In Sub-Saharan Africa, 15.1 million children have been orphaned because of human immunodeficiency virus (HIV). They face significant vulnerabilities, including stigma and discrimination, trauma and stress, illness, food insecurity, poverty, and difficulty accessing education. Millions of additional children who have living parents are vulnerable because their parents or other relatives are infected. This article reviews the current situation of orphans and vulnerable children, explores the underlying determinants of vulnerability and resilience, describes the response by the global community, and highlights the challenges as the HIV pandemic progresses through its fourth decade.
Key points
- •
Sub-Saharan Africa has the greatest human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) burden in the world, with children disproportionately affected by HIV compared with any other region of the world.
- •
Affected children face significant challenges to their education, mental health, physical health, social wellbeing, and are more likely to live in poverty than unaffected children.
- •
Global investments in achieving an AIDS-free generation focus on prevention of mother-to-child transmission and treatment of children infected with HIV, whereas the social, emotional, and developmental health of children orphaned or otherwise affected are less well-addressed.
- •
Children orphaned and otherwise affected by HIV are largely supported by external donor assistance, leaving children made vulnerable by poverty with few or no supports. Because poverty is a stronger predictor of negative outcomes for children than HIV status alone, this can result in the neediest being passed over for services and support.
Introduction
Globally, 39 million people have died since the beginning of the human immunodeficiency virus (HIV) pandemic. An estimated 17.8 million children have lost 1 or both parents to acquired immunodeficiency syndrome (AIDS) and countless more have had to leave school to take care of ill parents and been propelled into a state of economic and emotional insecurity. Yet these data do little to communicate the extent of HIV’s impact on children, families, and communities. Considerably more is known about the number of children infected with HIV, than about the number of children who are uninfected but whose lives have been affected by HIV. In 2013, more than 3 million children were living with the virus and 250,000 new pediatric infections were detected. Every day, approximately 660 children become infected with HIV and 530 die of an AIDS-related illness. Gender inequity results in disproportionately high infection rates in girls, who represent two-thirds of HIV-infected adolescents. In addition to the 15 million children orphaned by HIV in Sub-Saharan Africa (SSA), the United Nations Children’s Fund (UNICEF) has estimated that as many as 1 million children are made vulnerable each year when a parent becomes sick.
Preventing and treating pediatric HIV is well-understood and the global community has seen a measure of success with 58% fewer pediatric infections between 2001 and 2013, and the number of children receiving antiretroviral therapy (ART) more than doubling from 255,000 in 2009 to 740,000 in 2013. These improvements are largely due to the Global Plan to Establish an AIDS-Free Generation by 2015. The major components of the plan include prevention of mother-to-child transmission (PMTCT), treatment of children living with HIV, and mitigation of the social and economic impact faced by children.
During the last 15 years, children orphaned and made otherwise vulnerable by HIV have been a major focus of international policy and donor funding. On a continent where millions of children are living in poverty, undernourished, or struggling to stay in school and achieve their full potential, differential vulnerability between children affected by HIV and those who are not is largely determined by global donor assistance. Affected children being reached by services targeting their needs may, as a result, be no more vulnerable than their unaffected peers. However, in the absence of this assistance, the social impact of HIV on children in many African countries continues to overwhelm families and communities.
A child affected by HIV faces the emotional trauma of losing a parent and the stigma associated with an incurable sexually transmitted infection. Families caring for an ill adult or grieving a death caused by AIDS are frequently catapulted into poverty, with the ensuing problems of maintaining food, shelter, and a safe environment for children. In the absence of effective treatment of adult HIV, parents become ill and are forced to stop working. Children in these households are often required to leave school to work or care for parents and siblings. Even if HIV were eliminated in the near future, the devastating social and emotional impacts will continue to affect multiple generations of children. Prolonged conflict, political instability, and extreme poverty also contribute to child orphaning and vulnerability in some settings in SSA. The global community must continue to place high priority on mitigating the impacts of HIV on children for many years to come.
This article synthesizes background information and evidence from a wide variety of sources to provide an overview of the burden HIV has placed on children and families in SSA. Relevant policy developments at global and national levels are reviewed, key program innovations attempting to reduce disparities faced by orphans and vulnerable children (OVC) are summarized, and the core human rights challenges faced by OVC are examined. A glossary of terms commonly used when referring to children affected by HIV can be found in Table 1 .
