1. Community Responses for Children Affected by AIDS Challenges for the Future! RIATT Satellite – ICASA 2011 Dr Chewe Luo Senior Adviser HIV/AIDS, Team Leader Programme Scale up, HIV Section, Programme Division, UNICEF

2. Outline of Presentation 1.Context 2.Progress 3.Response Framework 4.Models of Care 5.Lessons Learned 6.Challenges 7.Recommendations

3. Context: Estimated number of children who lost one or both parents to AIDS & adult HIV prevalence - Africa & global, 1990-2009

4. SIGNS OF PROGRESS T RENDS IN ORPHAN AND NON - ORPHAN SCHOOL ATTENDANCE RATIOS IN SELECTED COUNTRIES, 1997–2008

5. Community & faith-based organisations at the forefront of responding to affected children – but often in isolation from government policy & services, small scale. Inadequate support reaching households with OVC: median 11% of households receive external support, 17 countries in East & Southern Africa have National Plans of Action for OVC – but little scale up & not integrated with national development plans. Lead Ministries of CABA response have insufficient human, financial, & institutional capacity. BUT Still need for more effective and accelerated response for CABA

6. THE FRAMEWORK for the Protection, Care & Support of Orphans & Vulnerable Children Living in a World with HIV/AIDS (2004) 1.Strengthen the capacity of families; 2.Mobilize & support community- based responses; 3.Ensure access to essential services; 4.Ensure that governments protect the most vulnerable children; 5.Raise awareness through advocacy & social mobilisation.

7. Key Themes in Taking Evidence to Impact: 1.Child vulnerability in the context of HIV. 2.Child-sensitive social protection to broaden coverage & sustain responses for CABA. 3.Strengthening national social welfare systems for all vulnerable children. 4.Increase aid effectiveness of programmes, services & funding. 5.Families and communities at the center of response. 6.Equity and rights – reaching the unreached TAKING EVIDENCE TO IMPACT: MAKING A DIFFERENCE FOR VULNERABLE CHILDREN LIVING IN A WORLD WITH HIV AND AIDS

8. HOW HIV AND AIDS CAN AFFECT CHILDREN ACROSS THE LIFE CYCLE Adapted from Wakhweya, A. 2003 and Robbins, D. 2003 Further increase in responsibilities as they assume role of provider and caretaker Exclusion from education Poor self-esteem Sexual abuse/pregnancy STIs including HIV Exclusion from formal employment ADOLESCENTS Becoming caretakers for parents and siblings Losing school access Increasing awareness of stigma Physical and verbal abuse Depression Increasing work load (Child Labour) SCHOOL AGE CHILDREN Loss of social contact and stimulation Begin to experience trauma and loss Poor nutrition and growth Exposure to abuse Frequent infections PRE-SCHOOL CHILDREN Exposure to mother to child transmission through birth & breastfeeding Frequent Infections Poor Nutrition Poor Growth Emotional Deprivation Development Delays INFANTS

9. MODELS OF CARE WITH AND THROUGH THE COMMUNITY

10. Case Study: INFANTS “Mothers2Mothers” model 8 country program reaching 275,000 HIV positive pregnant women and new mother (2010) Recruiting, training, and employing mothers living with HIV who have personally received PMTCT care. Support patients to understand, accept, and adhere to interventions that are prescribed. M2M has introduced a new tier of paid, professionalized health care providers – drawn from, trained in and serving on behalf of local communities – closing gaps in health care delivery.

11. Case Study: Pre-School Children “ Community-based Care Centres in Malawi” 1.In 2,000 centres run by community caregivers reaching over 200,000 vulnerable children between the ages of 3 – 5 years receive: early stimulation, food/nutrition, psychosocial support, play and school readiness 2.Contribution has assisted in addressing issues of stigma and discrimination by all children attending 3 Assisted to provide protection and care to vulnerable children while guardians undertake other activities.

12. Case Study: School Age Children “Child Protection Networks in Angola” 1.Run in 18 provinces in Angola reaching over 20,000 children these community volunteers: serve as surveillance and referral systems support tracing and social reintegration programme of children Support child participation Child radio programmes and child-friendly spaces Facilitate access to birth registration Ensure access to public schools and Vocational training 2 Recognised by Government as a part of the vulnerable children response through the National Children Plan and inform the development of Municipal Development Plans

13. Case Study: Adolescents “Baylor Teen Club” in Botswana 1.Reaches HIV-positive adolescents (50.7% girls) aged 13 – 15 years with: psychosocial support life skills through club activities and ` events and; peer education activities addresses the increasing numbers of children who grown up on treatment since HIV infection in infancy through mother-to-child transmission 2. Addresses issues of drug adherence, peer support and living positively as teens enter into a sexually active age.

14. Case Study: “Investment in the community is crucial to maintain quality of care” A recent evaluation has some impressive findings: high completion rates (89.5% overall) and student retention rates of very nearly 90%. training has had a “profound positive influence on the students and the majority have shown a growing awareness of what is involved in a human rights-based approach to care for vulnerable children in their own contexts.” The Supported Open Distance Learning Course led by REPSSI provides an exciting and innovative approach to developing the capacities of carers of vulnerable children in the region.

15. Lessons Learned: 7 Factors Contributed to the Effectiveness and Sustainability of Community- Based Child Focused Groups (Wessells) 1.Community ownership and responsibility 2.Incorporating and building on existing resources 3.Leaders’ support 4.Genuine child participation 5.Ongoing management of issues of power, diversity, inclusivity 6.Resourcing—ongoing training/capacity building, material support 7.Linkages—engagement with formal and nonformal, traditional systems

16. Challenges Many challenges but four highlights: 1.HIV Investment Framework: Defining and costing the critical enablers and synergies through community action work 2.Decreasing AIDS resources calls for a time of evidence-informed, prioritized, costed, and focus on efficiency and effectiveness interventions.(Schenk 2008) 3.Increasing linkages between ‘OVC responses’ and HIV specific prevention and treatment interventions e.g. referrals from community child welfare committees to treatment/PEP or referrals from clinics to psychosocial support 4.Demonstrating the impact of CBO responses for vulnerable children and understanding the relative value of civil society providing particular types of service or working with particular communities or children, versus investment in enhanced government service delivery

17. CRITICAL ENABLERS For Whom?: explicitly identify and prioritize on populations, geography, Age, Sex… Generalized Epidemic Social Protection, Education, Health Systems, STI treatment, Blood safety, Gender, Legal reform, Poverty reduction, Employer practices MAJOR SYNERGIES Outcomes Political commitment /Advocacy Management, M&E, Procurement Research and innovation Community mobilisation Testing, counselling and referral Stigma reduction Gender violence/ local response impacting exposure Laws, legal policies and practices Incentives Mortality and morbidity Risk reduction Likelihood of transmission Male Circumcision Sex Work Interventions PMTCT Treatment and care (incl. facility–based testing) Condom procurement, promotion and distribution CORE INTERVENTIONS Behaviour change communication

18. Recommendations Elimination Plans: Identify and cost models of care that contribute towards Strengthening the Evidence Base through Impact assessments and evaluations to convey the viability of community interventions which should then be taken to scale Operationalizing vulnerability (making sure we’re reaching the neediest with what they need most) Breaking Out of Our Silos: – Reaching OVC with Prevention/ASRH interventions – Reaching MARA and EVA with comprehensive protection – Reaching PMTCT/paediatric AIDS clients (& families) w/ protection – Reaching HIV+ OVC with AIDS treatment

19. THANK YOU !