X HIV/AIDS Prevention and Care in Resource-Constrained Settings

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P ROVIDING ASSISTANCE TO ORPHANSAND OTHER CHILDREN MADEVULNERABLE BY HIV/AIDSAn estimated 13.2 million children worldwide havelost a mother or both parents to AIDS. Many morechildren have lost a father to AIDS. Still others areliving with and often caring for an ill parent. Ninetyfivepercent of the children orphaned by AIDS live inAfrica. The overwhelming majority of childrenorphaned and otherwise made vulnerable byHIV/AIDS are living within their extended familiesand communities. But unfortunately, AIDS is underminingfamily and community capacity to protect andcare for the growing number of vulnerable children.As part of an expanded comprehensive program,the global community must help build and supportlocal responses through which public, private and voluntarysector donors in the industrialized world canchannel resources to national and grassroots programsin the countries hardest hit by HIV/AIDS. The mostpromising interventions for strengthening the capacityof families and communities to protect and care fororphans and other vulnerable children are systematiccommunity mobilization, capacity building andmicrofinance services. Together these approaches canbe mutually supportive and produce significant, sustainableresults.Community-based programs must support interventionsthat improve access to education for themost vulnerable children in areas seriously affected byHIV/AIDS. This will include a wide variety ofinterventions, ranging from policy reforms to directinterventions that enable orphans and other vulnerablechildren to return to or stay in school.Grassroots groups urgently need funds and food tosupport home care for PLHA and to integrate theidentification and support for vulnerable children intosuch programs. These programs need ongoing accessto food and medicines to treat the most commonopportunistic infections. This can enable parentsliving with HIV/AIDS to live longer and more comfortablyand can also greatly benefit their children.Strengthening these programs can make them aninitial point of identification and support for childrenwhose safety and well-being are being undermined byHIV/AIDS.CHALLENGES IN HIV/AIDSPREVENTION AND CARE, ANDMITIGATING THE IMPACT OFTHE HIV/AIDS EPIDEMICOur children’s children will confront the legacy ofthis pandemic, and what we are now doing inHIV/AIDS prevention and care will significantlydetermine the size of the social and economic burdenthey will have to bear. We are not powerless against theepidemic—there are large-scale responses that haveproven successful. Key elements of such responsesinclude strong leadership, openness about the issuesand broad-based multisectoral programs at all levels inthe community. But the global response thus far hasbeen limited by the following major factors:■■■Political commitment: There is still a profoundlack of political commitment at all levels of governmentin some of the most severely affected countries,though there has been considerable progress inpolitical mobilization in many countries throughoutthe world during the past several years.Available resources: The global pandemic has outstrippedavailable resources. About US$500 millionfrom all sources (donors, lending agencies andhost country contributions) is now being spent onHIV/AIDS prevention programs in all of sub-Saharan Africa. The World Bank, United NationsJoint Programme on AIDS (UNAIDS), U.S.Agency for International Development (USAID)and others in the international community haveanalyzed the costs of successful programs anddeveloped models to estimate resource needs forthe basic components of prevention and care.The estimated costs for sub-Saharan Africa rangebetween US$2.5 and US$5 billion per year. Thisfunding would provide prevention services for amajority of the population and basic care andsupport services for approximately 30 percent ofthose infected. These funding levels include accessto ARV therapies for only about three percent.Stigmatization: This epidemic is still plagued bythe immense problem of stigma. Until persons cantalk openly about risk behaviors and whether theyare infected or not, we will continue to have weakbehavior change and care and support programs.HIV/AIDS Prevention and Care in Resource-Constrained Settings XXIII
F igure 13HIV Seroprevalence in AdultPopulations at the End of 2000■Rank Country %PrevalenceAFRICA1 Botswana 362 Swaziland 253 Zimbabwe 254 Lesotho 245 Zambia 206 South Africa 207 Namibia 208 Malawi 169 Kenya 1410 Central African 14Republic11 Mozambique 1312 Djibouti 1213 Burundi 1114 Rwanda 1115 Cote d’Ivoire 1116 Ethiopia 1117 Uganda 818 United Rep. of 8Tanzania19 Cameroon 820 Burkina Faso 621 Congo 622 Togo 623 Dem. Republic 5of Congo24 Nigeria 525 Gabon 426 Ghana 427 Sierra Leone 328 Eritrea 329 Liberia 330 Angola 331 Chad 332 Guinea-Bissau 3Gender vulnerability: For both biological andsocioeconomic reasons, girls and women are particularlyvulnerable to HIV/AIDS. To counter theseinherent gender inequities, innovative programshave been implemented that involve a range ofactivities—such as improving girls’ access to basiceducation, providing women with microfinanceopportunities and modifying or adapting culturalRank Country %PrevalenceAFRICA — continued33 Benin 234 Mali 235 Gambia 236 Senegal 237 Guinea 238 Niger 1LATIN AMERICA / CARIBBEAN1 Haiti 52 Bahamas 43 Guyana 34 Dominican 3Republic5 Belize 26 Honduras 27 Panama 28 Guatemala 19 Suriname 110 Barbados 111 Trinidad and 1TobagoASIA AND THE NEAR EAST1 Cambodia 42 Thailand 23 Myanmar 24 Sudan 1EUROPE AND EURASIAUkraine 1■■practices and legislation that canempower women. But the realimpact of these programs hasyet to be determined.The scale of interventions:Existing prevention programsare not large enough. It is likelythat prevention services reachonly 10 percent of the world’svulnerable populations. Thislack of scale is further complicatedby the fact that the globalcommunity urgently needs abetter understanding of thenumbers of persons (coveragewithin a targeted community)and level of behavior change(e.g., condom use in casual relations)that must be reached toachieve measurable changes inincident infections.Basic care and support:Incorporating basic care andsupport for HIV-infected individuals,their families and theirsurvivors (orphans), as well asintroducing new interventions—suchas the short-courseARV regimens to reduceMTCT—must be done in waysthat will enhance rather thandiminish the primary preventionagenda.■ The need for vaccines andmicrobicides: There is still alack of critical technologies thatwould radically alter our abilityto reduce new infections andprovide compassionate care tothe infected. These includerapid, simple diagnostics for STDs; a vaginalmicrobicide; simpler, cost-realistic ARV regimens;and, most important of all, an effective preventivevaccine. We urgently need an HIV vaccine and aneffective topical microbicide. Our existing interventionsdo work, if implemented properly and toscale. But these additional tools would make anenormous difference in our ability to combatHIV/AIDS.XXIV HIV/AIDS Prevention and Care in Resource-Constrained Settings
Page 1 and 2: Edited byPeter R. Lamptey, MD, DrPH
Page 3 and 4: © 2001 Family Health International
Page 5 and 6: SECTION II:Chapter 6PAGE 137Chapter
Page 7 and 8: Chapter 21PAGE 501Chapter 22PAGE 51
Page 9 and 10: I N T R O D U C T I O NPAUL R. DE L
Page 11 and 12: F igure 1Factors That InfluenceThe
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Page 15 and 16: F igure 5HIV Seroprevalence for Com
Page 17 and 18: F igure 7HIV Seroprevalence for Pre
Page 19 and 20: F igure 9Life Expectancy With and W
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Page 29 and 30: ACKNOWLEDGEMENTSWe wish to express
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Page 34 and 35: THOMAS M. PAINTER, PHDBehavioral Sc
Page 36 and 37: glossary of A C R O N Y M SACTG AID

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