Saving Children, Enhancing Lives. Combating HIV and AIDS in South Africa

Transcription

1 Saving Children, Enhancing Lives Combating HIV and AIDS in South Africa

2 UNICEF/Rebecca Hearfield Cover photo UNICEF/Giacomo Pirozzi This publication was prepared and edited by the UNICEF South Africa Programme team, with the assistance of Osei G Kofi, communication consultant. Print production and design by Handmade Communications. b

3 SAVING CHILDREN, ENHANCING LIVES Combating HIV and AIDS in South Africa CONTENTS THE CONTEXT 2 THE CHALLENGE 3 THE SOLUTIONS 4 1. HALTING THE SPREAD OF HIV AMONG YOUNG PEOPLE THROUGH LIFESKILLS AND RESPONSE TO SEXUAL VIOLENCE 5 2. SCALING UP PMTCT-PLUS TO PREVENT CHILDREN FROM CONTRACTING HIV AND FROM BECOMING ORPHANS 9 3. SAVING INFANTS LIVES THROUGH EARLY HIV TESTING AND EFFECTIVE PAEDIATRIC ARV TREATMENT SUPPORTING SAFETY NETS TO CARE FOR ORPHANS AND VULNERABLE CHILDREN 17 SUMMARY BUDGET 21 1

4 THE CONTEXT The Government of South Africa is now implementing the biggest comprehensive plan for the management, treatment and care of HIV and AIDS in the world. Latest estimates put the number of treated HIV-positive clients on antiretrovirals at about 130,000, ahead of Brazil with about 120,000. The Government has also demonstrated an enormous financial commitment to achieve the objectives of the comprehensive plan. Still, there are gaps between the urgent needs of clients eligible for treatment and actual achieved numbers, and these indicate that there are numerous programmatic bottlenecks at all levels which need to be addressed urgently. It is clear that some of these challenges, one of which is the employment of South African health staff by other countries, can only be addressed in the longer term. However, there are also challenges which can be addressed immediately and with success. Health workers need to be mentored in the adminstration of antiretroviral treatment in children. District institutions, including hospitals and clinics, can learn in a relatively short time how to improve efficiency and effectiveness in delivering essential services. National co-ordination can be supported to quickly increase capacity of provinces to scale up early diagnosis of HIV in young children. Critical orphan care and support programmes need better targeting and uptake, etc. In the context of South Africa, UNICEF s engagement has to be strategic, informed by the rights and needs of children, while focusing on the organization s comparative advantages and its institutional ability to add value to government efforts. In this respect, UNICEF will focus in the immediate future on: prevention efforts through lifeskills and response to sexual violence; scaling up quality PMTCT; early diagnosis and treatment and supporting safety nets for orphans and vulnerable children. It is clear that external assistance needs to be complementary to the massive resources the South African Government commits to implement the comprehensive plan. These external resources need to be the thin layer of oil that will make the engine run much more smoothly and efficiently. UNICEF aims to use its resources to exemplify that role, by ensuring that certain district models of early diagnosis and treatment of children do work, that improved coordination is supported at different levels, that promising innovations are explored immediately and that, in the end, we keep reminding ourselves and our partners that the child can not wait. 2 UNICEF/Shelley

5 THE CHALLENGE Half of South Africa s HIV-positive infants die before their second birthday around 50,000 each year. 10% of the country s children have lost at least one parent to AIDS and are struggling to receive basic care and support. Some 5.4 million, or 11.4% of the 47 million population of South Africa, are infected with HIV. HIV and AIDS is now the greatest killer of children under five in South Africa. About 260 children are born HIV-positive every day and most die before their second birthday. The high mortality rate stems partly from the simple fact that their HIV status is rarely diagnosed, and subsequently, not treated despite increasing availability of life-prolonging antiretrovirals (ARVs) that would have helped them survive and lead a relatively healthy life. HIV-negative children born to HIV-positive mothers are extremely vulnerable too. Studies indicate they are up to four times more likely to die than infants of HIV-negative mothers. This is partly because AIDS-stricken mothers are often unable to provide adequate emotional and financial care and nutrition. The HIV infection rate is 29.5% among pregnant women visiting antenatal clinics countrywide, but this rate masks major differences between provinces. For example, in KwaZulu-Natal the infection rate is 40.7% amongst pregnant women, while in the Western Cape it is 15.4%. A most frustrating aspect of the high incidence of AIDS in South Africa is that it is avoidable. The quality of the South African health system in most of the urban centres can be likened to those in industrialized societies. The challenge in South Africa is the overwhelming numbers involved in the epidemic. Some 300,000 babies are born to HIV-positive mothers annually, a far higher caseload than in other industrialized societies. The situation is compounded by the fact that townships and rural areas, where the majority of the people live, lack the first world health systems of the urban areas. Improving these disadvantaged health services to deliver HIV drugs and treatment will also result in stronger overall health systems to combat other diseases, which actually cause 60% of child mortality in South Africa. Recent dramatic results from the use of ARVs in industrialized countries indicate the possibilities of the programme and prove that AIDS can be managed like other preventable Under one boys N=40608 Under one girls N= % HIV/AIDS 33.7% 15.9% 10.8% 7.4% 5.8% 3.9% 3.6% 3.4% 1.4% 1.2% Low birth weight Diarrhoeal diseases Other perinatal respiratory conditions Lower respiratory infections Neonatal infections Birth asphyxia and trauma Protein-energy malnutrition Congenital heart disease Neural tube defects 15.0% 11.0% 7.1% 6.3% 3.7% 3.1% 3.2% 1.5% 1.1% LEADING CAUSES OF DEATH AMONG INFANTS UNDER 1 YEAR OF AGE, SOUTH AFRICA

6 diseases such as malaria and measles. Effective PMTCT-plus programmes can lower infection rates. Efficient ARV therapy can provide HIV-positive children with a decent life. The crux of the challenge in South Africa lies in how to transmit the available technological advantages to an infected population many times larger than the numbers in industrialized societies. However, if any country in Africa can rise to the challenge to confront the overwhelming health needs of a developing world with the high-tech approaches of an industrialized country, it is South Africa. The country is uniquely poised to achieve a breakthrough in HIV prevention and treatment. Indeed, the South African Government has a National Comprehensive Plan for the Prevention, Care, Treatment and Support for HIV and AIDS, STIs and TB to combat HIV and AIDS but its potential for full progress has yet to be realized. THE SOLUTIONS UNICEF proposes four core strategies to assist the Government of South Africa in the fight against HIV and AIDS. The gains from these interventions will act as an example of what is possible in the entire sub-continent. Moreover, improving health systems for HIV and AIDS provides an excellent platform from which to enhance services to combat all diseases, which cause 60% of under-five mortality. The strategies are: 1. HALTING THE SPREAD OF HIV AMONG YOUNG PEOPLE THROUGH LIFESKILLS AND RESPONSE TO SEXUAL VIOLENCE 2. SCALING UP PMTCT-PLUS TO PREVENT CHILDREN FROM CONTRACTING HIV AND FROM BECOMING ORPHANS 3. SAVING INFANTS LIVES THROUGH EARLY HIV TESTING AND EFFECTIVE PAEDIATRIC ARV TREATMENT 4. SUPPORTING SAFETY NETS TO CARE FOR ORPHANS AND VULNERABLE CHILDREN This document elaborates on each of the four strategies, including an analysis of the situation, proposed activities, and a budget for the first year of the United Nations Global Campaign on Children and HIV and AIDS. Together with the Government of South Africa UNICEF has the ability, through its partners, such as bilateral donors, foundations, multilateral agencies and civil society, to promote, facilitate and fund actions to save children s lives. 4 UNICEF/Giacomo Pirozzi

7 UNICEF/Giacomo Pirozzi 1. HALTING THE SPREAD OF HIV AMONG YOUNG PEOPLE THROUGH LIFESKILLS AND RESPONSE TO SEXUAL VIOLENCE Key results for children and adolescents 550,000 children and adolescents, especially orphans and vulnerable children, have the life skills to prevent HIV infection and gender-based violence. Families, schools, communities and municipalities in three provinces will be mobilized and have the capacity to prevent, detect and respond to violence against children and women. Issue The HIV and AIDS epidemic in South Africa is devastating many parts of society but it particularly affects the most vulnerable women, children, young girls and boys. Infection rates among young people remain high but experience from other countries has shown that reducing infection rates among youth can result in lower death rates in a population over the medium and long term. In South Africa, HIV infection is compounded by high rates of sexual violence, through which HIV is often transmitted. National indicators for 2004 reveal that 245,000 children between the ages of 2 and 14, and 736,000 young women and 225,000 young men between the ages of 15 and 24 are 5

8 living with AIDS, with female prevalence for this age group being almost three times that for males. In many cases, HIV is transmitted through rape. The latest South African Police Services Annual Report reveals that in the 2004/2005 financial year, 40% (22,486) of the 55,114 rapes were against children and that at least 60 children under the age of 18 are sexually abused and raped every day. Numbers have increased at least in part due to the fact that more cases are being reported. However, even the police fear that this still only represents the tip of the iceberg, as they suspect that as much as two-thirds of all rapes may not be reported in part due to the survivor s economic dependence on the perpetrator. Furthermore, the school environment in South Africa is witness to dangerously high levels of violence, especially against girls, a matter of urgent concern in the fight against AIDS. Many girls report that they are afraid of their teachers or of assault while using toilets or walking long distances to school. Moreover, sensitive issues such as gender, sexuality, lifeskills and HIV and AIDS education are not openly and freely discussed either at home or at school. Reticence to bring such pressing issues to the surface has a devastating impact on the youth of South Africa. Ultimately, it is only through a combination of interventions that include information, education, lifeskills, anti-rape services and the will of young people to adopt and practice safe behaviours, supported by their communities, that HIV infection rates in adolescents will decrease. Action Lifeskills to prevent violence and HIV infection Information alone will not change young people s behaviour. Lifeskills are needed from the earliest possible age to help young people translate theory into practice and empower young boys and girls to negotiate life. They will then be able to make choices themselves regarding sex, drugs, alcohol abuse and other related development issues. 6 UNICEF/Mandla Zulu

9 The Girls Education Movement (GEM) and the Lifeskills programme in schools and communities, adopted by South Africa in 2004, encourage safe behaviour and contribute to the prevention of gender based violence and new HIV infection. There are currently 1,464 GEM clubs in the three provinces supported by UNICEF through which 30,000 children and adolescents are reached. In addition, there is an outcry from young South Africans in the GEM Agenda for the abolishment of harmful cultural practices that promote the spread of HIV. Youth workshops UNICEF also supports youth leadership and strategy development workshops through which young people are empowered to speak out and confront the challenges they face, including the threat of HIV and AIDS. These workshops act as catalysts to preparing youth action plans on HIV prevention, to be costed and included in municipal integrated development plans. Combating violence against children and women UNICEF supports the Government of South Africa s four-part anti-rape strategy: prevention of violence against women and children; response; care and support for survivors of sexual abuse. As part of the strategy, UNICEF supports Thuthuzela Care Centres (TCC) in public hospitals and clinics, linked to sexual offences courts in communities where the incidence of rape is particularly high and in areas critically affected by HIV and AIDS. Working together, the Thuthuzelas and the courts offer sexual assault survivors the services of committed police, prosecutors, social workers, investigating officers, magistrates and health professionals. In terms of HIV prevention, the centres offer voluntary counselling and testing, a critical service for HIV prevention. Thuthuzela staff also provide post-exposure prophylaxis (PEP) to HIV-negative rape survivors to prevent possible transmission of HIV. Furthermore, increased conviction rates of sexual offenders decrease the probability of HIV-positive rapists infecting other women through repeat assaults. In addition, UNICEF intends to support a range of efforts to reduce child abuse, including sexual abuse. A number of interventions are under development and will be scaled up and accelerated during Impact Lifeskills and GEM The proposed strategies will contribute to the broadening and strengthening of the Lifeskills programme for South African girls and boys. By giving children and adolescents improved tools to help them avoid and resist gender-based violence and HIV infection, UNICEF continues to contribute to behaviour development and change in young South Africans. The Lifeskills project will reach all GEM clubs supported by UNICEF in the three focal provinces of Eastern Cape (105 schools), KwaZulu-Natal (1,275 schools) and Limpopo (84 schools). During 2006, UNICEF plans to scale up Lifeskills activities in the Schools as Nodes of Care and Support strategy in KwaZulu-Natal. By the end of 2006 it is expected that GEM will be fully functional in all the schools in the Eastern Cape. In Limpopo, the GEM and Schools as Nodes of Care and Support strategy will reach 1,500 schools. Overall, it is expected that 550,000 children and young people, especially orphans and vulnerable children, will be reached. Youth workshops Three youth leadership workshops reached 110 young people in 2005 in Limpopo, Kwazulu- Natal and the Eastern Cape. Four youth strategy development workshops reached an additional 140 young people in the Eastern Cape and Limpopo. Because these young people are catalysts for change amongst their peers, the HIV messages ultimately reach at least 5,000 youths. Moreover, there is a strong chance that HIV and AIDS prevention will have a prominent place in the municipality s budgeting priorities. UNICEF will expand on these models of youth development in 2006 by working with additional youth groups to advocate for more HIV funds in municipal budgets. 7

10 Combating violence against children and women Currently, there are 12 Thuthuzelas functioning in South Africa linked to 60 child-friendly sexual offences courts, 20 of which are supported by UNICEF. During , the programme supported by UNICEF has trained over 3000 prosecutors, police officers, health workers, medical doctors, social workers, magistrates, police officials, teachers, and community volunteers. As a result of the work of the sexual offences courts perpetrator conviction rates have increased, and lead time for finalizing cases has significantly decreased from approximately 3-5 years, to less than 6 months today, thereby keeping greater numbers of sexual criminals off the streets. UNICEF proposes the following activities to increase the Lifeskills, Thuthuzela and Youth Workshop programmes: Activities and budget PROJECT ACTIVITIES COST US $ 550,000 adolescents have the lifeskills to prevent HIV infection and genderbased violence Youth workshops Combating violence Conduct leadership programmes in school holidays to increase the number of children participating in Lifeskills programmes, GEM, Soul Buddyz, and Youth Friendly Spaces to 150,000. Train 50 trainers of trainers in each of seven districts to develop lifeskills, leadership skills, and creative facilitation skills aimed at dealing with child abuse. Create training modules for parents, school governing bodies and peer educators on gender, sexuality and preventing HIV infections. Train 3,000 peer educators, 150 school governing bodies, including parents and caregivers. Assist young people, orphans and vulnerable children (OVC), girls, adolescents, out of school youth and caregivers to create a strategic plan for intergenerational dialogue about gender, sexuality, reproductive health, gender-based violence, and HIV prevention. Conduct operational research to identify barriers to girls and OVC exercising their right to education and freedom from gender-based violence and new HIV infections. Develop, test, and implement an assessment tool to gauge the impact of lifeskills education on the lives of adolescents and on social change in communities with specific relevance to HIV and AIDS. Assist youth groups in three provinces to create and monitor additional youth-focused HIV plans in municipal integrated development plans and budgets. Support the scaling up of Thuthuzela Care Centres to reach additional women and children. Accelerate and scale up efforts to prevent and respond to sexual abuse of children. 140, , , ,000 35,000 60,000 60, , , ,000 Project support 145,000 Indirect recovery cost 217,500 TOTAL 1,812,500 8

11 2. SCALING UP PMTCT-PLUS TO PREVENT CHILDREN FROM CONTRACTING HIV AND FROM BECOMING ORPHANS Key result for children Double the number of HIV-positive pregnant women receiving ARVs by the end of Improved nutritional status of mothers and young children at risk of contracting HIV. Issue Of the 1.1 million babies born every year In South Africa, 300,000 are born to HIV-positive mothers. About 93,000 of these babies will be infected by HIV, with 72,000 born HIV-positive and 21,000 born HIV-negative who will become positive through breastmilk. 50% of those will die before their second birthday if no effort is made to prevent mother to child transmission (PMTCT). At present, only some 20% of HIV-positive pregnant women participate in PMTCT programmes and receive ARV treatment which can prevent them from infecting their babies. Estimates place about one third of all child mortality in South Africa within the neonatal period, and AIDS-related deaths at 40% of childhood deaths before the age of five. 9 UNICEF/Rebecca Hearfield

12 UNICEF recognizes that the solution to the alarming infant and under-five death rates lies in effectively tackling the number of children who are infected before, during or after birth. Two interventions are critical to reducing infection in babies and saving mothers lives: 1) improving the efficiency of PMTCT-plus systems so that ARV treatment actually reaches mothers and babies and 2) encouraging appropriate infant feeding and other aspects of nutrition to ensure healthy babies. In addition, UNICEF will explore how mothers care practices for young children with AIDS affect their infants development. Current evidence indicates that PMTCT programmes are not yielding optimal benefits, despite increasing availability of life-prolonging ARVs. HIV prevalence rates of 6 week old infants at immunization clinics in the province of KwaZulu-Natal, for example, suggest that there is a high rate of vertical transmission. Infant and child mortality rates in these clinics have increased threefold over the last 15 years, probably in part due to the fact that not all pregnant women learn of their HIV-positive status. They either choose not to be tested or are not able to access satisfactory services. For the significant number of HIV-positive women who do not access PMTCT services, their antenatal care is no different from that of low risk women. Moreover, the present ARV regimen (a single dose of nevirapine) used in the PMTCT programme may not produce optimal results due to concerns about resistance and the short time period during which it can be taken. In addition to ARVs, nutritional aspects play a key role in preventing HIV transmission and in maintaining the mother s health. HIV-positive women have a greater risk of intrauterine growth retardation and premature birth, which are exacerbated by high viral loads and low CD4 counts. Small babies are often stunted and may not reach their intellectual 10 UNICEF/Giacomo Pirozzi

13 and physical potential, especially in resource poor settings. In many cases, mothers do not follow appropriate feeding practices. A Department of Health funded study recently showed that mixed feeding, which many mothers practice, is most likely to transmit HIV. Exclusive breastfeeding is likely the best option in resource poor areas where mothers do not have clean water and electricity to prepare infant formula. UNICEF believes that with aggressive intervention South Africa could save the majority of its children who would otherwise die by implementing large-scale programmes to prevent HIV transmission from mother to child, including nutritional and Early Childhood Development (ECD) aspects. Action UNICEF s immediate goal is to contribute to the doubling of the proportion of HIV-positive pregnant women receiving ARVs from 20% to 40% by the end of UNICEF believes in a comprehensive PMTCT-plus approach which provides ARVs to pregnant HIV-positive women to prevent transmission to their babies, while allowing mothers to live longer, healthier lives. As a result, the quality of life of their babies will be improved through sustained maternal care and protection. Ultimately, there is a strong possibility that the number of paediatric HIV infections would decrease, which would in time lower both the infant mortality rate and the under-five mortality rate. The following activities will contribute to this result. Boosting PMTCT-plus systems Increase the number of pregnant women who know their HIV status. This could happen through the introduction of a system of opt-out HIV testing in the antenatal period which would routinely offer repeat HIV testing at 36 weeks gestation as well as routinely offer repeat HIV testing in postnatal wards. Perform CD4 testing on all HIV infected women who have been identified during pregnancy and find effective and proactive ways of linking them to the antiretroviral therapy (ART) programme. Advocate for a revised ARV regimen. Improve comprehensive services for mothers and infants by strengthening the linkages between the PMTCT programmes and ART programmes and family planning services. Improve the quality of post-test counselling for pregnant women found to be HIV-negative. Develop an early stimulation programme for young children that are HIV-positive and on treatment to address and counter developmental and cognitive delays. Improving infant and maternal nutrition Revise the infant feeding training and counselling programme with a view to ensuring that mothers receive accurate information about their feeding options. Advocate for nutritional supplements or food parcels for pregnant and breastfeeding women, especially those who are HIV-positive. This is an important incentive that is currently not provided, in contrast to government programmes that provide women using formula with six months of free milk commodities. Stage a media campaign on safe infant feeding. Train child health workers (CHWs) to use growth monitoring as a proxy indicator for HIV and link the infant to paediatric ART services. Impact By doubling the proportion of HIV-positive pregnant women taking ARVs from 20% to 40%, and by improving infant and maternal nutrition, UNICEF is creating the potential of preventing some 10,000 babies from becoming infected with HIV in

14 UNICEF proposes the following activities to scale up PMTCT-plus programmes: Activities and budget PROJECT ACTIVITIES COST US$ Increase the number of HIV-positive women who receive ARVs for PMTCT from 20% to 40% Improve the management of district health systems to include PMTCT in existing ante-natal care and ARV facilities. Increase the number of CD4 tests at antenatal clinics as a means of quickly enrolling women in PMTCT-plus programmes. Introduce different scenarios of voluntary counselling and testing (VCT), including opt-out testing, in three districts of KwaZulu-Natal. Mobilize communities to utilize health services offered by the health system. Determine a baseline for the proportion of HIV infections prevented through PMTCT-plus, in order to monitor the impact of the above interventions. Commission an evaluation of the entire PMTCT system in South Africa to identify bottlenecks to improving quality and outreach. Develop an early stimulation programme for young HIVpositive children. 450, , ,000 75,000 75,000 75,000 85,000 Project support 125,000 PROJECT SUB-TOTAL 1,735,000 Indirect recovery cost 237,000 PROJECT TOTAL 1,972,000 Improve the nutritional status of vulnerable women and children Review, produce and disseminate national and provincial guidelines on HIV and nutrition. Strengthen the skills of 500 health workers in PMTCT and nutritional issues: Infant and young child feeding policy and appropriate infant feeding options Code on marketing of breastmilk substitutes Growth monitoring Vitamin A supplementation Implement study on nutritional status and care for HIV-positive pregnant women and young children, including adherence to and availability of supplements; and design intervention programme. Develop indicators to monitor the nutritional status of HIVpositive mothers. 50, , ,000 45,000 Project support 45,000 PROJECT SUB-TOTAL 440,000 Indirect recovery cost 60,000 PROJECT TOTAL 500, PMTCT-PLUS TOTAL 2,472,000

15 3. SAVING INFANTS LIVES THROUGH EARLY HIV TESTING AND EFFECTIVE PAEDIATRIC ARV TREATMENT Key result for children Double the number of children receiving ARVs from 5,000 to 10,000 by Double the number of children receiving ARVs from 10,000 to 20,000 by Issue Without aggressive medical intervention, half of the 100,000 HIV-positive children born each year in South Africa will die before their second birthday. However, South Africa can save the majority of its children who would otherwise die by implementing large-scale programmes to prevent HIV transmission from mother to child and to treat infected infants immediately. On average, around 10% of an infected population has CD4 counts below 200, thereby qualifying them for immediate antiretroviral therapy to save their lives. Of this total population needing ARVs, an estimated 10 to 15% are children. This means that between 55,000 and 82,000 children in South Africa are in immediate need of ARV treatment if they are to have a chance to lead relatively healthy lives. At present, only a fraction of those children actually receive ARVs. It was estimated that by mid-2005, about 5,000 children were benefiting from treatment. Moreover, distribution of paediatric ART is highly inequitable. Studies reveal considerable disparities between the care available to HIV-infected children between provinces and across the rural-urban divide. Provincial statistics reveal that most children are receiving 13 UNICEF/Giacomo Pirozzi

16 treatment around urban tertiary care centres in Cape Town, Gauteng and Durban. A major impediment to effective testing and roll out of ARV to children is that the majority of accredited ART sites outside the major urban areas do not provide adequate treatment to HIVinfected children. Practical mentoring and training is required in order to overcome the barriers which hinder these sites from providing appropriate services to children. In addition, only 30,000 of the 300,000 infants born to HIV-positive mothers are currently tested. Because ARVs are only offered to a child who has been tested, increasing diagnosis is a critical step toward treatment. Action UNICEF realizes that infant mortality due to AIDS can be combated through the increase of effective early diagnosis and early treatment for HIV, utilizing a variety of strategic approaches. To support these dual paediatric AIDS interventions, which need to become integrated with the PMTCT-plus programme, UNICEF proposes the following activities: Early diagnosis Develop and test an automated method of testing large numbers of infants through high volume dry blood Polymerase Chain Reaction methodology. Increase HIV testing capacity of National Health Laboratory Services ( NHLS) laboratories. Organize social mobilization events targeting mothers as well as parliamentarians, South African National Aids Council (SANAC) members, faith-based leaders, district and provisional AIDS councils, traditional leaders and traditional healers to encourage increased testing of infants. 14 UNICEF/Giacomo Pirozzi

17 Early treatment Expand district-wide collaborative networks from which experts train and mentor health workers from different levels of care. Centres of excellence will provide a platform from which paediatricians and other experts can assist rural areas and townships to accelerate and scale up their paediatric treatment (see map below). Advocate to improve the availability of paediatric ARV formulations and improve utilization of cotrimoxazol to prevent opportunistic infections in all HIV-positive children. Include ARV treatment and nutrition for children in existing guidelines on Community- Integrated Management of Childhood Illnesses (C-IMCI); and disseminate guidelines. Train 500+ health workers and community health workers to monitor children and mothers on ARV. Commission studies and design and implement training programmes to understand the psycho-social and community aspects of diagnosis of HIV in children on programme staff, mothers and children. Research the best practices of nutritional care for severely malnourished HIV-positive children and the impact of ARVs on the nutritional status of children in food-insecure settings. Impact By supporting the Government s efforts to address the dramatic issue of infant deaths due to AIDS, UNICEF aims to contribute to an increase in the number of infants tested for HIV to 80,000 by the end of 2006 and to 180,000 by the end of Furthermore, UNICEF expects to contribute to an increase in the proportion of children receiving treatment for HIV and AIDS to 15% of the total number of people treated: from 5,000 children currently on ARVs to 10,000 by the end of 2006 and to 20,000 by the end of In so doing, there is a strong chance that infant and under-five mortality due to AIDS will begin to diminish. 15

18 To this end, UNICEF proposes the following activities to increase the possibility of diminishing the infant and under-five mortality due to AIDS: Activities and budget PROJECT ACTIVITIES COST US $ Increase the number of infants tested for HIV Accelerate Polymerase Chain Reaction (PCR) training for 1,000 front line health workers in selected districts. Increase the capacity of NHLS laboratories to test more children with currently available technologies. Create, test, and implement new automated testing technologies that will increase the throughput of NHLS laboratories. 420,000 95, ,000 Advocacy and social mobilization. 85,000 Project support 75,000 PROJECT SUB-TOTAL 1,055,000 Indirect recovery cost 150,000 PROJECT TOTAL 1,205,000 Increase the proportion of children receiving ARV treatment to 15% of the number of people treated Expand district wide collaboratives from which experts train and mentor health workers from different levels of care. Implement an advocacy strategy to improve the availability of paediatric ARV formulations and improve utilization of cotrimoxazol to prevent opportunistic infections in all HIV-positive children. Review and disseminate existing guidelines on CIMCI to include ARV treatment and nutrition for children. Identify and train 500 health workers and CHWs to monitor children and mothers on ARV. Commission studies and design and implement training programmes to understand the psycho-social and community aspects of diagnosis of HIV in children on programme staff, mothers and children. Research and implement best practices of nutritional care for severely malnourished HIV-positive children. 850, ,000 80, , , ,000 Monitoring and evaluation. 120,000 Project support 150,000 PROJECT SUB-TOTAL 1,735,000 Indirect recovery cost 234,000 PROJECT TOTAL 1,969,000 PAEDIATRIC TREATMENT TOTAL 3,174,000 16

19 4. SUPPORTING SAFETY NETS TO CARE FOR ORPHANS AND VULNERABLE CHILDREN Key result for children 25% more orphans and other children in three most-affected provinces made vulnerable by HIV and AIDS access essential services by the end of Issue Children do not need to have HIV or AIDS to be devastated by it. When HIV or AIDS enters a child s household by infecting one or both parents, the very fabric of a child s life falls apart. The loss of a parent implies more than just the disappearance of the caregiver. It pervades every aspect of a child s existence; their emotional well-being, physical security, mental development and overall health. It implies that part of a child s safety net against violence, abuse, exploitation, stigmatization and discrimination is lost; often further isolating them from others at a time when they need as much care and support as possible. In the most extreme cases, children can find themselves utterly devoid of family support and end up living on the street. A child s right to an education is often jeopardized when caregivers become sick or die since money used to support school attendance will be reserved for food. It propels children out of the classroom and into the adult roles of caring and providing for their families. Their right to rest, play and recreation also suffer. Moreover, as HIV and AIDS often exacerbate poverty, it places children at an increased risk of engaging in 17 UNICEF/Giacomo Pirozzi

20 hazardous labour and of being exploited. The number of children who have been orphaned as a result of HIV and AIDS is rapidly increasing in South Africa. Currently, the South African Government estimates that at least 1,765,167 of the 18 million children in South Africa have lost a parent to AIDS and that millions more are living in households in which one or more person is ill, dying or dead from AIDS. Linked to the increase in the number of children orphaned by AIDS is the corresponding increase in the number of child/youth-headed households in South Africa. Around 40,000 child-headed households, including 85,000 children, are currently receiving home and community based care but thousands more remain unreached. Despite the increasing number of children whose families cannot provide basic assistance, few processes to support children affected or infected by HIV and AIDS have grown exponentially. A rare exception is the social grant system and even this achievement has not yet reached many eligible children. In many remote rural areas, only half of the eligible children are receiving a grant. As evidenced through online birth registration and the wide (though inadequate) reach of social grants, South Africa has the potential to apply first world strategies to a third world setting. The challenge lies in expanding social services to reach all vulnerable children, even in the deepest rural areas or the worst informal settlements. Unless these protective measures are strengthened decisively to reach all orphans and vulnerable children, increasing numbers of them will be left destitute. Action UNICEF s overall aim is to ensure that 25% more orphans and vulnerable children are able to access the essential social services that will enable them to survive and develop. The key to achieving this result lies within the Government s recently finalized Policy Framework and Action Plan for Orphans and Vulnerable Children. UNICEF is committed to providing technical support to the implementation of this plan, which was developed collaboratively with representatives from all sectors of government and civil society. Initial focus will be on the 18 UNICEF/Giacomo Pirozzi

21 situation of orphans and vulnerable children in the three most-affected provinces (KwaZulu- Natal, Eastern Cape and Limpopo). UNICEF will work closely with the Department of Social Development and civil society to carry out activities in two areas: National advocacy for children Advocate to increase the number of OVC receiving social grants to include eligible children who are not being reached and expand the eligibility to children aged between 14 and 18 years and child-headed households; Conduct targeted advocacy with Government Departments to improve OVCs access to social services such as health care, education, welfare, etc. Advocate for increased registration and support of ECD sites as nodes of support for community safety networks. Community safety networks for OVC Ultimately, communities are best placed to take responsibility for caring for their children, but the burden of the AIDS epidemic means that they need assistance to help their children to grow and develop. Community safety networks meet a critical need for the interface between vulnerable children, caregivers and available social services. When children and families deal with extreme poverty, sick and incapacitated parents, orphaning, etc., their suffering often bars them from accessing services. It is either too expensive, too much effort in the face of daily survival, the bureaucracy is opaque, or they are overwhelmed by the difficulties of living life while so many loved ones are sick and dying. Community Child Care Forums and similar models include trained workers or volunteers who identify OVC, take them to apply for social grants or get medical treatment, and in some cases even feed, bathe, and clothe children. UNICEF intends to support community safety network in three ways: Identifying more vulnerable children by 1) capitalizing on the networks of existing community workers such as community health and development workers; 2) expanding existing systems such as ECD centres or schools as centres of care and support and 3) developing communication strategies to inform families of how to access education, birth registration, social grants, health care, and adequate nutritious food. Prepare and roll out training on child care forums, including guidance on succession planning to help families to plan inheritance and guardianship. Support the development of national and local data systems to register and track care for OVC. At the local level, this will enable community groups to demonstrate the impact of their work on a quantifiable number of children s lives, thereby enabling them to attract additional government resources, plan their intervention strategies, and increase the number of children they can assist. Estimate the numbers and locations of orphans countrywide; Create a spatial framework to map OVC and services offered to OVC in key provinces; Train groups of Child Care Forums and other community groups in a district to utilize simple data management systems to track the progress of children and to report the number of children they assist. Coordinating services for OVC Support municipal governments to enact a First Call for Children in their local plans of action, integrated development plans, and municipal budgets. Assist the national and provincial Offices on the Rights of the Child to oversee coordinated action for OVC. Provide technical support to the National Action Committee for Children Affected by HIV and AIDS (NACCA) to monitor and implement the National Action Plan for OVC. 19

22 Impact By assisting the South African Government to increase its data knowledge of orphans and vulnerable children and plan appropriate care and support services accordingly, there is a strong chance that UNICEF will contribute to an increase in the number of registered children, and in parallel, an increase of 25% in the number of OVC who receive care and access essential services in three provinces by the end of UNICEF proposes the following activities: Activities and budget PROJECT ACTIVITIES COST US$ Increase the proportion of OVC access to essential services by 25% in 3 provinces Advocacy campaigns for increased social support for vulnerable children and for ECD sites. Support the development of data systems to register and track care for OVC in three provinces. Increase the number of OVC accessing essential services, including social grants. Assist municipalities to create local plans of action for OVC. Support the Office on the Rights of the Child in the President s office to coordinate OVC efforts. 50, , , ,000 75,000 Project support 95,000 PROJECT SUB-TOTAL 1,310,000 Indirect recovery cost 180,000 OVC PROJECT TOTAL 1,490, UNICEF/Giacomo Pirozzi

23 SUMMARY BUDGET PROPOSED STRATEGIES COST US$ A. Primary prevention through lifeskills and response to sexual assault 1,812,500 B. Scaling up PMTCT-plus to prevent children from contracting HIV 2,472,000 C. Paediatric treatment of AIDS: diagnosis and testing of infants and early ARV treatment for children D. Protection, care and support for orphans and children affected by HIV and AIDS: supporting safety net systems 3,174,000 1,490,000 TOTAL BUDGET 8,948,500 21

24 UNICEF SOUTH AFRICA 351 Schoeman Street 6th Floor Metro Park Building P O Box Pretoria Tel Fax