PHA-Exch> Impact of AIDS on children remains under-researched and poorly understood. (Peter Piot's Speech)

[Claudio Schuftan]

From: Vern Weitzel vern.weitzel at gmail.com
From: "[health-vn discussion group]" <health-vn at cairo.anu.edu.au>

"Impact of AIDS on children remains under-researched and poorly
understood", Peter  Piot

(Speech Check against Delivery) Dr Peter Piot UNAIDS Executive
Director's speech at the JOINT LEARNING INITIATIVE ON CHILDREN AND
HIV/AIDS: International Symposium. Harvard Medical School. 24
September 2007.

I first want to thank Jim Kim, Peter Bell, Agnes Binagwaho for
inviting me here today, and to pay tribute to the tremendous work
they – and all of you – are doing. It is a privilege to be here today
with so many experts and activists. The issue of children and AIDS
was overlooked for far too long. UNAIDS was one of the first to
welcome the creation of the Joint Learning Initiative on Children and
AIDS, and I look forward to hearing about the progress you've made.

Let's start by looking at progress on AIDS in general. It's a mixed
picture, but there definitely is progress.

Today, 2.5 million people in developing countries are taking anti-
retroviral treatment up from 100,000 in 2001.

And in some populations in East Africa, the Caribbean, and Asia, HIV
infections are falling.

But if HIV is declining in some populations, it is rising in others.
In some Asian countries there's an upsurge in HIV infections among
men who have sex with men, but infections are declining in other
groups. The most striking overall increases have taken place in East
Asia, Eastern Europe, and Central Asia: the number of people
living with HIV went up by one fifth here between 2004 and 2006.

Globally, young people (15-24) accounted for 40% of new HIV
infections last year.

One in seven new HIV infections last year occurred among under-
fifteens. By the end of 2006, 2.3 million (1.7-3.5 million) children
(under 15) were living with HIV.

Let's just remind ourselves that the United Nations Convention on the
Rights of the Child defines children as people up to the age of 18.

But AIDS epidemiologists compile information for under fifteens and
for 15-24-year-olds. Lack of disaggregated data for children makes it
even harder to take effective action on their behalf.

One reason for this is the feminization of the epidemic: almost half
of all adults living with HIV are women. Only one in ten pregnant
women with HIV in low and middleincome countries receives anti-
retroviral prophylaxis to prevent transmission of HIV to their
children. Every year, more than 500,000 children are infected via
transmission from their mothers.

But this is just one way children become infected with HIV. Sexual
abuse is another.

The second (and main) way is through sex – whether it's between young
girls and older men, sex between adolescents, or sex between
trafficked girls or boys and clients, sexual violence and rape, or
incest.

A third cause of infection is injecting drug use, which often starts
in adolescence. In Russia, 76% of all people living with HIV are or
have been injecting drug users.

This is all fuelled by ignorance about HIV transmission. It's amazing
how prevalent this still is in 2007. I've just come back from China
where most young people have barely a clue about how HIV is
transmitted.

At the same time, only one in ten children needing HIV treatment can
get it – even though paediatric drug formulations are much more
widely available, and the price of antiretroviral drugs for children
has dropped – in some cases to less than 16 US cents per day. Just 4%
of children born to HIV-positive mothers receive cotrimoxazole, which
WHO recommends providing to children when early diagnosis of HIV
infection is unavailable. In Botswana and Zimbabwe, child mortality
rates have nearly doubled since 1990.

Last eek UNICEF reported some remarkable declines in child mortality
throughout the world, for the first time fewer than 10 million
children under five died – except in countries with high HIV
prevalence and those in conflict.

More than 15 million children worldwide have now been orphaned by
AIDS – over 12 million in Southern and East Africa. Orphan
populations are increasing in some populations in Asia, Latin America
and the Caribbean, and Eastern Europe too.

This much we know. Now let me turn to what we don't know.

We are constantly striving to know more about the AIDS epidemic,
through better and more accurate data collection. But there's still a
long way to go.

Today's surveillance categories are too broad and too blurred.
Collecting data for children up to the age of 15 and then for young
people between the ages of 15 and 24 doesn't give us the sort of
information we need: there's a huge difference in terms
of action between HIV infection at 15 and acquiring HIV at 24.

We need much more refined data about different age groups. We also
need to distinguish between the different categories of orphan –
"double", "one parent", maternal and paternal. And we need to become
much more systematic in pinpointing the differences between epidemics
within countries.

We also need to re-evaluate the way we perceive the issue of children
and AIDS. As so often happens, we have tended to only do this through
the medical lens, with a primary focus on mother to child
transmission. But this is to over-simplify, and to
ignore critical social and rights-related issues.

One problem is that we don't know enough about what these issues are.
We sense that AIDS is breaking up families and communities and
challenging traditional safety nets. We know that the impact on
household welfare is greater on the poor than on the better off, and
that gender inequities make girls more vulnerable than boys. We
are aware that it is threatening children's rights - civil,
political, economic, social and cultural.

And then there's the new reality: older children living with HIV. In
recent years, I've been meeting increasing numbers of HIV positive
adolescents and young adults.

But we often still lack hard, empirical data: the impact of AIDS on
children remains under-researched and poorly understood. We simply
don't know enough about what is happening. That's why the Joint
Learning Initiative is so badly needed.

Now let's look at what action is being taken today.

It's nearly 20 years since world leaders decided that people under 18
needed their own convention. That convention - the 1989 United
Nations Convention on the Rights of the Child, famously ratified by
all UN Member States except the US and Somalia – stresses the
importance of making the "best interests of the child" a
primary consideration and lists a series of rights. These include
such basics as information, education, non-discrimination, health,
social security, an appropriate standard of living, to be protected
from violence and different forms of exploitation, and the right not
to be separated from their parents. All are critical if children are
to grow up to live safe and healthy lives in a world with AIDS.

Since then, a series of international meetings and declarations have
highlighted the urgent need to address the issue of children and
AIDS. But to what extent are these declarations being acted on?

A few countries have substantially increased access to services to
prevent transmission of HIV from parents to children. For example, in
Argentina, Botswana, Jamaica, and Ukraine, more than 85% of HIV-
positive pregnant women received antiretroviral drugs to prevent
transmission of HIV to their children.

Some countries - including Botswana, Rwanda, and Thailand - have
scaled up HIV treatment for children by integrating it into treatment
sites for adults. Thailand is getting antiretrovirals to more than
95% of the under-15s in need.

Several countries in southern Africa have provided child grants and
other benefits on a national scale. Kenya, Malawi and Mozambique have
piloted cash-transfer programmes in poor areas.

In 58 countries surveyed last year, 74% of primary schools and 81% of
secondary schools said they were providing AIDS education. This is
critical if adolescents are to protect themselves from infection. To
be effective, AIDS education must fulfil the right to information (as
required in the Convention on the Rights of the Child). It must
provide information about all risks, and offer a broad palette of
prevention options – including abstinence, condoms, and measures to
address inequalities between girls and boys.

More efforts are being made to see that children get a fair share of
AIDS funding. A number of donors including the US and UK have
earmarked at least 10% of their AIDS money to go towards services
for children.

And lastly, more is being done to integrate services – to forge links
across diseases and sectors and bring partners closer together. In
Kenya, Rwanda, Tanzania and Zambia, strategic investment of AIDS
funding is improving services such as immunization and antenatal
care. And Norway's Women and Children First Initiative sets out to
provide a continuum of care for mothers, newborns, and children.

Many organizations are providing support to help countries look after
their children better. UNAIDS co-sponsor UNICEF, for example, has
made tackling children and AIDS one of its top priorities.

In 2005, UNAIDS joined UNICEF to launch "Unite For Children, Unite
Against AIDS", which sets targets for scaling up "The Four Ps":
prevention of HIV transmission from mother to child, paediatric
treatment for HIV, prevention of HIV among adolescents and young
people, and protection and support for children affected by HIV.

And as Peter mentioned earlier, civil society groups –the Elizabeth
Glaser Paediatric Foundation, the Ecumenical Advocacy Alliance and,
of course, the Francois-Xavier Bagnoud Association – are doing
tremendous work.

But most importantly of all, communities are responding and adapting
to the new realities around children and AIDS – often with tremendous
resilience.

So how do we build on this progress and intensify its impact?

We're here today because there are no simple answers to these
questions.

AIDS, as many of you have heard me say before, is an exceptional
issue – in terms of its threat to humanity and its complexity. The
Joint Learning Initiative was itself born out of recognition that the
issue of children and AIDS is immensely complex – and that it
requires a complex response.

I would like to suggest seven elements that I regard as key to making
that response effective.

First, it must be firmly grounded in human rights principles – in
line with the 2003 Comment on the Convention on the Rights of the
Child that "the child should be placed at the centre of the response
to the pandemic, and strategies should be adapted to children's
rights and needs". To be effective, those strategies have to
work equally well for seven-year-olds as seventeen-year-olds.

Second, it must involve a wide range of actors – not least the
children concerned, their parents, grandparents, and members of the
communities they live in. This means bringing children and family
members – including those living with HIV - to the table when
programmes are designed.

Third, it must prevent new HIV infections – for example by scaling up
access to services to prevent mother to child transmission and by
making HIV prevention more available and accessible to adolescents.
By addressing vulnerability and – though I know this is
controversial – by preventing sexual transmission. Universal Access to
HIV prevention, treatment, care and support is not only for adults!

Fourth, it must provide treatment for children. This will mean
scaling up testing and counseling, and making antiretroviral drugs
and cotrimoxazole more easily available.

Fifth, it must provide adequate levels of social welfare to children
infected and affected by HIV, and to their families and communities –
for example through cash transfers.

Sixth, it must be fully funded at international and national level.
This means more money for children and AIDS from international donors
and a higher priority for children in national development plans. At
UNAIDS, we estimate that $2.7 billion will be needed for programmes
for orphans and vulnerable children in 2008.

And finally, as I mentioned earlier, it must be based on more
accurate information.

This means not just improving surveillance but also clarifying how
children become vulnerable, looking more closely at socio-economic
contexts, and intensifying research into psychosocial impacts and
responses. It means looking at children in the contexts of their
families and communities, improving monitoring and evaluation
systems, studying how households cope and what local care-giving
practices involve.

To turn this wish-list into reality, high levels of political will
and commitment will be required. To inform and drive the process
forward, we will need a growing body of knowledge about children and
AIDS. We will need evidence from successful

interventions to show what can be done. And we will need sustained
activism to make sure the right action is taken – now and in the
years to come.

This brings me to my conclusion: it is time now to bite the bullet
and start thinking and acting in the context of the longer term –
something we have repeatedly failed to do up to now. Here, children
clearly have a major role to play.

We need to be confident that what we are doing now works on two
levels – both now and in the years to come. We must take steps now so
a girl born today doesn't grow up to produce an HIV positive baby and
so children born with HIV get anti-retroviral treatment and live
longer, healthier lives.

This means doing what you are doing in the Joint Initiative: taking a
long, hard look at what we are doing, identifying what works and
coming up with new approaches and new research to address new trends.

It means working together in a coherent fashion, on long-term,
integrated programmes: the day of the short-term, ad-hoc project is
over.

And it means ensuring that our response is comprehensive, flexible
and anticipatory - tailored to different epidemics and ready to
change as epidemics evolve: AIDS doesn't stand still, and the world
around it is not standing still - nor can we.

Thank you.
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