1. An Overview: Linda Richter Global Partners Forum, Dublin, 2 October 2008

2. What is JLICA? Diverse, independent, multidisciplinary, time-limited 4 Learning Groups (Framework) 40+ authoritative research outputs – all externally reviewed Thousands of inputs Providing solid evidence for bold action

3. Presentation The global response to date: Accepting our failures Reframing the response New directions for policy and action

4. Accepting Failures - 2007 17% of new infections – failures of vertical prevention 2.1m children living with HIV globally – 90% in SSA <10% of eligible children receive early diagnosis of HIV at 6 weeks co-trimoxasole or ARV treatment Increasing parental deaths  Only 15% children/families receive external help 

5. Children living with HIV globally 1990-2007 Global SSA

6. Orphaned children in SSA

7. Orphan misunderstandings AIDS orphans ±37% of orphaning – 18.2m orphans! 80% of “AIDS orphans” have a surviving parent “Orphan” - confusing, miscomm- unicated, distorting the response Orphans are not the only or necessarily the most needy 

8. Problems with data Lack of data – gaps (5-14 years) Not consolidated - age inconsistencies, across agencies Poor data – 71% of 273 studies don’t define orphan Proliferation of non peer-reviewed grey literature Available good data not well used or disseminated 

9. Child-headed households <1% in 40 SSA surveys Very small, if any, in DSS sites in SSA 0% in Karonga (Malawi) and Kisesa (Tanzania) <2% in Africa Centre (SA) Only data errors in Agincourt (SA) <1% across 5 cross-sectional HH surveys (1995-2005) (SA) 

10. October Household Survey 1995 (%) October Household Survey 1997 (%) October Household Survey 1999 (%) General Household Survey 2002 (%) General Household Survey 2005 (%) Note: Source: Own calculations based on Stats SA data. No child in household ----- No adult - only children 0.110.340.450.670.66 Skip-generation1.692.442.232.32.29 Young adult (18- 25) with children 1.221.861.711.882.27 Single adult with children 7.319.289.399.7111.27 Other89.6886.0986.2285.4483.52 Total100 Percentage of children living in different household types in South Africa (1995-2005) Source: Richter and Desmond 2008

11. Roots of our failure 1. It is not only orphaned children who are affected 2. Critical gaps in essential services 3. Families, many in extreme poverty, support children without assistance 4. Family poverty & gender inequality undermine children’s outcomes

12. 1. It is not only “AIDS orphans” … Parental mortality in general JLICA reviewed 383 “orphan” studies 75 empirical Consistent detrimental effects Neither poverty nor HIV controlled Effects adversity and/or ill-health? Education is a vulnerable area, but gap narrowing (data 15 countries) Stigmatising effects of targeting

13. 2. Implementation failures and gaps PMTCT, infant testing, prophylaxis, treatment Children much less likely to receive treatment than adults in the same settings Integration of HIV/AIDS services Universal primary health care Universal primary education

14. 3. Families support children HIV and AIDS cluster in families >95% of affected children live in families Only 15% receive external help Families absorb ±90% of cost of impact on children Families are a critical network to expand prevention, treatment & care

15. 4. Undermining child outcomes Family poverty + 60% of children in SSA live in poverty By very low poverty lines Kagera survey RIATT: $3.5/month average family of 3 HIV/AIDS impoverish families – 25%pm Consumption drops – food, education, care Child labour increases May limit expansion of prevention and treatment Gender inequalities Drive infections

16. Reframing the response Five key lines of action: 1.Support children through families 2.Build social protection to protect the weak and vulnerable 3.Expand income transfers to poor families 4.Implement comprehensive & integrated family-centred services 5.Address powerlessness of women & girls

17. 1. Support children through families Optimal care arrangement for children Most children are in family care Families have responded – at cost Preferable to orphanage/ group residential care  Families are a critical entry point for prevention, treatment & care Strengthen the capacity of families

18. Strong arguments against orphanages Cater overwhelmingly for poor rather than orphaned children Well-established negative effects on brain, language, cognitive, emotional & social behaviour Cost up to 10 times family care Opportunity cost of not investing in families De-institutionalisation is very costly to children & society

19. Strengthen families Family-centered PMTCT & other HIV/AIDS interventions Keep families intact through treatment Support extended family fostering Provide home health visiting & ECD Support community organizations that backstop families Build social protection 

20. 2. Build social protection Individual, family & social impoverishment makes it harder to prevent HIV & mitigate AIDS Responds to children’s needs – cut consumption, schooling, care and increase labour & mobility On developmental agenda & responds to popular concerns HIV/AIDS adds impetus to human rights arguments

21. 3. Expand income transfers Provide relief, avert borrowing, sale of assets Demonstrated effectiveness in poor countries Can take variable forms Affordable eg Mozambique, Lesotho Reduces intermediaries, overheads Enables uptake of essential services The entry point for improved social protection

22. Transfers increase spending on children’s basic needs Source: Adato and Bassett, 2008 JLICA

23. 4. Integrated family-centred services Income transfers increase use of services. JLICA review of successful programmes: Partnerships under government leadership Community-based care system linking medical & social support services HIV/AIDS services integrated with poverty reduction (income transfers, job creation) Community health workers Funding commitments (least 5 years)

24. 4. Structural changes for girls Empower women through increased social protection & income transfers Keep girls in school – secondary education Increase physical safety of girls Address men’s values, roles and prospects – work

25. Directions – way forward National social protection, starting with income transfers, is critical to improve children’s outcomes Target programmes based on need, not HIV or orphan status Adopt family-centered models in social policy & service delivery Prioritize structural prevention measures to address gender inequalities

26. The Joint Learning Initiative on Children and HIV/AIDS on Children and HIV/AIDS www.jlica.org