.

2002: Eastern and Southern Africa workshop on orphans and vulnerable children (with representation from 20 countries) held in Windhoek, Namibia, to assess the progress of countries toward meeting the UNGASS goals.

2003: UNAIDS and UNICEF convened the first Global Partners Forum in Geneva. The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS was endorsed.


SOURCE: Adapted from Smart, 2003.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

(2) to identify and remove constraints to expanding the response to children affected by HIV/AIDS; and (3) to enter into a global compact with an agreed-upon manageable and prioritized agenda aimed at expanding efforts to meet the needs and rights of children affected by HIV/AIDS on the basis of emerging evidence (DFID et al., 2006). The United Nations Convention on the Rights of the Child and other human rights instruments guide all actions in support of orphans and other vulnerable children (UNICEF and UNAIDS, 2004). While all eight goals of the United Nations’ Millennium Declaration of 2000 can have an impact on the lives of children, one goal relates directly to HIV/AIDS (UNICEF, 2006c). While the authors of The Framework acknowledged that the response to the orphan crisis was growing, they maintained that the response lacked the “necessary urgency and remain[ed] unfocused and limited in scope.” They also stated that “thousands of community-based programs have been implemented by faith-based and non-governmental organizations as well as communities themselves to ensure the well-being of orphans, but opportunities for significant expansion have not yet been grasped” (UNICEF and UNAIDS, 2004, p. 10). In addition, while more attention is being paid to the inclusion of the needs of these children in poverty reduction and other national development strategies, only two PEPFAR focus countries in sub-Saharan Africa identify orphans and other vulnerable children as “priority actions” in their full poverty reduction strategy papers,1 but neither cites this area specifically in its poverty reduction strategy paper budgets (UNICEF, 2004). In addition, not all focus countries even have national strategies to address the needs of orphans and other vulnerable children.

Although OGAC representatives have participated in international efforts to address issues related to implementation of The Framework, OGAC delayed creating official program guidance for services to orphans and other vulnerable children until the late stages of PEPFAR and issued the guidance in final form in July 2006. A specific but limited care package for children living with AIDS was included as an appendix in OGAC’s draft palliative care guidance issued early in 2005 before the issuance of its preventive care guidance for children in 2006. While palliative and preventive care guidance are important, they are not, however, equivalent to official guidance on meeting the needs of orphans and other vulnerable children who are HIV-negative or asymptomatic children living with HIV/AIDS, which was not disseminated until after the publication of OGAC’s second annual

1

According to the World Bank, poverty reduction strategy papers describe a country’s macroeconomic, structural, and social policies and programs to promote growth and reduce poverty, as well as associated external financing needs. The papers are prepared by governments through a participatory process involving civil society and development partners, including the World Bank and the International Monetary Fund (World Bank, 2006).

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

report to Congress. OGAC also issued preventive care guidance for children in April 2006 (which is discussed further in this chapter), but this guidance did not comprehensively address the needs of orphans and other vulnerable children as described in The Framework. The sequencing of the various guidance documents issued for orphans and other vulnerable children may have contributed to the fragmented programming that the Committee heard about during its country visits.

The Framework

The Framework is a consensus document drafted jointly by the U.S. Agency for International Development (USAID), UNAIDS, UNICEF, and more than 90 other child advocacy organizations (UNICEF and UNAIDS, 2004). The five key strategies codified in The Framework evolved from those presented in “Urgent Action for Children on the Brink” in 2002 (UNAIDS et al., 2002):

  • Strengthen the capacity of families to protect and care for orphans and vulnerable children by prolonging the lives of parents and providing economic, psychosocial, and other support.

  • Mobilize and support community-based responses.

  • Ensure access for orphans and vulnerable children to essential services, including education, health care, birth registration, and others.

  • Ensure that governments protect the most vulnerable children through improved policy and legislation and channeling of resources to families and communities.

  • Raise awareness at all levels through advocacy and social mobilization to create a supportive environment for children and families affected by HIV/AIDS (UNICEF and UNAIDS, 2004).

These strategies are detailed in Box 7-2. The Country Operational Plans provide examples of PEPFAR-supported activities aimed at meeting the needs of orphans and other vulnerable children. These examples are presented in the next section, organized according to the five key strategies listed above. As families and communities are the first line of response to HIV/AIDS, PEPFAR, through its collaboration with and funding to USAID, has adopted The Framework to address the needs of orphans and other vulnerable children through its community and family-based programs. Many organizations receive PEPFAR funds through grants and contracts from USAID, as it has primary responsibility for oversight and development of programming for orphans and other vulnerable children (OGAC, 2004). PEPFAR has not, however, adopted all of UNICEF’s recommended core or additional indicators for measuring either the services provided or their impact on the lives of orphans and other vulnerable children and communities.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

BOX 7-2

Key Strategies of UNICEF’s The Framework for the Protection, Care, and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS

Strengthen the Capacity of Families

  • Improve household economic capacity

  • Provide psychosocial support to affected children and their caregivers

  • Strengthen and support child care capacities

  • Support succession planning

  • Prolong the lives of parents

  • Strengthen young people’s life skills

Mobilize and Support Community-Based Responses

  • Engage local leaders in responding to the needs of vulnerable community members

  • Organize and support activities that enable community members to talk more openly about HIV/AIDS

  • Organize cooperative support activities

  • Promote and support community care for children without family support

Ensure Access to Essential Services

  • Increase school enrollment and attendance

  • Ensure birth registration for all children

  • Provide basic health and nutrition services

  • Improve access to safe water and sanitation

  • Ensure that judicial systems protect vulnerable children

  • Ensure placement services for family care for children

  • Strengthen local planning and action

Ensure That Governments Protect the Most Vulnerable Children

  • Adopt national policies, strategies, and action plans

  • Enhance government capacity

  • Ensure that resources reach communities

  • Develop and enforce a supportive legislative framework

  • Establish mechanisms for ensuring information exchange and collaborative efforts

Raise Awareness to Create a Supportive Environment

  • Conduct a collaborative situation analysis

  • Mobilize influential leaders to reduce stigma, silence, and discrimination

  • Strengthen and support social mobilization activities at the community level

SOURCE: UNICEF and UNAIDS, 2004.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

The Director of Program Services for OGAC participated in the third GPFC convention in London in February 2006. During the meeting, the OGAC representative shared the challenges faced by PEPFAR in providing services to orphans and other vulnerable children, including operationalizing a coordinated response across sectors that incorporates children into the Three Ones principles of harmonization (see Chapter 2), decentralizing to facilitate a scaled-up response and strengthen public systems while mobilizing and engaging communities, and tailoring approaches to the context created by the state of the epidemic and addressing gender- and age-specific needs. In addition, the GPFC identified the United States as only one of three donor countries that had actually provided a specific budget allocation (10 percent) for orphans and other vulnerable children, the United Kingdom and Ireland being the others (UNICEF, 2006b). Despite the difficulties encountered, the early success of PEPFAR in the planning and implementation of services for orphans and other vulnerable children, as discussed below, may be attributable in part to an existing international framework specific to the population and targeted to their needs that could inform programming, resource planning, and implementation.

REVIEW OF PROGRESS TO DATE

Strategies of the Framework
Strategy #1: Strengthen the Capacity of Families

Some of the strategies of The Framework prescribe specific services children need, while others describe the catalysts for action necessary in communities, governments, and legislative and judicial frameworks and institutions. Strategy #1 is aimed at strengthening the capacity of families to protect and care for orphans and other vulnerable children by prolonging the lives of parents and providing economic, psychosocial, and other support. If a mother or father loses a spouse to AIDS, the remaining parent is left to care for their children as a single parent and generally faces increased economic and child care responsibilities (UNICEF and UNAIDS, 2004). In many cases, the remaining parent may also be ill and face the prospect of his or her own eventual death, while also having to find adequate, appropriate, and permanent caregivers for his/her surviving children. Often, the role of caregiving for children and sick family members falls to adult women of the household. While shouldering these responsibilities, women may not be able to continue to give adequate attention to subsistence crop production. This in turn is likely to have an impact on both income generation and food security and availability for the entire household, including the children. Some research has shown that the impact of HIV/AIDS can

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

reduce household income by as much as 60 percent (Donahue, 2005). Other studies have shown that families and households experience “distinct peaks of financial pressure” that correspond to the clinical stages experienced by ill family members (Donahue, 2005). For example, in the early stage after diagnosis, family members and caregivers may spare no expense for care and treatment.

In addition, women who bear the burden of caregiving for sick family members may become less able to care for their children (Donahue, 2005). The intergenerational transfer of knowledge and skills is also threatened by the extended illness and/or premature death of parents and other adults in the community (UNICEF and UNAIDS, 2004). Save the Children’s (2004) report Beyond the Targets: Ensuring Children Benefit from Expanded Access to HIV/AIDS Treatment states that “children whose parent(s) are HIV-positive are at risk for losing their right to survival and development for a number of reasons” and that expanding access to care and treatment will likely help maintain a family unit and its livelihood. The result could be fewer children becoming orphaned because of HIV/AIDS, or if they do eventually become orphaned, perhaps when they are older and with less of an impact on their developmental and survival needs.

The PEPFAR strategy articulates support for a community-based, family-centered approach, especially for the care of orphans and other vulnerable children (OGAC, 2004). It also states that “best practices of community-support for these households will be identified and promulgated. Home-based care and support programs will be especially targeted to such families in order to do all that is possible to keep them intact and organizations with particular expertise in family care will be targeted for funding” (OGAC, 2004, p. 48). Based on the Committee’s review of Country Operational Plans and documents from the Orphan and Vulnerable Children Technical Working Group, it appears that the majority of the allocation of PEPFAR funds for orphans and other vulnerable children services is mostly channeled through a limited number of agencies, mostly large, international non-profit, nongovernmental organizations.

The Committee examined Country Operational Plans from 2005 for examples of activities aimed at strengthening the capacity of families to provide care and support for orphans and other vulnerable children (see Box 7-3). The Committee’s visits to the focus countries revealed that some of these programs were more advanced than others not only in their networks, but also in the extent to which they were supported by the community and integrated into overall HIV/AIDS service efforts, as well as in the scope and duration of services provided to meet the needs of children. These variations are likely due to differences in countries’ efforts to develop and implement programs prior to PEPFAR. In the examples cited in Box 7-3, multiple partners and U.S. government agencies and programs (such as the

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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BOX 7-3

Selected Examples of PEPFAR-Supported Activities Intended to Strengthen the Capacity of Families for Care and Support of Orphans and Other Vulnerable Children

Côte d’Ivoire: home- and community-based counseling, psychosocial support, including counseling, play therapy, referrals, and education support and health and nutritional services

Mozambique: provision of basic income and shelter/housing needs with microfinancing and mobile banks

Ethiopia: training in business and financial skills for both adult women and older orphans and other vulnerable children who are heads of households, with increasing focus on those in rural areas

Kenya: provision of food and clothing including school uniforms and payment of school fees and other efforts to ensure school enrollment

Rwanda: increasing awareness of children’s protection and rights

Tanzania: vocational training and life skills education to avoid more risky professions and activities


SOURCE: OGAC, 2005a,d, 2006b,g.

Peace Corps) were consistently involved. System-strengthening activities also characterized many of the programs, such as support for the development of a monitoring and evaluation system for programs and activities addressing orphan and other vulnerable children activities and programs. Other system-strengthening examples include facilitating collaborations among community-based organizations (including nongovernmental, community-based, and faith-based organizations); encouraging national and provincial coordination of services; cross-training providers of microfinance services in HIV/AIDS prevention, care, and treatment services; and facilitating collaboration with the civil sector to find sustainable alternatives to institutional care and support for these children (OGAC, 2005d).

Strategy #2: Mobilize and Support Community-Based Responses

As noted in Chapter 6, OGAC concurs with UNICEF’s assessment that the community is the safety net after the family, and intends to provide direct support for building the capacity of community-based and nongovernmental organizations to support a greater number of community initiatives. According to UNICEF and UNAIDS (2004), the community can be instrumental in assisting the extended family in keeping family relationships intact when the nuclear family is struggling with caring for an increased

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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number of dependent children. Activities should include engaging local leaders in responding to these needs; enabling communities to talk more openly about HIV/AIDS to combat stigma and discrimination; organizing cooperative support activities, such as providing respite care, communal gardens, and day care centers; and promoting and supporting community care for children without family support, such as foster care, adoption, and community monitoring of new caregivers to prevent neglect and abuse (UNICEF and UNAIDS, 2004). In addition, UNICEF and UNAIDS have stated that faith-based and nongovernmental organizations have an instrumental role in galvanizing and supporting community efforts (UNICEF and UNAIDS, 2004). Local leaders ranging from political and religious figures to journalists and teachers need to be made aware of the impact of HIV/AIDS on children and encouraged to take action to care for and protect the most vulnerable—particularly from the risks of sexual abuse and exploitative labor practices. In Africa, cultural values are often passed down through oral traditions, and traditional African culture reinforces the practice of caring for vulnerable children, while faith-based responses to orphans and other vulnerable children are widespread (Foster et al., 2005). A coordinated response will require partnerships among policy and resource organizations and the religious sector (Foster et al., 2005). Nonetheless, historical misunderstandings, a lack of appreciation of different perspectives, assumptions about the HIV status of children of HIV-positive or deceased parents, and difficulties in communicating because of differing organizational cultures and languages have all hampered coordinated and integrated efforts to respond to these children’s needs.

Some of the literature has offered compelling arguments against providing institutional care for these children in orphanages and group homes. Ironically, the idea of institutional care was imported from the industrialized world, with the belief that its modernity would provide better care (Phiri and Tolfree, 2005). Institutional or residential care may have additional appeal because of its organizational convenience to social service professionals, its provision of a means to deal with large numbers of children when families and communities are overwhelmed with the children’s needs, and the tangibility and visibility of the resources provided by donors (Phiri and Tolfree, 2005). Yet the literature also points to several disadvantages and negative impacts of institutional or residential care, including systematic exposure of children to malnutrition and exploitative behaviors; inadequate health care and hygiene; educational deprivation; harsh discipline; lack of stimulation, personal care, and attention; and institutional dependence. From a policy standpoint, institutional care yields poor results by serving small numbers at a high cost per child—estimated to be five to ten times higher than the cost of foster care provided by unrelated caregivers. There is evidence that community initiatives (with the help

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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of external resources) can promote local solutions involving family- and community-based resources that achieve good results for large numbers at a low cost per child (Phiri and Tolfree, 2005). As noted, PEPFAR focuses most of its service provision for orphans and other vulnerable children in the context of community-based settings and as often as possible within a family (including extended family) unit. The program has, however, been criticized for a predominant emphasis on physical and material needs and a lack of attention to the psychosocial well-being of children (Huni, 2006). PEPFAR often uses linkages to antiretroviral therapy as a means to keep parents alive and keep family units intact to reduce the number of orphans and vulnerable status of children. In a few countries, however, PEPFAR, at the direction of the country leadership, is supporting institutional care in the form of orphanages.

Examples of activities in Country Operational Plans for fiscal years 2005 and 2006 designed to mobilize and support community-based responses for orphans and other vulnerable children are presented in Box 7-4. Several of these activities involved partnering with either U.S. government programs such as the Peace Corps or working closely with large interna-

BOX 7-4

Selected Examples of PEPFAR-Supported Activities Intended to Mobilize and Support Community-Based Responses for Orphans and Other Vulnerable Children

Botswana: support for selected community-based organizations for grant making and program promotion in the areas of volunteer management, equipment, materials development, service delivery, vocational training, and other income-generating projects to teach small-business skills for sustainable income

Kenya: technical support to conduct needs assessments, write proposals, manage programs, establish eligibility criteria, train community groups and providers to understand the rights and health needs of children, and develop training materials

Guyana: support for equity in access to educational, nutritional, and physical and social health opportunities for girls

Mozambique: collaboration with Peace Corps volunteers to support community mobilization and training to implement modest rehabilitation projects and support training for caregivers

Namibia: collaboration with national interfaith organizations to develop and sustain grassroots support programs focused on training providers, improving program management, mobilizing the involvement of community groups and their leaders, and providing small start-up grants for community projects


SOURCE: OGAC, 2005a,d, 2006b,g.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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tional, nongovernmental organizations for institutional and community capacity building.

Strategy #3: Ensure Access to Essential Services

Essential services for orphans and other vulnerable children include education, health care, birth registration, and others. Article 65 of the Declaration of Commitment of the 2001 United Nations General Assembly Special Session (UNGASS) calls for increased access to such services and parity for orphans and other vulnerable children, with governments identified as critical actors in realizing this goal (UNICEF and UNAIDS, 2004). All sectors are called upon to develop innovative strategies and increase the resources available to meet the developmental needs of these children in an effective and sustainable way.

Of particular concern under this strategy are the issues of birth registration and education. One component of an effective national child welfare policy is a vital statistics program that registers births and deaths. The Millennium Development Initiative considers birth registration a basic vital statistic deemed important for countries to own, track, report, and record and is generally the responsibility of signatory governments to the Convention of the Rights of the Child (UNICEF and UNAIDS, 2004). It has many benefits, including enabling determination of service eligibility and inheritance, as well as permission for school attendance. Unfortunately, in several countries, particularly in rural areas, birth registration does not occur until a child approaches school age. An alternative to birth registration is sworn affidavits by parents, but this method places an undue burden on orphans. Of the 48 million children annually who are not registered at birth, 55 percent are born in sub-Saharan Africa, compared with only 2 percent in industrialized countries (Sharp, 2005). This situation has implications for gender equity in service eligibility and for efforts to decrease vulnerability to HIV/AIDS for young girls and women, especially if female children are born out of wedlock. Institutional, financial, and political constraints that affect the scaling-up of birth registration have a ripple effect on constraining the scale-up of interventions for orphans and other vulnerable children (Sharp, 2005).

Education can make a difference in the lives of orphans and other vulnerable children by providing information and skills that reduce their vulnerability to HIV exposure and infection. Moreover, schools can serve as important resource centers to meet broader community needs and can provide safe and structured environments although caution must be exercised to ensure that adolescent girls are safe from sexual harassment and coerced sexual behavior in school. Schools also provide emotional support and adult supervision (UNICEF and UNAIDS, 2004), which can serve as

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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a daily respite to children whose homes are affected by HIV/AIDS. The introduction of school meals for children can provide relief in areas where food security is an issue. In-school meals combined with take-home rations (with the consultation of community leaders and donors to avoid dependency) may also improve food security for members of the child’s household (UNICEF and UNAIDS, 2004). Despite these benefits, several studies have shown that sick and orphaned children have lower rates of school attendance than nonorphaned children, often exacerbated by high transaction costs associated with education, including school fees and transportation. Overburdened caregivers also contribute to missed opportunities for school attendance (UNICEF, 2006a).

BOX 7-5

Selected Examples of PEPFAR-Supported Activities Intended to Ensure Access to Essential Services for Orphans and Other Vulnerable Children

Ethiopia: linkage with USAID agricultural programs to improve food security by expanding the program coverage to focus on the needs of orphans and vulnerable children, with particular emphasis on female- and orphan-headed households. The focus is on the increased use of urban gardening systems to generate food for household consumption while decreasing water use, labor, and land requirements. Beneficiaries are linked to a network of nongovernmental organizations that are already running such programs and can facilitate market linkages for surplus income generation

Namibia: funding of a full-time position for a technical advisor to work with government ministries, focusing on the management of trust funds to serve orphans and other vulnerable children, as well as on aspects of database creation and management for the collection, tracking, and analysis of data related to these services

Tanzania: collaborations with regional and referral hospitals to facilitate development of caregiver capacity for patient care and monitoring adherence to antiretroviral therapy for HIV-positive orphans and other vulnerable children

Kenya: training of paraprofessional counselors and/or community members in HIV/AIDS awareness, child care and counseling, parenting skills, legal rights, and other topics necessary to the care of orphans and other vulnerable children and the provision of economic support or income generation

Côte d’Ivoire: monitoring and evaluation of the continued implementation of pilot programming to serve as a model for a network of linked social and health services through public–private partnerships that reinforce coordination and two-way referrals


SOURCE: OGAC, 2005d, 2006g.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Country Operational Plans for fiscal years 2005 and 2006 yield examples of a number of programs aimed at ensuring access to essential services for orphans and other vulnerable children (see Box 7-5). As with many of the other strategies, the Peace Corps is partnering with local organizations to implement and expand many of these activities. Some common characteristics of these initiatives include integration with existing PEPFAR-assisted health networks and home-based care programs, which may often be collocated or linked with existing prevention, treatment, and care programs. Other shared characteristics include integration with food security and nutrition programs, expansion of coverage to out-of-school youths and children in rural areas, and use of multiple agencies in local and regional partnerships to promote human and legal rights for orphans and other vulnerable children (OGAC, 2005d, 2006g).

Strategy #4: Ensure That Governments Protect the Most Vulnerable Children

Implementation of this strategy involves improving policy and legislation by channeling resources to families and communities. To meet their obligations under ratified human rights conventions, country governments must undertake and be supported in efforts to mobilize multisectoral responses. Most countries have policies and mechanisms to protect, care for, and support children, but these need to be reviewed to ascertain whether they reflect current international standards (UNICEF and UNAIDS, 2004; UNICEF, 2006a). Situational analyses conducted among and with a variety of key stakeholders can provide the data needed to inform the development and implementation of prioritized, costed, and evidence-based national strategic plans (UNICEF, 2006a).

There is great variability in national policies on child health, welfare, and education. Where these policies are most effective, they articulate the rights of children and provide a culturally appropriate background for the development of services for orphans and other vulnerable children. Challenges related to the provision of such services, identified at PEPFAR’s third annual meeting, include the need for linkages to care and psychosocial support services for HIV-positive children, educational interventions, and linkages to child protective services—a particular challenge in countries with nascent or nonexistent social welfare systems. Other challenges identified include volunteer retention, targeting of the most vulnerable children, multiple displacements, support for elderly caregivers, and government leadership. OGAC reported some lessons learned, including the success of local child protection committees, the use of child-friendly national plans of action for orphans and other vulnerable children, the use of inheritance documents for children, and the provision of educational block grants (OGAC, 2006b).

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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Social security funded by national governments—including free access to health services for the poor, free basic education, and a package of social transfers to ensure a minimum standard of living (DFID et al., 2006)—has been shown to be a key tool for poverty reduction and growth. Yet one study (supported by the Nelson Mandela Children’s Fund and Development Research Africa) involving a survey of 29,000 members of nearly 5,000 households in eight predominantly rural sites revealed that in countries where social security stipends are available for the elderly and for child support and dependency grants, eligible caregivers were not accessing the child-related grants for a variety of reasons. Less than one-third of eligible households reported that they were receiving child support, foster care, disability, and care dependency grants (Population Council, 2004).

As reported at PEPFAR’s second annual meeting, small-scale interventions for orphans and other vulnerable children have been initiated in most focus countries. According to one presenter at the meeting, “It is easier for programs to focus on one marketable aspect that is easy to fund and get quick results; as well as to be clustered in accessible areas to reach a few children with duplicative services.” At the same time, this presenter observed, “While many countries have expressed commitment by the development of national plans, there has been little legislative review for meeting the essential needs of children—particularly beyond policies that advocate free education for all” (Huni, 2006).

PEPFAR has funded projects in multiple countries to measure country efforts responding to the needs of orphans and other vulnerable children (see Box 7-6), including the joint development of the Orphans and Vulnerable Children Programme Index (UNICEF et al., 2004). The Index enabled country governments to conduct situational analyses of the state of orphans and vulnerable children. Its design built upon previous tools for measuring HIV/AIDS efforts, such as the AIDS Programme Effort Index, developed by USAID, UNAIDS, and the Policy Project, and the National Composite Policy Index, implemented by UNAIDS to measure progress toward specific UNGASS goals. The Index scores provide a profile of national and regional efforts, as well as measure the change in efforts over time. It provides a composite score (0–100, with 100 being the highest) based on an examination of eight components: national situation analysis, consultative process, coordinating mechanism, national action plans, policy, legislative review, monitoring and evaluation, and resources. In 2004, 36 countries in sub-Saharan Africa undertook application of the Index (UNICEF et al., 2004). See Table 7-2 for Index scores of the PEPFAR focus countries. According to the developers of the Index, their intent was not to rank or grade individual countries, but to provide useful data to international agencies and donors through profiles of regional and national efforts that have led to

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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BOX 7-6

Selected Examples of PEPFAR-Supported Activities Intended to Ensure That Governments Protect the Most Vulnerable Children

Botswana and Côte D’Ivoire: development and dissemination of national policy and planning documents to address the needs of children and development of in- and preservice training materials for social workers

Guyana: development and strengthening of referral networks among governments, nongovernmental organizations, social services, and care and support services, as well as support services for both in- and out-of-school children

Mozambique: assistance with capacity-building efforts for child advocacy staff in government ministries, including workshops on finance, coordination, and project oversight

Tanzania: support for programs that increase access to government benefits and building of the capacity of local government authorities, faith-based and nongovernmental organizations, and national organizations, and provision of resources for monitoring and evaluation

South Africa: support for the programs of the Department of Social Development to provide comprehensive services with special attention given to life skills education and training of community-based child and youth workers


SOURCE: OGAC, 2005a,d, 2006b,g.

improvements and identification of areas that may need greater emphasis in the future (UNICEF et al., 2004).

Strategy #5: Raise Awareness to Create a Supportive Environment

Implementation of this strategy for children and families affected by HIV/AIDS encompasses advocacy and social mobilization. Since the beginning of the pandemic, stigma and discrimination have been experienced by people with HIV and their family members, including orphans and other vulnerable children. It is thought that reducing stigma and discrimination may decrease the risk and opportunity of sexual and labor exploitation faced by many orphans and other vulnerable children as a result of their economic vulnerability and the failure to meet their basic needs in a safe and appropriate manner. Faith- and community-based organizations, the media, and nongovernmental organizations can play significant roles along with governmental organizations in raising awareness and promoting acceptance of community responsibility for caring for these children. Examples of PEPFAR-supported activities intended to create supportive environments for orphans and other vulnerable children are listed in Box 7-7.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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BOX 7-7

Selected Examples of PEPFAR-Supported Activities Intended to Create a Supportive Environment for Children and Families Affected by HIV/AIDS

Botswana: technical support for monitoring and evaluation, geographic, mapping of services countrywide, training, development of materials on life skills, kids clubs, memory book development, child counseling, community mobilization and advocacy, and caring for caregivers. In a new initiative implemented by the Ministry of Education, it supported training of school administrators, school conveners, neighborhood agents, and social workers in all areas of support for orphans and other vulnerable children in pilot school-based programs, including addressing the psychosocial support needs of children by facilitating linkages among local networks to reintroduce children to school and ensure that they remain to realize their academic potential

South Africa: support for initiatives of local organizations to integrate services of the public and private sectors, improve multisectoral collaboration, strengthen existing and/or build new networks, increase access to foster care grants, develop materials and provide training to caregivers on psychosocial aspects of working with orphans and other vulnerable children that focus on their developmental needs and ways to eliminate stigma and discrimination

Côte d’Ivoire: targeted evaluation of programs and services that support adolescent girls in rebel-occupied zones, support for data collection, management, and analysis to develop an integrated national monitoring and evaluation system

Namibia: identification of significant concentrations of orphans and other vulnerable children, school attendance patterns, and reasons for nonattendance for service and program planning purposes


SOURCE: OGAC, 2005a,d, 2006b,g.

HIV Prevention

While many of PEPFAR’s prevention activities target youths, it has been difficult to determine to what extent these programs are directed specifically at orphans and other vulnerable children. OGAC has made a number of procedural changes to both improve program linkages and provide more programmatic information on orphans and other vulnerable children, but it remains unclear how well PEPFAR is doing in reaching orphans and other vulnerable children with appropriate prevention messages. The fiscal year 2006 Country Operational Plans provide a number of examples of prevention interventions being funded by PEPFAR that target orphans and other vulnerable children, many of which are linked to other services being provided by PEPFAR (see Box 7-8).

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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BOX 7-8

Selected Examples of PEPFAR-Supported Prevention Activities Targeting Orphans and Other Vulnerable Children

In Kenya, a faith-based charity funded by PEPFAR trains young people to serve as volunteers in actively reaching out to their peers with targeted abstinence, be faithful, and other behavior change messages. The focus is on reducing the vulnerability of orphans and other vulnerable children to HIV infection through a community approach to prevention.

In Namibia, a faith-based organization’s HIV youth prevention program aims to reduce the rate of HIV prevalence among youths aged 14–25, with a special focus on orphans and other vulnerable children, through delay of sexual debut, abstinence until marriage, and messages discouraging risk behaviors among sexually active youth. Another faith-based organization is working with its local congregations to offer abstinence and be faithful messages through community dramas as a component of a holistic program that also includes home-based care and counseling/referrals.

In Uganda, a community-based organization promotes HIV prevention beyond abstinence and being faithful by imparting comprehensive information and skills to the most at-risk populations and making environments safer for women, youths, and people living with HIV. A portion of the programs funding is used to work directly with older orphans and other vulnerable children to promote positive behaviors, such as delay in sexual debut and avoidance of early marriage and exchange of sex for money and gifts.


SOURCE: OGAC, 2006g.

PEPFAR’s 2005 guidance for implementation of the ABC model (abstinence until marriage, being faithful, and using condoms), includes a number of programmatic directives related to young people that apply to orphans and other vulnerable children (OGAC, 2005e). Young people who have not had their sexual debut are to be encouraged to practice abstinence until they have established a lifetime monogamous relationship. For those youths who have initiated sexual activity, returning to abstinence is a primary message of PEPFAR’s prevention programs. The guidance includes the following restrictions (OGAC, 2006c,d):

  • PEPFAR funds may be used in schools to support programs that deliver age-appropriate AB information to young people aged 10 to 14.

  • PEPFAR funds may be used in schools to support programs that deliver age-appropriate ABC information for young people above age 14.

  • PEPFAR funds may be used to support integrated ABC programs

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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that include condom provision in out-of-school programs for youths identified as engaging in or at high risk of engaging in risky sexual behaviors.

  • PEPFAR funds may not be used to distribute or otherwise provide condoms in school settings.

  • PEPFAR funds may not be used in schools for marketing efforts to promote the use of condoms to youths.

  • PEPFAR funds may not be used in any setting for marketing campaigns that target youths and encourage condom use as the primary intervention for HIV prevention.

These guidelines are reinforced in the draft work plans of the Technical Working Groups, which promote life skills and AIDS education programs delivered in school settings because these interventions have been shown to be effective, and which encourage programs targeting youth aged 10–14 to emphasize abstinence and the delay of sexual initiation. Given the reported early average age of sexual debut (and sometimes marriage) in many countries, however, PEPFAR may wish to re-examine its exclusive AB focus for younger adolescents.

A number of potential challenges to meeting the needs of orphans and other vulnerable children are associated with these funding restrictions and program considerations, in terms of both the location of programs (e.g., in versus out of school) and ages targeted. As discussed previously, the deteriorating health or death of parents or adult guardians forces many orphans and other vulnerable children to drop out of or interrupt school attendance because funds for tuition are lacking, or other obligations become the child’s priority. Prevention programs in the school environment often will not reach this critical population. A number of out-of-school prevention programs exist in many of the focus countries, including community mobilization efforts that often include outreach to peers, adults, and out-of-school youths to expand access to prevention (OGAC, 2005d, 2006g). However, it is not possible to determine how many children are reached with prevention messages through these programs.

The age focus of prevention programs can also be limiting. Being orphaned and otherwise affected by HIV/AIDS can put children in situations in which they are vulnerable to becoming exposed to HIV. Prevention programs must also target these vulnerabilities, including sexual coercion by adults in exchange for food, money, housing, and educational/school opportunities. Such sexually predatory behavior can be committed by extended family members who may be caregivers, employers using an orphaned or vulnerable child’s labor for domestic help, or school teachers promising better grades. Thus the risk of HIV exposure and infection may extend beyond the scope of age-specific interventions or school programs communicating abstinence and be faithful messages. While there are some

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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examples of comprehensive prevention programs for children funded by PEPFAR, it is not clear how the Country Teams can ensure that prevention programs in the school environment will provide the range of prevention and care services needed given the current guidelines and planning and funding restrictions.

Preventive Care

Secondary preventive care services (including the administration of cotrimoxazole prophylaxis as early as possible for infants and children) have reduced mortality and morbidity not only for those living with HIV, but also for their family members and children (see Chapter 6). As discussed previously, OGAC released guidance for preventive care services for children aged 0–14 born to mothers who are HIV-positive, which was produced through the collaboration of several of the Technical Working Groups—Palliative Care, Food and Nutrition, and Orphans and Vulnerable Children. In recognition of the specific and age-dependent needs of children, the preventive care package for children varies from that for adults in significant ways. OGAC continues to encourage linkages of these services to other programs that support the basic health care and social service needs of children. Antiretroviral therapy and palliative care for children are addressed in additional guidance from OGAC.

In addition to the services identified in the adult preventive care guidance as outlined in Chapter 6, the guidance for children specifies direct funding for the following services (OGAC, 2006d):

  • Diagnosis of HIV infection in infants, including purchase of reagents and equipment; establishment of laboratory programs needed to diagnose HIV infection in infants according to national guidelines; training of staff to perform testing; targeted evaluation of practical approaches for scaling up testing in infants; and follow-up and referral at the facility and community levels in accordance with PEPFAR’s network model (see Chapter 6).

  • Childhood immunization, including routine childhood immunizations and pneumococcal and influenza vaccines, referral and follow-up, linkages to routine immunization programs, and technical assistance to develop national policies and training programs for children living with HIV/AIDS. It should be noted that PEPFAR does not directly fund the purchase of routine vaccines for infants and children exposed to HIV, but does support the purchase of vaccines for pilot programs and targeted evaluations of new vaccines for children who are HIV-positive.

  • Prevention of serious infections, including technical assistance for the development of national guidelines and training programs for preventing pneumonia, tuberculosis, malaria, and diarrheal disease in children who

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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have not been exposed to HIV or are HIV-positive, with recommended linkages to the President’s Malaria Initiative and the Global Funds to Fight AIDS, Tuberculosis and Malaria.

  • Providing nutritional care, including the provision of daily multiple micronutrient supplements for pregnant and lactating women, children, and especially infants weaned early and children under age 2; vitamin A and zinc supplementation according to national guidelines; and nutritional counseling linked to clinical and home-based care in areas where malnutrition is endemic.

Scale-up of PEPFAR’s secondary preventive care services for both children and adults has the potential to help keep parents and families healthier longer, decrease the numbers of children who may become orphaned or otherwise made vulnerable as a result of HIV/AIDS, decrease stigma and discrimination against children and their family members, and improve a household’s ability to positively cope with being affected by HIV/AIDS.

Progress in Addressing the Vulnerability of Young Girls

OGAC has articulated a commitment to focusing on the special vulnerability of girls to HIV/AIDS and its effects (OGAC, 2005a, 2006a). Many interventions are addressing the factors that make girls vulnerable, including efforts to increase their means of economic/social support, enable them to continue their education, and advocate an end to the practices of early marriage and transgenerational sex as solutions to what families may view as burdens created by orphaned girls (OGAC, 2006a). OGAC has reported that among the orphans and other vulnerable children served by PEPFAR activities, 52 percent have been girls (OGAC, 2006h). OGAC has also reported that PEPFAR is supporting 97 activities aimed at increasing the access of women and girls to income and productive resources (OGAC, 2006h). PEPFAR is also attempting to increase the focus of its programs on gender by working with community partners to reduce violence, including sexual coercion and rape, toward orphans and other vulnerable children, particularly adolescents (OGAC, 2006a).

ISSUES AND OPPORTUNITIES FOR IMPROVEMENT

Varying Definitions

Although the definition of an orphan can differ by country, the main variables are generally age and parental loss (USAID, 2003). International organizations and governments have variably used the under-15 or under-18 age groups to define a child as an orphan if one or both of the parents

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
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are deceased. USAID supports community definitions of orphans and does not specify a particular age to delimit childhood and adulthood; it also recognizes the international use of the term “child” as defined by the United Nations Convention on the Rights of the Child as any person under the age of 18 (USAID, 2002). The UNAIDS and UNICEF (2003) Report on the Technical Consultation on Indicators Development for Children Orphaned and Made Vulnerable by HIV/AIDS defined an orphan or otherwise vulnerable child as “ a child below the age of 18 who has lost one or both parents or lives in a household with an adult death (age 18–59 years) in the past 12 months or is living outside of family care” (p. 4). In addition, “the concept of vulnerability is complex and may include children who are destitute from causes other than HIV/AIDS” (USAID, 2004, p. 1). The Children on the Brink series was issued in 2002 and 2004 (UNAIDS et al., 2002, 2004). The 2004 publication revised the age used to delimit childhood from under 15 to under 18 in recognition that “orphans and vulnerable children are not necessarily young children and that problems caused by orphaning extend well beyond the age of 15, [with] available data suggesting that adolescents make up the majority of orphans in all countries” (UNAIDS, 2004, p. 4).

The definition of an orphan in PEPFAR’s second annual report as a child below age 15 who has lost one or both parents is consistent with that in the 2002 version of Children on the Brink (UNAIDS et al., 2002), but is inconsistent with the 2004 revision. This inconsistency between definitions raises concern about whether PEPFAR service outlets are providing and targeting services to the entire population eligible for those services, and whether the program is overlooking a population of children aged 16–18 who are often the heads of households after the death of a parent or are primary caregivers during the illness of a parent.

Another deviation from international definitions is PEPFAR’s definition of vulnerable children as those affected by HIV through the illness of a parent or principal caretaker, which may limit the availability of services for those children who may be in greatest need and at greatest risk for exploitation and increased risk for exposure to HIV. The international community and premier child advocates generally have a more expansive definition of a child’s vulnerability as being affected by any disease, including HIV/AIDS, that afflicts a parent/caregiver; living in a household that has taken in orphans; or living on the streets (UNAIDS, 2004). Vulnerability may also differ by community and intervention (Mahy, 2006). These misaligned definitions may also result in underserving child-headed households and many children who may become vulnerable when their households accept orphans.

USAID (2004) acknowledges that the concepts of orphans and other vulnerable children as social constructs have cultural variability, and that depending on their intended versus adopted use, the definitions can often be at odds with each other. For example, the terms may be used for collecting

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

and reporting quantitative data, which would differ from their use for the development and implementation of programs and policies. USAID believes that making these distinctions is important and that “firewalls” should be built around the definitions to minimize the potential consequences of deviation from their original purposes. One of the most common misuses of the terms appears to be the use of quantitative definitions for program eligibility. USAID cautions that quantitative definitions must allow for absolute distinctions, whereas the definitions used in policy and program development and implementation must allow for the local variations that contribute to or cause vulnerability.

UNICEF has called for programs that address the needs of orphans and other vulnerable children living in a world with HIV/AIDS to serve all children who are orphans and are vulnerable regardless of the cause of their state. The primary reason for this position is that either referring to these children as “AIDS orphans” or limiting their eligibility for services to disease-specific vulnerability could further stigmatize them in their communities and families, which in turn could result in mistreatment and discrimination, alienation, or reluctance to access the very services intended to reduce their vulnerability and exposure to HIV infection and improve the quality of their lives. While PEPFAR remains focused on HIV/AIDS, it has put increasing emphasis on the provision of services to children in the context of other service programs and activities for all children in communities and states that “programs must implement effective measures to prevent gender inequity, avoid further degradation of family structures, reduce stigma, avoid marginalization, and that do not generate jealousy and conflict for beneficiaries. Services need to be designed to reduce stigma, not increase it” (OGAC, 2006i, p. 4).

After the publication of its second annual report to Congress and as the program evolved, OGAC disseminated its “Orphans and Other Vulnerable Children Programming Guidance for United States Government In-Country Staff and Implementing Partners.” The guidance includes updated definitions for children orphaned or otherwise made vulnerable as a result of HIV/AIDS (OGAC, 2006i, p. 2):

An orphan is a child, 0–17 years old, who has lost one or both parents to HIV/AIDS. A vulnerable child is a child, 0–17 years old, who is 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 a chronic illness, a household headed by a grandparent, and/or a household headed by child)

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
  • Lives outside of family care (e.g. in residential care or on the streets), or

  • Is marginalized, stigmatized, or discriminated against.

OGAC’s adoption of definitions that are more closely aligned with the current international consensus (and the realities of the needs of children) eliminates some of the Committee’s concerns about PEPFAR-supported programming, particularly for adolescents and child heads of household who may be in great need of support and services.

Establishment of Targets

If funding allocations and other budgetary constraints were removed, it would be appropriate for Country Teams, with the help of community-based service providers, to establish quantifiable targets for orphans and other vulnerable children to be served as has been done with PEPFAR’s other categories. Even this target setting should be guided not only by the needs of children orphaned and otherwise made vulnerable by HIV/AIDS, but also by the needs of all children who have been orphaned or made vulnerable by any cause—not equivalently based on the estimated numbers of orphans in each country. Communities and countries would then have the flexibility to tailor their responses to all causes of orphanhood and vulnerability and integrate services for all children, while PEPFAR would be able to implement programs for these children in a community-based, family-centered context that would not increase stigma and discrimination due to HIV/AIDS.

Recommendation 7-1: The needs of orphans and other children made vulnerable by AIDS cover a wide spectrum that cuts across all of PEPFAR’s categories of prevention, treatment, and care and extends well beyond the health sector. It is essential for an HIV/AIDS response to address these needs adequately—not only to support these children in living healthy and productive lives, but also to protect them from becoming the next wave of the pandemic. The U.S. Global AIDS Initiative should continue to support countries in the development of national plans that address the needs of orphans and other children made vulnerable by AIDS, as well as to support the priorities delineated in these plans. To ensure adequate focus on and accountability for addressing the needs of orphans and other vulnerable children, the U.S. Global AIDS Coordinator should work with Congress to set a distinct and meaningful performance target for this population. This target should be developed in a manner that both builds on the improvements PEPFAR has made in its indicator for children served and enhances its ability to support comprehensive and integrated HIV/AIDS programming.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
Types and Quality of Services

The Committee had difficulty interpreting the reported results for this category and was left with the question of what it really means to have been served or received care as an orphan or otherwise vulnerable child. The Committee has expressed its concern throughout this report about the variability in types and quality of services, but this concern is most pressing with regard to orphans and other vulnerable children. It was difficult for the Committee to discern whether the current measure reflects how many children have received services or the number of times children have received services. Specific concerns relate to which services the children may have received as described in The Framework, whether the services met their changing needs or the intensity of those needs, and whether a child was counted as served each time if he or she received fewer than the core services from multiple providers. Additional concerns include the length of time over which services were provided and the coverage or reach of the program—especially to children in rural areas. The Committee strongly encourages attention to all of these concerns as OGAC collects data based on its revised indicator for orphans and other vulnerable children indicator. It should be noted that PEPFAR is supporting cost-effectiveness studies for orphans and other vulnerable children care as part of its pursuit of best practices for services to this population.

Workforce Issues
Capacity

Providers of health care services to orphans and other vulnerable children are suffering shortages similar to those discussed elsewhere in this report, which will not be repeated here. The multifaceted needs of children, however, require that other sectors, such as education and social welfare, receive more support for increased resources and technical assistance for development. Many countries, for example, have seen an increase in student enrollment with the abolition of fees to create universal access. As mentioned in Chapter 2, however, increasing deaths among teachers and parents or adult caregivers who can pay school fees have affected the quality of education (through interruptions in education; classroom overcrowding, which may be exacerbated by the desire to decrease the vulnerability of orphans and other vulnerable children by increasing school attendance; inadequate teacher training; and closures of schools). The numbers and characteristics of the school-age population have also been affected, as has the ability to attend school at all for children once they have been orphaned or otherwise made vulnerable as a result of HIV/AIDS (Africa Renewal, 1999, 2007; Earth Policy Institute, 2000; Bundy, 2003).

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×

The U.S. Congressional Research Service (CRS, 2005) cites a study conducted by Hepburn (2001), who found that a teacher who is HIV-positive may lose 6 months of teaching time before dying from the disease. In 2006, Namibia—the country with the smallest reported percentage (0.6 percent) of the global estimate of children orphaned and otherwise made vulnerable because of AIDS—reported that since 2005, it had lost a significant number of teachers to AIDS-related illnesses. According to the Namibian Ministry of Basic Education, Sport, and Culture, roughly 550 teachers annually will die of AIDS-related complications by 2011—fueling teacher absenteeism and leading to a decline in productivity (Kaiser Daily HIV/AIDS Report, 2006). One potential consequence of the deaths of teachers and the interruptions in school enrollment and attendance in many countries is that the countries may not reach their Millennium Development Goals in the area of education. Bundy (2003) has summed it well with the “HIV/AIDS education paradox,” in which “education is seen as the one of the most effective ‘social vaccines’ to prevent HIV/AIDS, but HIV/AIDS destroys education systems.”

Child Welfare

In August 2006, UNICEF published a companion paper to The Framework entitled Child Protection and Children Affected by AIDS, with the primary purpose of articulating the need to recognize social welfare as a basic part of social services and identify strategies for strengthening this sector to better address vulnerability, abuse, and exploitation. These strategies also include creating legislative frameworks to enforce protective laws; improving the formal care system; supporting and monitoring the well-being of children in informal care; and involving other sectors, such as justice, education, and health, to protect the needs of vulnerable children (UNICEF, 2006c). As most nations have agreed to international conventions on human and children’s rights, governments have a primary role of providing social services to vulnerable people and groups. Of particular importance, skilled staff in social service policy, strategic planning, and child welfare and coordination are critical to implementing any recommendation to provide social services. PEPFAR is strongly encouraged to ensure that social workers, child welfare workers, education leaders, law enforcement personnel, and teachers are accorded equal emphasis in human workforce development initiatives—both in in-service and preservice education efforts, and as part of partnerships between government and nongovernment organizations that may possess the expertise and skilled workers sufficiently and urgently needed to meet the needs of these children.

Suggested Citation:"7 PEPFAR's Orphans and Other Vulnerable Children Category." Institute of Medicine. 2007. PEPFAR Implementation: Progress and Promise. Washington, DC: The National Academies Press. doi: 10.17226/11905.
×
Training and Monitoring of Providers

While the Committee may have been able to ascertain the names of the implementing partners contracted to offer the training for providers of services to orphans and other vulnerable children from the Country Operational Plans, little information was available about the training facilitators or the curricula. Moreover, monitoring of the performance of these providers may have unique features. For some services, those trained may be facilitators or supervisors of others providing the actual service. For example, those trained do not provide educational services, but ensure that children are enrolled in school, have access to funds for educational fees if necessary, have the supplies needed, and participate actively in school. The training curricula may also vary considerably if caring for children involves awareness campaigns for birth registration; skills needed to navigate systems that provide or certify eligibility for services; and other issues related to child survival, such as immunizations and increased use of cotrimaxozole and other preventive care services. The Committee would also like to see more active monitoring of providers and services that include emotional and nutritional support for children.

CONCLUSION

The needs of children orphaned or otherwise made vulnerable by HIV/AIDS will continue to grow as the numbers of these children dramatically escalates as the pandemic continues. It is necessary for PEPFAR and other donors to continue to work with national leaders, families, communities, and organizations to focus their program and policy development efforts on ensuring the survival of these children—breaking the cycle of poverty, despair, disease, and death in which they have lived and seen loved ones die. Through these efforts, the U.S. Global AIDS Initiative can make positive and measurable contributions to the improved health, safety, vitality, and happiness of these children in the most appropriate environments for their development—families and communities.

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PEPFAR Implementation: Progress and Promise Get This Book
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In 2003, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act, which established a 5-year, $15 billion initiative to help countries around the world respond to their AIDS epidemics. The initiative is generally referred to by the title of the 5-year strategy required by the act--PEPFAR, or the President's Emergency Plan for AIDS Relief.

PEPFAR Implementation evaluates this initiative's progress and concludes that although PEPFAR has made a promising start, U.S. leadership is still needed in the effort to respond to the HIV/AIDS pandemic. The book recommends that the program transition from its focus on emergency relief to an emphasis on the long-term strategic planning and capacity building necessary for a sustainable response. PEPFAR Implementation will be of interest to policy makers, health care professionals, special interest groups, and others interested in global AIDS relief.

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