Home Truths: Facing the Facts on Children, AIDS, and Poverty

This final report of the Joint Learning Initiative on Children and HIV/AIDS (JLICA) summarises its main results and recommendations, which focus on the following principles: support children through families; strengthen community action that backstops families; address family poverty through national social protection; and deliver integrated, family-centred services to meet children’s needs. JLICA is an alliance of researchers, implementers, activists, policy-makers, and people living with HIV (PLHIV). Its goal is to improve the well-being of children, families, and communities affected by HIV/AIDS by producing actionable, evidence-based recommendations for policy and practice.

From Chapter 1 The Global Response to Children Affected by AIDS: Where Have We Gone Wrong?:

"The first chapter of this report describes the impacts of HIV/AIDS on children and examines why the response from governments and their partners has fallen short. The chapter argues that these shortcomings will not be overcome by incremental advances in current forms of action. A bold change in approach is necessary that":

1. extends support and services to all children in need.
   
2. builds policies and programmes that support extended family and community networks in caring for children; and
   
3. tackles poverty and gender inequality, which strongly influence child outcomes and amplify the impact of HIV and AIDS on children.

The document particularly notes its recommendation for expanding the United Nations (UN) definition of "orphan" from its present form: "a child who has lost one or both parents". This is recommended to help overcome the idea that children without parents are completely cut off from family support, which, according to the document, can result in narrow interventions that may miss the chance to support families and communities who care for children affected by HIV/AIDS.

The document emphasises refocusing the response to children affected by HIV/AIDS by redirecting policies and programmes to support children in and through their families. In raising the question of whether family structures, particularly in high prevalence settings in Africa, are eroding, the document found: "What longitudinal population-based survey data are available suggest a strong predisposition for the survival of households, including in high-prevalence settings....There is still time to strengthen vulnerable families in hard-hit areas. But for millions of children and families, the window of opportunity for supportive action is narrowing."

Strategies for preserving families include:

1. Keep children and parents alive - through prevention of vertical transmission and treatment for all family members, rather than treating individuals. For example, "Family-centred approaches to PMTCT [prevention of mother to child transmission] and ART [antiretroviral therapy] embody a fresh strategic direction critical for breaking the momentum of HIV/AIDS in high burden settings in sub-Saharan Africa."
   
2. Keep children in families.
   
3. Build family caring capacities. "Two promising strategies are home health visiting and early childhood development interventions....Although the research evidence is still emerging, there are indications that one of the main indirect effects of maternal HIV on infants is compromised parenting, mediated, in part, by maternal depression (footnote removed by editor). Home health visiting programmes could provide positive mothers with psychosocial support, in addition to enhanced parenting knowledge, thereby improving health outcomes for both mothers and children.... In Sub-Saharan Africa, home visiting programmes can build upon existing structures of community health worker and home-based care programmes, the latter having become an established intervention strategy for meeting the health-care needs of people living with HIV/AIDS. Early childhood development (ECD) programmes constitute another promising strategy to increase family caring capacity while building children’s human capital at a crucial life stage....Scaling up high-quality early childhood development programmes in high-prevalence countries could strengthen families and positively impact the life trajectories of poor children. Programmes might also engage fathers and provide opportunities to better understand and meet the needs of other family members, including siblings and grandparents."
4. Empower families to educate children. Girls’ education has been shown to be a protection from HIV education due to later sexual début, enhanced self-efficacy in relationships, enhanced condom use, greater capacity to benefit from the protective effects of social networks, and, subsequently, improved parenting. 5. Backstop Families with Child Protection. When family care breaks down, community organisations must provide child protective services and may need external support to do so.
   

Community strengthening includes recognising social networks where families can transfer social and economic capital to the relatives in need. Community-based organisations (CBOs), including faith-based organisations (FBOs), are the next line of protection. "Surveys indicate that people value the compassion and commitment of FBO workers and their capacity to deliver spiritual and psychosocial support, in addition to medical care." As these resources are stretched, more capacity building, training, mentoring, and economic support through affiliating with external NGO networks may be needed.

However, outside support can distort functioning community CBO systems. Principles for collaboration between external funders and communities are listed as:

• Community action must be strengthened: community initiatives are primary; external agencies must support and facilitate, complementing, not replacing, community action.

• Resources must be channelled to communities in appropriate ways - distributed using mechanisms and timelines that respect community processes and enable community groups to increase their effectiveness and expand the scale of their response.

• Affected children and youth should take part in defining the goals and methods of programmes that are conducted for their benefit.

• Community efforts and donor action must both be aligned and coordinated with evidence-informed national policy. The document recommends the following coordination mechanisms: district committees; resource tracking and aid effectiveness; and best practice frameworks for partnership and accountability, including partnerships which clearly spell out mutual rights, responsibilities, and expectations.  Additional recommendations include capacity building; periodic participatory monitoring, review, and learning; and mapping and regularly updating information on: (a) the needs of children and families; (b) initiatives in place to meet these needs at all levels (community, district, and national); and (c) the flow of resources to support these initiatives.

Vulnerability can be addressed through social protection including: food distribution programmes for people facing emergencies or chronic food insecurity; social security income transfers for people experiencing unemployment, poverty, disability, or other forms of vulnerability; child and adult education and skills strengthening, especially universal primary education; early child development interventions; school feeding programmes ; public works projects (cash for work or food for work schemes); health or asset insurance; livelihoods programmes; and microcredit programmes.

A primary recommendation of the document is to use income transfers because, as stated here, they have demonstrated benefits to children’s nutrition, growth, education, health status, and use of health services in the past decade. They are direct and immediate, empower women and reduce gender inequity if delivered to the female members of the household, stabilise households to enable them to "graduate" to further programmes like microcredit; and they can be AIDS-sensitive in distribution when used in high HIV-prevalence areas. As stated here, "The positive effects of income transfers are established. The critical factor now is national government leadership to take successful models to scale." As families stabilise, they have sought increased social services, which can be a challenge to government providers unless planning is done to bring services to the necessary scale.

If income transfers are implemented, governments need to prepare to scale up social service programmes. One model for integrated services is the Village Model, developed by the NGO FXB International, an integrated strategy of support to children and families living in extreme poverty in communities affected by HIV/AIDS. The step after implementing integrated social models is to accelerate scale-up using community health workers and community workers from other sectors who are well trained, supervised, and compensated. Monitoring and improving services can be facilitated to overcome bottlenecks in implementing integrated services and to inform policy. JLICA's agenda includes the creation, on local, national, and international levels, of a policy environment for innovation and action that seeks to: build political momentum, mobilise resources, accelerate implementation and foster continuous learning; broaden participation at regional, national, and local levels; and track success and maintain accountability.