According to the United Nations Children's Fund (UNICEF), approximately 15 million children worldwide have lost one or both parents to AIDS. Nearly 12 million of these children live in sub-Saharan Africa.⁶ Many more children have been made vulnerable because of family illness and the widespread impact of HIV/AIDS on their communities. OVC populations will continue to grow as HIV incidence rates increase.

Although the vast majority of OVC can be found in family situations, some OVC live in institutions, in youth-headed households, or on the streets. The epidemic has decimated populations of teachers, healthcare workers, police, and other service providers that help to create strong networks of support for children and adolescents. As a result, OVC are more vulnerable to abuse and exploitation, and are also more likely to engage in unsafe behaviors, increasing the risk of HIV infection.

As part of the reauthorization of PEPFAR, Congress maintained the requirement to direct 10% of PEPFAR program funds be directed to OVC activities. This 10% earmark reflects the importance of PEPFAR's role in mitigating the impact of HIV/AIDS for the millions of children and adolescents living in affected communities.

PEPFAR is supporting child-centered, family-focused, community-based, and government-supported OVC programming. This evidence-based programming targets the full range of OVC needs at different developmental stages. It is linked with broader development efforts around education, food and nutrition, and livelihood assistance. PEPFAR works with countries to address the long-term impact of HIV/AIDS on child development. The quality services provided to OVC today can benefit the future well-being of a partner country. In its next phase, PEPFAR is supporting countries in pursuing the following objectives in OVC programming:

Building national systems of care

In an effort to promote a harmonized national response to the impact of HIV/AIDS on child development, PEPFAR is supporting and building capacity for multisectoral approaches. These efforts encourage governments to coordinate among various ministries, including those overseeing education, food and nutrition, social welfare, and health. PEPFAR is contributing to this coordination by ensuring that its OVC programs are integrated with other USG programs targeting children and vulnerable populations. In order to ensure a true continuum of care, PEPFAR will assist countries to bridge the gaps between medical, social service, and civil society stakeholders, and coordinate support services with prevention, treatment and care programs.

At the national level, PEPFAR is facilitating the adoption of child-friendly policies to address the needs of children infected and affected by HIV/AIDS, and to encourage alignment with broader health systems strengthening efforts. In keeping with PEPFAR's focus on creating government capacity for management and operation of HIV services, programs will also support the training of professional and paraprofessional staff. Finally, PEPFAR is supportive of country efforts to develop national standards for quality services provided by both the public and the private sector.

Strengthening the capacity of families and communities to care for vulnerable children

In Africa, an estimated 95% of orphaned children are cared for by other family members or neighbors.⁷ Much of the current research on OVC care and support identifies family environments as better able to meet the needs of OVC than more institutional models. Many families caring for OVC are already impoverished and overextended. Children within these households often face great risk of malnutrition, disease, and limited access to education and health care. PEPFAR is working with governments to prioritize family-focused and community-based programs that strengthen the capacity of caregivers and communities to function as social safety nets. OVC programs should assess, monitor, and address, as needed, the well-being of OVC within six key areas: food and nutrition, shelter and care, protection, health, psychosocial, and education. Progress in these areas is measured across countries using the standardized Child Status Index (CSI) tool, developed to monitor PEPFAR's OVC programming.

Developing and targeting need-based OVC responses that are sensitive to the diversity of sub-populations within the larger OVC population

The needs of OVC vary according to age, gender, socioeconomic status, and geography. Various studies and research tools have recently contributed to the development of more effective and targeted strategies for specific sub-sets of the OVC population. PEPFAR is working with partner countries to ensure that the diverse needs of OVC are included in efforts to identify, map, and plan to address overall HIV/AIDS needs in a given country.

In its next phase, PEPFAR is also coordinating with other USG and donor efforts to expand country-led initiatives intended to identify and address the needs of several previously neglected sub-sets. For example:

• To better address the needs of newborns, infants, and toddlers, PEPFAR is strengthening linkages with food and nutrition programming, PMTCT and adult and pediatric treatment sites. It will also improve training for community health workers and home visitors to monitor child growth and development.
• To better address the needs of young school-age children, PEPFAR is linking programs to basic education initiatives, enabling OVC to stay in school.
• To better address the needs of adolescents, who comprise the largest number of OVC, PEPFAR will increase efforts in youth livelihood development initiatives, focusing on higher levels of skill development. PEPFAR will also work to support adolescents and young adults as they transition from OVC programs into society and careers.

PEPFAR is also working with countries to prioritize programming for most vulnerable children, including children living outside of family-based care; abused, exploited and neglected children; and children and adolescents who meet the criteria for other most-at-risk categories. Although these children account for only a small percentage of the total OVC population, they are often at higher risk for HIV infection, and less able to access traditional social service channels.

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