Reaching the Other Half by 2015

Background

At the September 2005 UN World Summit, world leaders agreed to reach the goal of Universal Access to prevention, treatment, care and support by 2010, to reduce the “vulnerability of persons affected by HIV/AIDS … in particular orphaned and vulnerable children and older persons.” This policy commitment has formed the focus of the global response to the HIV epidemic, as well for national and international advocacy. With the deadline for this policy commitment approaching rapidly it is essential to undertake four tasks: firstly, to investigate how far the goal of Universal Access for children has been achieved, secondly to review the possible reasons why universal access has not been achieved, thirdly to define priority actions and set a new goal for 2015 which should enable the remaining aspects of Universal Access to be achieved and fourthly to develop policy to enable effective Universal Access by 2015.

Significant progress has recently been made in several areas of the response to achieve Universal Access by 2010 to prevention, treatment care and support for children affected by AIDS, particularly on preventing the transmission of HIV from mothers to their babies (PMTCT), but also paediatric treatment. However, there are other areas where very little progress has been made, such as early infant HIV diagnosis, youth prevention (especially young women under the age of 15) and cotrimoxazole preventative therapy to reduce infant mortality from opportunistic infections and also care and protection of children affected by HIV. Where significant progress has been achieved it has generally been made with those people and locations that have been relatively easy to reach, the so-called “low hanging fruit.” The larger challenge remains: to reach those most marginalised and hardest to reach. An effective strategy and action plan is needed to reach those children still barely touched by the HIV response. World Vision International currently engages in a research that aims to contribute to this strategy and action plan to reach the other half of children affected by AIDS by 2015. Following is an outline of the research outline and an invitation to organisations to actively participate and contribute data to this research process.

Goal of the Research

The goal of the research is to identify who are the most neglected children in the global HIV response, which countries they live in and whereabouts they can be found within those countries. It will attempt to quantify the extent of their neglect, document their principal demographic and socio-economic characteristics, identify the key factors that have prevented them from being reached by past HIV programmes and spell out what actions need to be taken for them to have their needs met by 2015. The ultimate goal is to use the findings to influence the direction of the global HIV response on children affected by HIV & AIDS between 2011 and 2015 and to shape the direction that World Vision’s HIV programming should take over the same period.

Key areas that we need to get answers to map the next phase of the global Children and AIDS response

Estimate the numbers of children affected by HIV and AIDS that have not been reached by the HIV response. By a critical review of the available estimates (starting with the UNICEF publication Children and AIDS – Fourth Stock Taking Report 2009) the best estimate of the total numbers of children in each of the 4 “Ps” (Preventing MTCT, Providing paediatric treatment, Preventing infection among adolescents and young people and Protecting and supporting children affected by HIV/AIDS) will be developed. This will be accompanied by the development of the best estimates of the percentage of children who do not access services relevant for each of the 4 “Ps”. The percentage of children who do not access services will be calculated for as many low and middle-income countries as possible. Where possible the data will be analysed by province.

A key initial piece of work will be clarification of the indictors for each of the 4 “Ps”; these are of variable rigour.

a) Prevention of MTCT is mostly assessed by the number of HIV +ve pregnant women who receive ARVs during pregnancy and lactation

b) Providing paediatric treatment is mostly assessed by the percentage of Infants of HIV +ve mothers who receive co-trimoxazole and the percentage of children who require ARVs who actually get them. As diagnosis of HIV in children is often done late (because many countries still rely on ELISA or clinical signs) and as the transmission rates are variable the precise numbers of infected children may be difficult to ascertain.

c) Preventing infection among adolescents and young people is usually done by assessment of young people (age 15-25 years) who have a comprehensive knowledge of HIV, the percentage of young people who had sex with more than one partner in the last 12months, the percentage of young people with multiple partners who used a condom at last sex and the percentage of young people who had sex before 15 years. However all these are outcome indicators rather than service provision indicators. They are likely to be available from DHS data. Clarification will be needed on which indicators should be used because “prevention of HIV in young people” could be viewed as acquisition of knowledge only or it could be viewed as “knowledge and behaviour”. Key informants within World Vision and other agencies including UNICEF etc will be consulted for clarification but the Steering Group will take responsibility for deciding on the precise format of the indicators for this assignment.

d) Protecting and supporting children affected by HIV is the least well defined. It is sometimes assessed by the school attendance ratio (compared with children who are not affected by HIV/AIDS) or the % of children affected by HIV who “receive external support”. Definitions of what “external support” comprises are rarely provided. Key informants within World Vision and other agencies including UNICEF etc will be consulted for clarification but the Steering Group will take responsibility for deciding on the precise format of the indicators for this assignment.

To achieve the research goal and objectives, World Vision International, together with the institute of child health, UCL will conduct a Delphi exercise that relies on getting fast turn around from key people using questions that invite scores for “intuitive feelings” which are rapidly achieved asking few questions, requiring 5 minutes to respond. The data from a large number of key informants can be used to build up typical profiles of vulnerable, unserved groups and giving reason for their lack of uptake of services. This will facilitate the development of predictions using predictive modeling. This analysis will seek to explain the gap between those who have been reached and those who have been left behind. We therefore invite organizations to utilize their networks to share this Delphi survey as it will strengthen the research considerably.

* Dr. Stefan Germann, World Vision International, Director for Global Health Partnerships, Switzerland (presenting author). Interested people and organizations should contact Stefan Germann via email at stefan_germann@wvi.org

Dr. Stuart Kean World Vision International, Senior HIV Policy Advisor, United Kingdom

Prof. Andrew Tomkins, Institute of Child Health, University College London, United Kingdom