Keeping parents living with HIV alive International Social Protection Conference Arusha December

Kwa Wazee – Nshamba Experience in Social Cash Transfers Since 2003: Payment of pensions to 1’150 older people (TZS 14’500/=) and child benefits to 750 grandchildren (TZS 7’000/= each) Since 2009: Cash transfer to PLWHA to 350 PLWHA (among them 85 children) Since 2011: Micro-Loans to PLWHA-groups (around 1’000 participants)

HIV/AIDS:Change of the paradigma BEFORE ART: Terminal illness Requirement of intensive but short end of life care Leaving behind a growing number of orphans

AFTER ART (in Muleba accessible since 2006) Shift from fatal to chronic life-long disease > living with a “fragile body” and volatility of health Requires a long-term day-to-day illness management including self-care and adherence. Children live a long(er) time with their parents. They are included and often a main pillar in the day-to-day illness management within the family. Disclosure to the children becomes the norm. HIV/AIDS:Change of the paradigma

Stages of strategies in Household Economy Stage 1: Used strategies are reversible and have little impact on earnings of the household (e.g. switch to low maintenance food crops, borrowing small amounts, selling chicken etc. Stage 2: The impact of the strategies are difficult to reverse (e.g. selling land, borrowing at high interest rates Stage 3: Destitution of the household and break down of the family

Case-study P.I.: CD4 80, not capable to work, his wife E. has a CD4 647 and the child D., three years old, is HIV+ N.C.: CD4 70, blind, husband died in October 2013, 7 children, one with epilepsy F.H.: CD4 71 and H.Y. CD4 320, 4 children, the oldest 12 years old

ART is not enough Main hypothesis guiding the PLWHA program in Nshamba: ART is a NECESSARY but not a SUFFICIENT condition to keep the parents living with HIV (mostly female headed households) alive

Rationale to underpin the hypothesis WHO assumes a high level of non-adherence to ART in ASS. Reasons are To become hungry and have not enough food No money for transport to the hospital Stigma Surveys in Rwanda and Tanzania suggest that lack of food is a major reason NOT to seek treat- ment for HIV/AIDS (WFP)

ART + cash transfer = adding value to ART 1.Cash transfer as a continuous, expectable and steady flow of small amount can add value to ART and keeping parents alive. 2.Cash transfer is the leading edge and the floor for a broader social protection agenda: rebuilding assets, building social capital and developing the human capital of the next generation

Impact Before getting sick Before joining the project but on ART December 2011 Working capacity Food Keep animals Savings Social Integration 738.3

Impact FGD: Health has improved, CD4 and weight increased We are less stressed – we get food for our families and children The concerns about the school of the children have decreased We found new friends

The issue of “promotion options” The PLWHA-program will not lead to “graduation” in terms of a definitive exit from poverty, but perhaps from extreme vulnerability. According to the recovery of health “promotion options” can be offered - this in the absence of a (national) social protection program for PLWHA. In Kwa Wazee the loan program has this function.

“Ecological” understanding of ART+ Includes a strong focus on the children as “CARERS” in the day-to-day illness management: - household chores -economic support (including begging) -health support e.g. reminding take medication -personal care -emotional support

An additional aspect of “protection” Girl-children who are affected by HIV and AIDS seem to be extremely vulnerable to sexual violence. Example: out of the 62 girls attending a training in Self-Defense 50% had experiences of rape (30%) or attempted rape. (National survey: 6%). Kwa Wazee offers Self-defense for girls and “Peace is a Decision” for boys.

Conclusions and lessons learned ART+ enables the continuation of the family care as the first line for protection of children – helps to stop the “orphan crisis” ART+ will contribute to preserve the productive capacity of PLWHA and help to rebuild financial, social and human capital ART+ supports the integration of PLWHA in the society

Who will buy in? Kwa Wazee is a social “laboratory” developing and testing models and approaches. Experimenting! But who will buy in into the reflections? MKUKUTA – “National Strategy for Growth and Reduction of Poverty”? Cluster1: “Growth and reduction of Poverty”?

MKUKUTA Cluster 2: “Improvement of quality of life and social well-being including expanding social protection for vulnerable groups”? National Multi-Sectoral Strategy for HIV and AIDS? Nobody?

ASANTE