1. A snapshot of the situation of children in SA Sonja Giese Yezingane Network Summit 2009

2. Child population A child is a person under the age of 18 years There are over 18 million children in SA Children make up 40% of the total population Two thirds of all children live in 4 provinces – – KZN (22%) – EC (16%) – Gauteng (16%) – Limpopo (14%)

3. Situational analysis of children Infant / child mortality (and the link to HIV) Prevention of mother to child transmission Provision of post exposure prophylaxis following rape Access to treatment for children Maternal health Access to treatment for adults Orphaning and child care arrangements Child poverty Social services

4. Infant mortality In 1992, the infant mortality rate was 43 per 1000 live births In 1998, this had increased to 63 per 1000 live births There is NO reliable national data on infant mortality since 1998! However information from demographic surveillance sites suggest that IMR has continued to climb since 1998. In order to meet MDG for IMR by 2015, SA’s IMR should have been reduced to 14 deaths per 1,000 live births by 2009.

5. Child mortality and HIV 57% of deaths of children under the age of 5 during 2007 were as a result of HIV Babies who are HIV-positive are 15 times (1500%) more likely to die within the first six months of life than uninfected babies. Child health is therefore interwoven with HIV-prevalence among pregnant women Prevention of mother to child transmission is critical

6. 6 HIV prevalence amongst antenatal clinic attendees

7. Antenatal summary In 2008, the average antenatal HIV prevalence was 29.3% Pockets of prevalence over 40%! Highest prevalence amongst women aged 25 to 34 years

8. PMTCT services The PMTCT programme is a comprehensive health service package which aims to prevent HIV transmission from mother to Child. It includes: routine voluntary HIV counselling and testing to pregnant women labour practices that minimize the risk of HIV transmission dual- or triple antiretroviral drug combinations to the mother during pregnancy and labour and a daily dose of Zidovudine (AZT) to the baby for the first week after birth a single-dose of nevirapine (sd-NVP) to the mother if she is not taking triple therapy, and to the baby immediately after delivery safe infant feeding counselling and support to pregnant women and mothers infant formula to women who choose not to breast feed and who are able to formula feed safely in an acceptable, affordable and sustainable way.

9. PMTCT access and child outcomes The proportion of women attending public antenatal clinics who receive HIV testing has increased dramatically between 2001 and 2007 – from 6.9% to 69.2% Nevirapine (NVP) uptake has also increased to 65% of HIV- positive pregnant women in 2007 This exceeds the NSP target of 60% for that year Data are not available from most provinces on access to dual therapy / HAART (as recommended by new PMTCT guidelines) Data on child outcomes (i.e. proportion of babies born to HIV- positive mothers who test HIV-negative at 3 months) are also not available for 8/9 provinces.

10. Post exposure prophylaxis Children who are raped are at high risk of contracting HIV Risk of HIV-infection for an HIV-negative child is reduced if child gets ART (post exposure prophylaxis) within 72 hours of the rape Data on access to PEP not consistently collected or publicly available In Gauteng in 2008/2009 ~1 in 5 eligible children who had been raped did NOT receive PEP (82% did) No NSP target for access to PEP – 100%?

11. ART access - children For children who acquire HIV, it is critical that treatment starts early Without treatment, >40% of children who are infected as babies will die before their 1 st birthday ART coverage increased from 26% btw mid-2006 and mid-2007 to 36% the following year Exceeding NSP target ~ 35% Provincial variance: 22% in FS to 97% in WC But access to ART over this period improved in all provinces

12. Maternal health AIDS is leading cause of maternal mortality Life expectancy in SA is 56 years (females) Actuarial Society of SA estimate life expectancy in South Africa to be 13 years below what it would be without HIV Access to treatment for adults is an important part of the service response to children

13. ART access - women Access to ART in adults in SA improved: – 40% in mid-2006 to mid-2007 – 54% in following year In both periods, ART access exceeded NSP targets (24% in 2007, 35% in 2008) However, large unmet need - 120,000 women who developed AIDS did not start treatment Do we need to review our targets? Provincial variability, although all provinces exceeded treatment targets

14. Orphaning Largely as a result of HIV and AIDS, there were ~ 3.7 million orphans in SA in 2007 This equates to 20% of the child population! Includes children who have lost one or both biological parents Important to disaggregate because different impact: ~ 600,000 maternal orphans ~ 700,000 double orphans ~ 2,360,000 paternal orphans In 2007, half of all orphans lived in EC and KZN 1 in every 4 children in EC, KZN and FS have lost one or both parents Total number of orphans has increased substantially ~ 700,000 more orphans in 2007 than in 2002

15. Care arrangements for children In terms of living arrangements: – 34% of children live with both parents – 40% live with mothers, but not fathers – 3% live with fathers, but not mothers – 23% live with neither parent (yet 83% of these children have at least one surviving parent) Young children (0-5 years) are more likely to be living with their mothers than older children Importance of early access to birth registration and grants

16. Child headed households In 2007, there were 150,000 children living in a total of 79,000 child-only households (defined as all members younger than 18) 49% of these children were older than 14 years Despite significant increases in the number of orphans between 2002 and 2007, the proportion of children living in CHH has not increased.

17. Child poverty SA has very high rates of child poverty Nearly 7 million children live in households where no adult is working In 2007, two-thirds of children (68%) lived in households with an income of less than R350 per person per month This has reduced from 77% in 2002 However, in EC and Limpopo ~ 80% of children live in such households 37% of children live in households without water on site Despite improvements to sanitation services over the past six years, 41% of children still use unventilated pit-latrines, buckets or open land

18. Access to poverty relief Child Support Grant is primary poverty intervention for children Uptake of CSG has increased dramatically over past decade ~ 86% of eligible children (under 14 years) were accessing the CSG in 2007 Grant access far lower for children under 1 year (~60% of eligible children) Substantial evidence that grants used for food, education and basic goods and services Early access to CSG needs to be promoted

19. Social services Goal of NSP – provide care and support to 80% people with HIV and their families One measure of capacity for care and support is the number of registered social workers relative to need Number increased from 11,372 (2005) to 14,322 (2009) However, by 2011 we need over 60,000 social workers to fully implement Children’s Act alone Action needed to address shortfall, including recognition and remuneration for broad spectrum of social service providers

20. In summary There is an urgent need for more and better information on service delivery and child outcomes related to HIV and AIDS More needs to be done to ensure access to dual therapy and HAART for HIV-positive pregnant women. We have done well in reaching our treatment targets (children and adults). However, targets need to be brought in line with need. We need to substantially increase the capacity of our care and support systems to ensure that we meet the NSP targets by 2011. This includes early access to social grants (before child is 1 year) South Africa is far from meeting our target for reduced infant mortality. Absence of reliable annual data on IMR is a critical gap. Special attention needs to be paid to provincial inequalities in service access and child outcomes.

21. Information drawn from Scorecard 2009, Yezingane Network South African Child Gauge 2008/2009, Children’s Institute, UCT Situational analysis of children April 2009, the Presidency HIV and AIDS: Business as usual?, Media briefing by Minister of Health, Nov 2009