TECHNICAL_ANNEX_CONSOLIDATED.pdf

Technical Annex

1. PEPFAR OVC GUIDANCE 2012

2. 2010-2014 DRC NATIONAL PLAN OF ACTION

3. 2014-2017 HIV NATIONAL STRATEGIC PLAN

4. PEPFAR DRC OVC STRATEGY

5. DRC PROVIC FINAL EVALUATION REPORT

6. ACCELERATION PLAN PMTCT DRC

7. HEALTH ZONE MODEL DRAFT

8. USAID DRC CDCS

Technical Annex

Part 1

The U.S. President‘s Emergency Plan for AIDS Relief

GUIDANCE FOR ORPHANS

AND VULNERABLE CHILDREN

PROGRAMMING

July 2012

List of Abbreviations

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy

CBO Community-Based Organization

CDC Centers for Disease Control and Prevention

COP Country Operational Plan

CoR Continuum of Response

CSO Civil Society Organization

DFID Department for International Development (U.K.)

ECD Early Childhood Development

FBO Faith-Based Organization

GBV Gender-Based Violence

GHI Global Health Initiative

HES Household Economic Strengthening

HIV Human Immunodeficiency Virus

ITN Insecticide-Treated Bed Net

JLICA Joint Learning Initiative on Children and HIV/AIDS

M&E Monitoring and Evaluation

MCH Maternal/Child Health

MERL Monitoring, Evaluation, Reporting, and Learning

MIS Management Information System

NGI Next Generation Indicator

NGO Nongovernmental Organization

OVC Orphans and Vulnerable Children

PEPFAR U.S. President‘s Emergency Plan for AIDS Relief

PMI President‘s Malaria Initiative

PMTCT Prevention of Mother-to-Child Transmission

RCT Randomized Control Trial

SRGBV School-Related Gender-Based Violence

STD Sexually Transmitted Disease

TB Tuberculosis

UNAIDS Joint United Nations Programme on HIV/AIDS

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

USG United States Government

WASH Water, Sanitation, and Hygiene

WHO World Health Organization

1. INTRODUCTION 5

1.1 Orphans and Vulnerable Children (OVC)Programming and PEPFAR’s AIDS Response 5

1.2 Purpose 6

1.3 Important Themes in this Guidance 6

1.4 Summary of Priority Activities 7

1.5 Background 8

1.6 Response 9

2. PEPFAR OVC PRINCIPLES AND APPROACH FOR PROGRAMMING 11

2.1 PEPFAR OVC Guiding Principles 11

2.2 PEPFAR OVC Program Approach 12

2.3 From Affected to Infected: Categories of Interventions to Reduce Vulnerability 15

3. STRATEGIC PORTFOLIO DEVELOPMENT 18

3.1 Gather and Analyze the Evidence: The “Five Knows” 18

3.2 Assembling a Portfolio 20

4. EDUCATION 26

4.1 Background 26

4.2 Evidence-Based Implementation Recommendations 26

4.3 Prioritization of Recommended Interventions 30

5. PSYCHOSOCIAL 32

5.1 Background 32

5.2 Evidence-Based Implementation Recommendations 34

5.3 Prioritization of Recommended Interventions 37

6. HOUSEHOLD ECONOMIC STRENGTHENING 38

6.1 Background 38

6.2 Evidence-Based Implementation Recommendations 38

6.3 Prioritization of Recommended Interventions 43

7. SOCIAL PROTECTION 44

7.1 Background 44

7.2 Evidence-based Implementation Recommendations 45

7.3 Prioritization of Recommended Interventions 47

8. HEALTH AND NUTRITION 48

8.1 Background 48

8.2 Evidence-based Implementation Recommendations 49

8.3 Prioritization of Recommended Interventions 52

9. CHILD PROTECTION AND GENDER-BASED VIOLENCE 53

9.1 Background 53

9.2 Evidence-Based Implementation Recommendations 54

9.3 Prioritization of Recommended Interventions 58

10. LEGAL PROTECTION 59

10.1 Background 59

10.2 Evidence-Based Implementation Recommendations 59

10.3 Prioritization of Recommended Interventions 61

11. BUILDING CAPACITY AND SYSTEMS STRENGTHENING FOR COUNTRY

OWNERSHIP 62

11.1 Background 62

11.2 Evidence-Based Implementation Recommendations 63

11.3 Prioritization of Recommended Interventions 67

12. CRITICAL ISSUES IN MONITORING AND EVALUATING OVC PROGRAMS 68

12.1 Improving the Quality of OVC M&E Systems 68

12.2 Improving Program Evaluations 69

12.3 Imroving Data Analysis and Usage 72

ANNEX A: Key Terms and Concepts 73

ANNEX B: Evidence Matrix 76

1. INTRODUCTION

1.1 Orphans and Vulnerable Children (OVC) Programming and PEPFAR’s AIDS Response

For people infected and affected by the epidemic, HIV is not only a medical experience. It is also a social and emotional experience that profoundly affects their lives and their futures. Programming for children orphaned and made vulnerable by HIV/AIDS contributes to the achievement of an AIDS-free generation by responding to the social (including economic) and emotional consequences of the disease on children, their families, and communities that support them.

PEPFAR programs for AIDS-affected children have promoted resilience in children and broader society by reducing adversity and by building services and systems that reach people directly in their households and communities.1 And the evidence – highlighted here and throughout the document – shows that these interventions are working. They have kept children in school and improved education2,3 and psychosocial outcomes at the child level.4 They have developed household economic strengthening (HES) initiatives; established parent/caregiver education and support groups;5 and increased health care access and food and nutrition outcomes at the family and household level.6,7 Over 4 million children have benefitted from these efforts in 20ll alone.

OVC programs also support the medical goals of the response in key and mutually beneficial ways. For example, efforts to keep children in school have positive impacts on prevention.8 Economic strengthening activities help remove barriers to accessing facility-based services,9 and child-focused health interventions are important platforms for targeting mothers for prevention of mother-to-child transmission (PMTCT). In addition, OVC community-based programming helps to reduce stigma and discrimination and create an enabling environment for people infected and affected by HIV/AIDS to access services.10,11 By addressing socio-emotional effects of the epidemic, OVC programs reduce the likelihood of children and adolescents moving from being affected by the epidemic to infected.

1 Binagwaho A, Noguchi J., et al. (2008). Community-Centered Integrated Services for Orphans and Vulnerable Children in Rwanda. Joint Learning Initiative on Children and HIV/AIDS.

2 Blackett-Dibinga K, Anah K, Matinhure N. (2006). Innovations in Education: The role of the education sector in combating HIV/AIDS. Africare:

Office of Health and HIV/AIDS;

3 Bryant M, et al. (2011) Evaluating the Effectiveness of Educational Block Grants to Orphans and Vulnerable Children. USAID Project SEARCH Research Report: Boston University OVC‐CARE Project.

4 Nyangara F, Obiero W, Kalungwa Z, Thurman T. (2009). Community-Based Psychosocial Intervention for HIV-Affected Children and their Caregivers: Evaluation of The Salvation Army. USAID MEASURE Evaluation Project.

5 Thurman T, Rice J, Ikamari L, Jarabi B, Mutuku A, Nyangara F. (2009). The Difference Interventions for Guardians Can Make: Evaluation of the Kilifi Orphans and Vulnerable Children Project in Kenya. USAID MEASURE Evaluation Project.

6 Adato M, Bassett L. (2009). Social protection to support vulnerable children and families: the potential of cash transfers to protect education, health and nutrition. AIDS Care. 21(S1), 60-75.

7 Nyangara F, Kalungwa Z, Obiero W, Thurman TR, Chapman J. (2009). Promoting a Home-Based Program Model for Supporting Children Affected by HIV/AIDS: Evaluation of Tumaini Project in Iringa Region, Tanzania. USAID MEASURE Evaluation Project.

8 Cho H, Hallfors DD, Mbai II, Itindi J, Milimo BW, Halpern CT, Iritani BJ. (2011). Keeping Adolescent Orphans in School to Prevent Human Immunodeficiency Virus Infection : Evidence From a Randomized Controlled Trial in Kenya. J Adolesc Health. 48(5), 523-526. Epub 2011 Feb 18.

9 Stene A, Chandani T, Arur A, Patsika R, Carmona, A. (2009). Economic Strengthening Programs for HIV/AIDS Affected Communities: Evidence of Impact and Good Practice Guidelines. Private Sector Partnerships One Project, Abt Associates, Inc.

10 Apinundecha C,. Laohasiriwong, Cameron M, Lim S. (2007). A community participation intervention to reduce HIV/AIDS stigma, Nakhon Ratchasima province, northeast Thailand. AIDS Care 19, 1157-1165.

11 Nyblade, L, MacQuarrie K, Kwesigabo G, Jain A, Kajula L, Philip F, Tibesigwa WH, Mbwambo J. (2008). Moving Forward: Tackling Stigma in a Tanzanian Community: A Horizons Final Report. Washington, D.C.: Population Council.

1.2 Purpose

The purpose of this guidance is to help PEPFAR country teams and implementing partners develop country operational plans (COPs) and design programs that support vulnerable children in their contexts, align with known best practice, and incorporate potential innovation. It seeks to aid teams in identifying and implementing appropriate, evidence-based, and cost-effective activities that will maximize improvement in the well-being of vulnerable children in the epidemic and close gaps in past programming efforts. Importantly, the guidance clearly places the OVC programming within the HIV/AIDS continuum of response at the country level.

This guidance, however, is not a “how to” manual for implementing specific technical activities. Those resources already exist and can be referenced for more detailed implementation guidance. Rather, this document outlines in general terms strategic, evidence-based interventions that PEPFAR OVC programs can consider implementing based on assessed context and need.

1.3 Important Themes in this Guidance

This guidance builds on past programming and guidance, with new emphasis on the key points highlighted in the box below. These points are elaborated upon and emphasized throughout the document.

Key Points There is no “minimum package of services.” Program planners and implementers should ensure prioritized and focused interventions that address children’s most critical care needs through family strengthening.

While programs must continue to improve child outcomes, the primary strategy for achieving this is strengthening parents and caregivers so they can provide for their children’s basic needs. The seven core areas have been reinterpreted to better reflect this shift.

Child-focused, family-centered interventions at the household level take precedence over handing out materials only to children identified as “OVC.”

Sustainability through capacity building and transfer of program responsibility to promote country ownership are imperative and must be balanced with careful planning and monitoring to ensure children’s immediate needs are also met.

A young person who turns 18 while receiving OVC services should not automatically be terminated from receiving assistance. Programs should plan for appropriate transition strategies and be prepared to cover a buffer period for a seamless transition to adulthood.

There is a growing evidence base for OVC programming reflected in this document. Programs should build interventions on evidence-based practice. This guidance includes summaries of the evidence for the efficacy of a range of child and family support interventions.

Programs should allocate at least 10 percent of project funding to monitoring and evaluation (M&E) to ensure that the evidence base continues to grow and to inform better practice.

Experienced and specialized technical expertise is required for many types of interventions included in this guidance. Country teams and implementing partners should call upon individuals and resources with this expertise when designing programs and country strategies.

1.4 Summary of Priority Activities

The technical sections included in this guidance (Sections 4-11) include explanatory narrative on how and when to prioritize specific technical interventions. These prioritized interventions are summarized below, although the more detailed technical sections should be referenced, along with the guidance on strategic planning processes, for clarification and better understanding when planning programs.

Education: PEPFAR OVC programs should support efforts to reduce educational disparities and barriers to access among school-age children through sustainable “systemic” interventions (for example, school block grants) and by:

1) Ensuring children have a safe school environment and complete their primary education

2) Promoting access to early childhood development (ECD) programs

3) Ensuring personnel create child-friendly and HIV/AIDS- and gender-sensitive classrooms

4) Strengthening community- school relationships, including partnering with out-of-school programming

5) Consider supporting post-primary school programming and especially the transition for girls from primary to secondary school

6) Implementing market-driven vocational training only when previous lessons learned are integrated into intervention designs

Psychosocial Care and Support: PEPFAR OVC programs should prioritize psychosocial interventions that build on existing resources and place and maintain children in stable and affectionate environments through:

1) Parents and family support programs

2) Peer and social group interventions

3) Mentorship programs

4) Community caregiver support

Household Economic Strengthening (HES): HES aims to reduce the economic vulnerability of families and empower them to provide for the essential needs of the children in their care through:

1) Money management interventions for savings, access to consumer credit, and fostering knowledge and behaviors for better family financial management

2) Integration of HES activities with complementary interventions, such as parenting skills

3) Income promotion using low-risk activities to diversify and stimulate growth in household income

Social Protection: PEPFAR support for social protection aims to reduce vulnerability and risks, foster human capital development, and interrupt the transmission of poverty from one generation to the next through:

1) Supporting host-country governments to initiate, expand, or be innovative in their social protection initiatives at both the policy and operational levels

Health and Nutrition: PEPFAR OVC programs aim to improve children’s and families’ access to health and nutritional services through:

1) A child-focused, family-centered approach to health and nutrition through ECD and school-based programs

2) Effective integration with existing or planned child-focused community- and home-based activities, including PMTCT, treatment, the President’s Malaria Initiative (PMI), and child survival

3) Reducing access barriers to health services through HES and social protection schemes, such as health insurance opportunities

4) Establishing linkages and referral systems between community- and clinic-based programs

Child Protection: PEPFAR OVC programs aim to develop appropriate strategies for preventing and responding to child abuse, exploitation, violence, and family separation through:

1) Implementing child safeguarding policies

2) Integrating child protection activities

3) Supporting communities to prevent and respond to child protection issues

4) Strengthening linkages between the formal and informal child protection systems

5) Building government capacity to carry out and improve child protection responses

Legal Protection: PEPFAR OVC programs aim to develop strategies to ensure basic legal rights, birth registration, and inheritance rights to improve access to essential services and opportunities through:

1) Raising awareness about birth registration and succession planning

2) Linking birth registration and succession planning to other essential services

3) Improving government birth registration systems and legal mechanisms for enforcing fair and equitable inheritance laws and guardianship

Capacity Building: PEPFAR programs should prioritize within their country context the following capacity-building and systems-strengthening interventions:

1) Investing in efforts to build strong leadership and governance

2) Pursuing strategies to strengthen the social service workforce

3) Supporting strategies to improve financing for social service systems

4) Strengthening information management and accountability mechanisms of the social service system

5) Supporting coordination and networking within the social service system

1.5 Background

The HIV/AIDS epidemic has exacted a terrible toll on children and their families. During the 30 years of the global HIV epidemic, an estimated 17 million children have lost one or both parents due to AIDS; 90 percent of these children live in sub-Saharan Africa. In addition, 3.4 million children under age 15 are living with HIV. Despite some decline in HIV adult prevalence worldwide and increasing access to treatment, the number of children affected by or vulnerable to HIV remains alarmingly high.12

The social and emotional effects of the disease are numerous and profound. While poverty is at the core of many of these issues, HIV/AIDS deeply complicates the environment both for the consequences of and the response to the epidemic. As a result of the social effects of HIV/AIDS, millions of HIV-affected children are highly vulnerable, as they are more likely to be victims of abuse, live in institutional care or on the street, and engage in hazardous and/or exploitive labor. More specifically, children who live with an ill adult or who have been orphaned by AIDS have a dramatically greater risk of abuse and exploitation,13 school drop-out (as children leave school to care for ailing family members), and

12 Joint United Nations Programme on HIV/AIDS (UNAIDS). (2010). UNAIDS Report on the Global AIDS Epidemic 2010. Geneva: UNAIDS.

13 Cluver L, Orkin M, Boyes ME, Gardner F, Meinck, F. (2011). Transactional sex amongst AIDS-orphaned and AIDS-affected adolescents predicted by abuse and extreme poverty. Journal of Acquired Immune Deficiency Syndromes. 58, 336-342.

psychosocial distress.14,15,16 Orphaned and vulnerable children are also far more likely to move from being “affected” by the virus to becoming infected, as well as facing other risks. 17 This is especially true for adolescent girls who have lost a mother and who are then more likely to engage in risky sexual behavior.18

Children infected by the disease are even more greatly impacted. Where there is no PMTCT program, children are often infected by the virus at birth or soon after. Even with the mother on treatment, HIV-negative but exposed children experience delayed cognitive development.19,20 Additionally, HIV-positive children sometimes have the compounded tragedy of being rejected by their families and abandoned to orphanages, further contributing to impaired cognitive and physical development.21

1.6 Response

Over the 30 years of the pandemic, families and communities have led a massive response to protect, care for, and support children affected by HIV/AIDS. Since 2003, $2 billion in funding and technical support from PEPFAR has greatly enhanced these efforts for orphans and vulnerable children. In 2008, the Hyde-Lantos Act reauthorized PEPFAR, including a requirement that programs for orphans and vulnerable children continue to be 10 percent of all PEPFAR program funds, a recognition of the importance of these holistic interventions and the strong foundation built during PEPFAR’s first phase.

These investments have enabled children to stay in school, strengthened households, and allowed families to reclaim their roles as primary caregivers. Efforts to build the capacity of local organizations and improve the quality of community-based services have also helped communities to better address the needs of vulnerable children and families.22 PEPFAR OVC programs support a vast network of community groups and organizations addressing the needs of orphaned and vulnerable children and their families. In 2011, one-third of all PEPFAR OVC prime partners were national organizations,23 and substantial resources went directly to national organizations as subgrantees to larger organizations.

14 Guo Y, Sherr L. (2012). The impact of HIV/AIDS on children's educational outcome: A critical review of global literature. AIDS Care. Apr 23 Epub ahead of print.

15 Cluver L, Orkin M, Boyes ME, Gardner F. (2012). AIDS-orphanhood and caregiver AIDS-sickness-status: Effects on psychological symptoms in South African youth. Journal of Pediatric Psychology. DOI: 10.1093/jpegsy/jss004. (IF 2.943) 16 Atwine B, Cantor-Graae E, Bujunirwe F. (2005). Psychological Distress among AIDS Orphans in Rural Uganda. Science & Medicine. 61 (3), 555- 564.

17 Operario D, Underhill K, Chuong C, Cluver L. (2011). HIV Infection and Sexual Risk Behavior Among Youth who have Experienced Orphanhood:

Systematic Review and Meta-Analysis. International Aids Society. 14:25.

18 Ibid.

19 Smith R, Malee K, Leighty R, Brouwers P, Mellins C, Hittelman J, Chase, C, Blasini, I. (2006). Effects of Perinatal HIV Infection and Associated Risk Factors on Cognitive Development Among Young Children. Pediatrics. 117, 851.

20 Sherr,L, Mueller J, Varrall, R. (2009). A systematic review of cognitive development and child HIV infection. Pscyhology, Health & Medicine. 14 (4), 387-404..

21 Nelson C, Zeanah C, Fox N, Marshall P, Smyke A, Guthrie D. (2007). Cognitive Recovery in Socially Deprived Young Children: The Bucharest Early Intervention Project. Science. 318 (5858), 1937-1940.

22 Yates, D, Richter, L, Zingu, J, Yates, R, Wolfe, J.(2011).PEPFAR HKID Portfolio Review: Children in the Epidemic. Global Health Technical Assistance Project, USAID.

23 According to a review of 2011 Country Operational Plans.

Adolescents girls affected by AIDS orphanhood showed a sixfold higher likelihood of transactional sexual exploitation, compared with those in healthy families.

- Operario et al, 2011 http://www.tandfonline.com/doi/abs/10.1080/13548500903012897

Increasingly, PEPFAR has complemented strong community-level investments with investments at the national level to care for millions of children through country-owned, sustainable solutions. For example, as a result of PEPFAR systems- strengthening efforts, the global social welfare workforce has greatly expanded in number and capacity, and 17 countries in sub-Saharan Africa have formulated national plans of action for vulnerable children with robust coverage data.

While significant progress has been made, multiple factors continue to challenge effective care and support for vulnerable children. These include the challenges of implementing complex, multisectoral interventions; limited rigorous program evaluation; only partial integration with prevention, care, and treatment activities; and limited evaluation of child outcomes achieved. This guidance builds upon the solid foundation of past PEPFAR OVC programming and addresses some of the challenges to more effectively respond to children and achieve a generation free from AIDS and its devastating effects.

2. PEPFAR OVC PRINCIPLES AND APPROACH FOR PROGRAMMING

2.1 PEPFAR OVC Guiding Principles

This guidance mirrors principles found in the Framework for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV/AIDS (The Global Framework) as well as those found in the UNAIDS Investment Framework for HIV/AIDS. The principles are also aligned with the objectives included in the U.S. Government (USG) National Action Plan for Children in Adversity: A Framework for U.S. Government Foreign Assistance, which was developed under the auspices of the USG Secretariat for Children in Adversity (PL 109-95).

Specifically, the following principles undergird all PEPFAR OVC programming:

Strengthening families as primary caregivers of children

Strengthening systems to support country ownership, including community ownership

Ensuring prioritized and focused interventions that address children’s most critical care needs

Working within the continuum of response to achieve an AIDS-free generation

2.1.1 Strengthening families as primary caregivers of children Within PEPFAR OVC programs, the family should be the primary unit of intervention. In fact, 95 percent of all children affected by HIV/AIDS live in families, and interventions that support entire households to provide for children’s needs are encouraged. Interventions that promote family involvement in children’s development, build parental knowledge and skills, and improve family stability through, for example, efforts toward economic security and social inclusion fall under the rubric of “family strengthening.”24 These efforts are foundational to programs addressing children affected by HIV/AIDS.25 Programs should not singularly target any child within the family without considering the needs of other siblings/children as well as the needs of primary caregivers at the household level.

2.1.2 Strengthening systems to support country ownership, including community ownership All PEPFAR OVC programs should support country ownership and systems strengthening (see Section 11) and remember that the USG is only one of many funders and implementers supporting the HIV/AIDS response. Working with host-country governments as well as other key stakeholders, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, is a key facet of building country ownership. The principles and approaches within this guidance should inform collaboration and interaction with all players at the country level.

Community ownership is a central but often overlooked element of country ownership at the micro level. It contributes to macro outcomes and is crucial for sustainable, positive outcomes for children in both the short and long terms. It is also a central and long-standing feature of OVC programming.

Country ownership is central to the PEPFAR strategy and has been widely endorsed by both donor and recipient nations. The Paris Declaration, developed in 2005 and supported by the United States, outlines country ownership as one of five fundamental principles for aid effectiveness.26 Without strong

24 Caspe M, Lopez M. (2006). Lessons from family-strengthening interventions: Learning from evidence-based practice. Cambridge, Mass.:

Harvard Family Research Project.

25 Richter L, Sherr L, et al. (2009). Strengthening families to support children affected by HIV and AIDS, AIDS Care. 21 (S1), 3-12.

26 Organization for Economic Co-operation and Development; Development Co-operation Directorate; [web site]. Accessible at:

http://www.oecd.org/document/18/0,3746,en_2649_3236398_35401554_1_1_1_1,00.html. Online. Internet. Accessed 2011 Sept. 7.

http://www.oecd.org/document/18/0,3746,en_2649_3236398_35401554_1_1_1_1,00.html community ownership, government initiatives and services can ultimately be weak and ineffective at the point of delivery, where effectiveness matters most.27 PEPFAR OVC programs also support country ownership at the national level through social welfare workforce strengthening to increase human resources that serve children and complement health systems strengthening.

2.1.3 Ensuring prioritized, focused interventions that address children’s most critical care needs

The number of intervention areas pursued by country programs, as well as the level of technical competence required to deliver different interventions, depends largely on country context and the budget and longevity of the program. There are thus no preset minimums for the number or range of interventions required by partners, nor is there a “one size fits all” package for most country programs.

When working with children with multiple needs, it is tempting to try to do everything. However, such attempts generally lead to poor quality programming with little depth or sustainable impact. In all programs, assessments should be done to identify children’s most critical care needs, prioritized based on urgency as well as proven effectiveness. In this guidance, the seven core areas have been reinterpreted to better acknowledge the important role of strengthening parents and caregivers so that they may provide for their children’s basic needs. While all needs cannot be met through OVC programs, linkages can be made within and throughout a system of care to help cover the range of needs identified through household assessment.

2.1.4 Working within the continuum of response to achieve an AIDS-free generation

When considering OVC interventions and program implementation, all actors should intentionally consider how the interventions planned fit into the HIV/AIDS continuum of response (CoR). The CoR approach addresses the lifetime needs of the target populations to ensure adequate access to a wide range of prevention, care, and treatment services based on the changing needs and circumstances of the families that are being served. HIV services, including OVC programming, are part of the larger CoR that addresses the entirety of the population‘s needs, including social and emotional needs that result from the effects of the epidemic. The CoR approach should be set within an organized and coordinated system of community- and facility-based services and providers. OVC programs find their place in the continuum by considering the ways in which HIV/ AIDS is a biosocial event and how the different interventions advance the goal of an AIDS-free generation (see Section 2.3).

2.2 PEPFAR OVC Program Approach

Stable, caring families and communities and strong child welfare systems are the best defenses against the effects of HIV AIDS in the lives of children. Nurturing families are critical to children’s lifelong health and well-being, including their prospects for living HIV-free, or positively with HIV. 28, 29 The PEPFAR approach to children in the epidemic is based on a social-ecological model that considers the child, family, community, and country contexts and recognizes the unique yet interdependent contributions of actors at all levels of society to the well-being of children affected by HIV/AIDS.30

27 Busza J, et al. (2012). Community-based approaches for PMTCT in resource poor settings: a social-ecological view. JIAS. Special issue, forthcoming.

28 Felitti V, Anda R, Nordenberg D, et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 14(4), 245-258.

29 Hillis S, Anda R, Felitti V, Marchbanks, PA. (2001). Adverse childhood experiences and sexual risk behaviors in women: a retrospective cohort study. Fam Plann Perspect. 33(5), 206–211.

30 Bronfenbrenner U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology. 22, 723–742.

Families, communities, and governments share responsibility to protect children from HIV infection and to ensure children thrive despite the impacts of HIV/AIDS. Meeting the needs of children made vulnerable by HIV/AIDS provides a unique opportunity for collective action on individual, local, and national levels. No single government, civil society organization, or community can do it alone, and each of these has an important role to play in improving the lives and futures of all children affected by

HIV/AIDS.

As shown in Figure 1, children and families and the communities that surround them are at the center of PEPFAR efforts. Governments and nongovernmental organizations (NGOs) working from national to local levels also play a critical role in the response to children.

The following sections discuss each of these actors in terms of their role and contribution as partners in PEPFAR’s response to children in the epidemic.

2.2.1 Children and Families

Families are the first line of support and defense for children. Even in the most resource-deprived settings, families and communities have critically important strengths.

Programs should focus on the promotion of the “strengths and resources” of children, families, and communities, rather than their “needs and deficits”. Providing direct support to children rather than empowering families to provide for children’s needs can undermine family relationships and capacity to care for children over the long term.

2.2.2 Civil Society

Communities

Community actors include organizations and individuals operating at a very local level, in a social unit larger than a household, and who share common values and social cohesion and commit themselves to

Figure 1: PEPFAR's Approach to Programming for Orphans & Vulnerable Children the group’s well‐being.31 Communities contribute to the welfare and protection of children and families by establishing a set of norms and expectations of community members that encourage mutual responsibility. Community members serve as frontline responders, identifying and responding to children and families in crisis before they come to the attention of government and civil society as well as monitoring their well-being and advocating on their behalf.

The importance of communities in the lives of at-risk children has been studied over decades, and such research informs evidence-based practice for programs aiming to minimize childhood adversity.32 Community-oriented programs have positive benefits for children in both the short and long term. This is especially true when such efforts are linked with government structures that facilitate access to financial and technical resources and when faith-based groups are a leading part of the response. Poorly executed assistance at the community level can, however, undermine the community’s sense of responsibility toward vulnerable children.33,34

Nongovernmental Organizations

Local NGOs and other civil society organizations (CSOs) or community-based organizations (CBOs) play an important role in championing the rights of children affected by AIDS and in holding governments accountable to commitments made on their behalf. They often have the advantage of working quickly and flexibly and tend to be well suited to working with marginalized groups, including children of sex workers and injecting drug users and street children. This work includes conducting assessments of vulnerable children to identify priority needs, making referrals or directly providing services, and monitoring service delivery. PEPFAR OVC programs should support NGOs in their role as champions for marginalized populations and as watchdogs for government accountability to vulnerable children.

International NGOs support the host-country response for vulnerable children at all levels to strengthen the care management system. Larger international NGOs are also a channel for technical and financial resources to smaller NGOs and CBOs. The balance between larger and smaller organizations can often be uneven, however, resulting in usurped local ownership and bottlenecks to effective distribution of resources at the local level.35 At the same time, funneling large amounts of resources to smaller local NGOs before they have the absorptive and technical capacity can also undermine local ownership. A balance between smaller and larger CSOs is required.

Faith-based organizations (FBOs) are defined as faith-influenced NGOs. FBOs are often structured around development and/or relief service delivery programs and can be local, national, or international.36 Such organizations play a central role in the civil society response to children in the

31 Khumalo‐Sakutukwa, G, et al. (2008). Project Accept (HPTN 043): A community‐based intervention to reduce HIV incidence in populations at risk for HIV in sub‐Saharan Africa and Thailand. *Randomized Controlled Trial Research Support, N.I.H., Extramural]. J Acquir Immune Defic Syndr. 49(4), 422‐431.

32 Leventhal T, Brooks-Gunn J. (2000). The neighborhoods they live in: The effects of neighborhood residence on child and adolescent outcomes. Psychological Bulletin. 126 (2), 309-337.

33 For example, provision of material supplies to children identified as “children affected by AIDS” led neighbors and community members in Kenya and Tanzania to resent children and families who benefited and to refer to them as the responsibility of NGOs. Nyangara F, et al. Effects of Programs Supporting Orphans and Vulnerable Children: Key Findings, Emerging Issues, and Future Directions from Evaluations of Four Projects in Kenya and Tanzania. MEASURE Evaluation for USAID. New Orleans: Tulane University School of Public Health.

34 Thurman T, et al. (2008). Barriers to the community support of orphans and vulnerable youth in Rwanda. Soc Sci Med. 66(7), 1557-1567.

35 Foster G. (2005). Channelling Resources to Communities Responding to Orphans and Vulnerable Children in Southern Africa. Save the Children Fund.

36 Definition taken from the UNAIDS Partnership with Faith-based Organizations UNAIDS Strategic Framework (2009).

epidemic. They have a unique and powerful ability to mobilize resources and faith communities at the local level for the benefit of children. FBOs are also central to the spiritual elements of response to the epidemic that often undergird emotional and social responses for individuals and communities.

Private Sector

Private sector entities have been actors in the response to the AIDS pandemic in several notable ways.

They provide health care and other social services to employees and area residents; they provide job opportunities for families that contribute to economic strengthening of households and youth empowerment; and many undertake corporate social responsibility actions that contribute to community infrastructure. Opportunities to partner with private sector entities to expand access to market opportunities and health and social services for children and families should be considered.

2.2.3 Governments

Government actors include publicly funded ministries and departments at the national, regional, and local levels. They contribute to the welfare and protection of children and families by developing large-scale and long-term government-endorsed policies and action plans. They coordinate all actors in the response to vulnerable children, provide public benefits and services, and collect and manage official data. Government actors have the authority to ensure the safe and equitable delivery of essential services and to provide safety nets that alleviate poverty.

The many needs of children and families affected by HIV/AIDS require a multisectoral effort that leverages a “whole of government” response. All government actors are concerned to some extent with the welfare of children, including “allied” ministries, such as ministries of education, health, justice, etc.

However, social welfare ministries play a central role in the overall HIV/AIDS response by ensuring the welfare and protection of marginalized groups, including persons living with and children affected by HIV /AIDS. OVC programs should engage all child-serving government agencies in the AIDS response and provide focused systems-strengthening efforts to social welfare agencies. They should also partner with governments to support AIDS-sensitive social welfare and child protection policies and programs that benefit all highly vulnerable children

2.3 From Affected to Infected: Categories of Interventions to Reduce Vulnerability

In addition to the above principles and approach, multiple types of interventions must be employed to address the vulnerability of children in the epidemic. Vulnerability is multifaceted and, as the diagram below shows, the destructive social effects of HIV/AIDS also contribute to children moving from being affected by the virus to infected.

Addressing issues included in the accompanying figure entails a multisectoral approach that assesses the complexities of vulnerability at the individual level while understanding contextual and collective effects.

Descriptions of evidence-based sectors that can address these effects are included in this guidance and also reflected in brief in the diagram below (color-coded to reflect where sectors correspond to the illustrative effects of HIV above). The sectors are:

Child protection

Health and nutrition

Capacity building

Education

Household economic strengthening

Legal protection

Psychosocial care and support

Social protection

The various sectors should be integrated in program designs along with other interventions in the HIV continuum of response to serve the needs of children and help achieve an AIDS-free generation. The OVC approach calls for program designs to intentionally consider the types of interventions to be

HIV infection of Parents

Possible distancing by parent, disclosure issues

Children may become caregivers

Psychosocial distress

Deaths of parents

Increasingly serious illness

Children withdraw from school

Inadequate food

Problems with shelter

& material needs

Economic problems

Problems with inheritance

Reduced access to health services

Children without adequate adult care

Discrimination

Increased vulnerability to HIV infection

Life on the street

Institutionalization

Sexual exploitation

Exploitative child labor

How HIV Affects Children (adapted from John Williamson)

Figure 2: How HIV Affects Children

Figure 3: Sectors that Address Child Vulnerability included across the levels of society to create an overall protective environment for children in the epidemic.

Addressing these multiple effects due to vulnerability resulting from HIV/AIDS also includes enhancing integration with and coordination among prevention, care, and treatment activities. While the majority of care for children in the epidemic happens in the home and in communities, programs should not miss opportunities for integration, especially with PMTCT, antiretroviral therapy (ART), and other health services that are critically important for children to survive, thrive, and avoid infection. The strong presence of OVC programs in the home and community provide a foundation to actualize a true continuum of response across the PEPFAR portfolio. Numerous opportunities exist to ensure that care provided in clinical settings is complemented by socioeconomic, psychological, and spiritual support.

Section 3 of this guidance on strategic portfolio development is central to designing programs or solicitations and includes more detail on integration and general guidelines for strategic planning for OVC portfolios. The technical sections that follow outline specific sectoral interventions as well as linkages to other sectors and across the continuum of response to reach the goal of an AIDS-free generation.

3. STRATEGIC PORTFOLIO DEVELOPMENT

Each PEPFAR country program is responsible for developing a strategic portfolio that includes prioritized and focused interventions that address children’s most critical care needs. In a world of limited resources and a multitude of children in need, prioritization and focus are critical.

The impact of the AIDS pandemic on children’s well-being differs across individuals, communities, and countries. Similarly, a child’s risk of contracting HIV or of experiencing parental loss also varies across epidemics. Strategic portfolio development is predicated on having an evidenced-based understanding of the unique challenges and opportunities faced by children and families within a specific country context as well as an informed perspective of the existing and potential capacity of partners to respond.

Building on the “four knows” outlined in the PEPFAR sexual prevention guidance, the evidence required by programs to inform an effective plan of support is outlined below. The additional “fifth know” speaks to the need for clarity on child risk factors that often underlie and impact HIV specific effects.

3.1 Gather and Analyze the Evidence: The “Five Knows”

The “Five Knows” outlined below help to set the parameters of the portfolio as well as identify key priorities particularly at national level.

1.) Know your epidemic: Children’s vulnerability to the impacts of HIV/AIDS differs by epidemic. Where transmission occurs primarily between marginalized populations, children may face more intense stigma and discrimination than their counterparts in hyper-epidemics, where almost every family has been in some way touched by AIDS. Conversely, the larger group of children made vulnerable by all causes in more concentrated epidemics are less likely to be exposed to HIV infection. Knowing where HIV epidemic “hotspots” are geographically located and understanding the drivers of the epidemic and how these drivers affect societal perceptions and risk profiles can help programs plan appropriately.

2.) Know your children: HIV/AIDS impacts children’s health and well-being outcomes in numerous and often overlapping ways. Evidence can provide a clearer picture of a child’s risk of HIV as well as from HIV/AIDS in regard to defined poor outcomes. By using available evidence, programs can avoid making simplistic assumptions about which children are at risk of a range of poor outcomes over the age span.

For example, in an attempt to tease out HIV/AIDS effects on child health and well-being, one recent study analyzed data from 60 population-based surveys37 across 36 countries. The study examined the relationship between children and age-specific outcome measures (including wasting, school attendance, and early sexual debut) and found that wealth and the educational attainment of senior household members were the only variables that consistently showed power to differentiate across the vulnerability-related outcomes studied.38 Other studies, however, have found unique correlations

37 Demographic and Health Survey (DHS] and Multiple Index Cluster Survey (MICS).

38 Akwara PA, et al. (2010). Who is the vulnerable child? Using survey data to identify children at risk in the era of HIV and AIDS. AIDS Care:

Psychological and Socio-medical Aspects of AIDS/HIV. 22 (9), 1066-1085.

between children orphaned by AIDS and those orphaned by other causes.39 These data highlight the importance of not only “knowing your epidemic” but also of “knowing your children” in each country.

3) Know your context: Knowing your context includes information such as HIV/AIDS’ special impact on children due to sociocultural norms, legal and policy environments, and rural-urban disparities. Knowing your context also implies having an appreciation for the feasibility of different investments based on an assessment of local capacity, technical competence, and willingness to commit to long-term interventions. This is particularly important when determining the appropriate balance between systems support activities and direct service activities. Countries and the formal and informal systems within them vary considerably in capacity, so portfolio planners should recognize the rate at which country partners are able to absorb and take ownership of new initiatives. In higher-capacity contexts where portfolios are shifting the emphasis of investment from direct service delivery to technical assistance models, it is critical to set realistic timeframes and to monitor the impact that such shifts have on children’s receipt of services.

4) Know your response: A true continuum of response relies on the existence of a comprehensive array of support and services, including those that respond to vulnerable children and their families, many of whom include persons living with HIV. Therefore as a first step, portfolio planners must assess how OVC programs are currently integrated within the HIV continuum of response. This involves both geographical as well as resource mapping. Decisions about where to geographically place services should begin with a mapping that identifies gaps in child/family support services in catchment areas surrounding PEPFAR-supported HIV clinical care sites. OVC programs must intentionally situate themselves within the clinical portions of response to both support biomedical goals as well as to leverage clinical interventions to reach the social and emotional goals included in the PEPFAR response.

Knowing your HIV/AIDS child-focused response also includes other related activities aimed at highly vulnerable children (for example, anti-trafficking, child labor, street children, etc.). Mapping of such child-focused initiatives can identify opportunities for complementary or joint programming. More selective mapping of Global Health Initiative (GHI) and specifically PEPFAR-funded HIV/AIDS activities should also be completed in order to ensure that activities are co-located and appropriately integrated across the continuum of response. Programs should also be cognizant of other USG-funded inputs that can be leveraged, including food and economic security and education activities. Under PL 109-95, the USG maintains a database of programs for vulnerable children in numerous countries.

5) Know your costs: Accurate costing of OVC activities is essential to achieving a sustainable response at scale. Government and civil society planners require several levels of costing data to inform sound programming decisions, including cost data that informs basic budgeting, indicates the potential outcomes to be achieved by different interventions, and supports scenario planning. Several costing methodologies specific to OVC programs have been developed for this purpose.

39For example, a longitudinal study in South Africa found that children who were orphaned due to AIDS or whose parents were ill with AIDS had a higher incidence of physical abuse and sexual exploitation than children orphaned by other causes and children with healthy parents. Cluver, L, et al. (2011). Children of the AIDS Pandemic. Nature. 27, 474.

3.2 Assembling a Portfolio

Based on an analysis of evidence gathered under the “Five Knows,” programs must determine achievable objectives for the portfolio over for a three- to five-year timeframe.40 Objectives of the portfolio include those required to achieve PEPFAR global goals and those that achieve the unique goals of the country program as articulated in country national plans of action and the Partnership Framework.

3.2.1 Determining Program Beneficiaries

By any estimate, the vast numbers of children who are potential beneficiaries for USG assistance far outstrip resources available. The intended beneficiaries of PEPFAR programs as defined in the Hyde- Lantos Act include “Children who have lost a parent to HIV/AIDS, who are otherwise directly affected by the disease, or who live in areas of high HIV prevalence and may be vulnerable to the disease or its socioeconomic effects.” The legislation further states that PEPFAR strategies should be guided…