3. Implementation of OVC Programs

3. A. Guiding Principles

The HIV/AIDS pandemic strikes at the heart of family and community support structures. The Emergency Plan envisions a comprehensive and multi-sectoral approach that builds on community and family support structures, and engages communities in taking action to care for and track the welfare of affected children. Programs supported by the PEPFAR should adhere closely to the following principles and sound practices:

Focus on the Best Interests of the Child and His or Her Family
The needs and context of the children served must guide interventions, while respecting the duties and rights of parents (if they are alive and present). Programs must implement effective measures to prevent gender inequity, avoid further degradation of family structures, reduce stigma, avoid social marginalization, and that do not generate jealousy and conflict for beneficiaries. Services need to be designed to reduce stigma, not increase it. Focusing interventions on the family unit and the community ? and not only on the affected child?will promote the best interest of the child.

Prioritize Family/Household Care
The family is generally the optimal environment for a child to develop. Assistance programs should enable vulnerable children to remain in a loving family situation in which they can maintain stability, care, predictability, and protection. Supporting family capacity, whether the head of household is an ill or widowed parent, an elderly grandparent, or a young person, helps build a protective environment for vulnerable children. Institutional care is not optimal for child development, sustainability, or cost-effectiveness. There are, however, instances when residential care could be the only practical alternative; for example, abandoned children, particularly HIV positive children, for whom there is no alternative. Every institution that cares for children should prioritize the maintenance of strong links with extended families, the reintegration of children back into the community and securing a stable, family-based placement. Attention should also be given to keeping siblings together.

Bolster Families and Communities
Families and communities are both involved in raising children. The Emergency Plan seeks to support interventions that strengthen the capacities of families and communities to make informed decisions on who needs what care and how best to provide it, especially for the long term. Urgent humanitarian needs often necessitate the direct, immediate provision of food, medicine, and other basic social services to save the lives of vulnerable children. Sustainability requires fortifying the abilities of communities, local government, and indigenous institutions to continue supporting vulnerable children and their families after external assistance is no longer available. The Emergency Plan?s goal of building the long-term sustainability of OVC interventions requires planning for this transition and for the continuity of service delivery to and by the community.

Nurture Meaningful Participation of Children
Children and their families should participate, to the fullest extent of their capacities, throughout the project cycle of planning, implementing, monitoring, and evaluating. Participation increases program responsiveness to the best interests of the child and his or her families, and improves the likelihood of making a measurable difference in their lives. Adults often need support in understanding the value of listening to children and taking action to engage children?s capacities as actors, not just beneficiaries. Possible means for participation include involvement in community committees, youth mapping of interventions, input into program design, and developing versions of national plans of action, understandable for children.

Promote Action on Gender Disparities
All aspects of OVC programming design must consider issues of gender to ensure the appropriate addressing and differing needs of boys and girls at various developmental stages. However, both girls and boys face discrimination and violence, exacerbated when they are living outside of family care. Within HIV/AIDS-affected communities, the girl child often faces a disproportionate level of risk and vulnerability¹²,¹³ for exploitation, physical and sexual abuse, trafficking, HIV infection and burdens of caring for family members¹⁴,¹⁵,¹⁶. Programs must address these risks and excessive burdens of care along with their root causes. Strategies include prioritizing girls? enrollment and retention in school, including enrollment at the secondary level¹⁷; creating safe social spaces for pre-adolescent and adolescent girls, such as through youth centers or kids' clubs. These can provide psychosocial support, along with age-appropriate knowledge in the areas of reproductive health, nutrition, and HIV prevention. Linking girl heads of households to supportive local women?s groups, faith-based programs, or local non-governmental organizations (NGOs) can also provide them with both psychosocial support and protection.

Respond to Country Context
Activities must be contextually relevant and responsive to variances in high and low HIV prevalence areas. In most instances, national orphan rates conceal substantial differences among communities affected in different ways by the epidemic, which need consideration when targeting OVCs. The identification of ?hot spot? sub-regions with higher OVC burdens is important for making decisions about the allocation of scarce program resources. Activities also must be mindful and respectful of local, cultural, and religious values, and should seek to reinforce or include community norms that bolster the establishment of safe, loving, and secure environments for children, while attempting to change beliefs and practices that cause harm to children.

Strengthen Networks and Systems; Leverage Wrap-Around Programs
Networks (e.g., Parent-Teacher Associations, co-ops) and systems (education, health) within communities offer opportunities for referral mechanisms and case management in delivering comprehensive support to children. Identifying and coordinating multi-sectoral responses is important so a) agencies play to their strengths; b) all core interventions are available for children and families in need; c) programs are sustainable; and d) children and their families have access to interventions outside the purview of the Emergency Plan funds. Mapping the existence of networks and systems is an essential step to leveraging beyond the scope and funds of the Emergency Plan. U.S. Government Country Teams should institute a process for identifying and coordinating multi-sector responses to the needs of OVCs. The process should address partnerships with other U.S. Government agencies and programs, other international partners, United Nations agencies, host Governments, and the private sector to coordinate activities, share training opportunities, and exchange sound practices among implementing entities. Using proportional funding to co-sponsor activities that reach beyond the Emergency Plan mandate can be another means of more holistically addressing the needs of vulnerable children and their families.

Link HIV/AIDS Prevention, Treatment, and Care Programs
A family-centered approach to prevention, treatment, and care relies upon functioning referral systems. Children of parents, families, or other caregivers who are benefiting from Emergency Plan programs need referral to OVC programs. Likewise, caregivers of vulnerable children cared for by Emergency Plan programs should obtain referrals to obtain needed support. Referring parents to anti-retroviral therapy programs should be a priority. When parents or caregivers are terminally ill, Emergency Plan OVC programs need to prepare families for the upcoming transition. U.S. Government Country Teams should consider formal mechanisms to facilitate inter-agency and inter-sector coordination to ensure that referral systems work for families. This effort can rely upon U.S. Government staff, or Country Teams can identify a partner to coordinate this effort. Linkages to prevention programs are also extremely critical, since OVCs are particularly vulnerable to sexual exploitation and trafficking, and thus risk becoming HIV infected.

Support Capacity of Host-Country Structures
The long-term impact of investments by the Emergency Plan will largely depend on the capacity of host-countries to assume responsibility for lessening the impact of HIV/AIDS on vulnerable children and their families. By providing technical assistance and investing in systems that strengthen Provincial, District and national authorities along with NGOs, FBOs and CBOs, Emergency Plan funds can help countries scale up care for more OVCs while also improving the quality of care. Improving coordination between Ministries and clarifying their roles can contribute to more effective policies and programming for OVCs.

Country Teams and OVC partners should participate in and contribute to national planning efforts, including mapping, reporting systems and quality-assurance methodologies. PEPFAR OVC programs must be part and parcel of national HIV/AIDS strategies and plans, and OVC national plans of action, as well as have the active support and engagement of local and national Governments, and multilateral organizations and institutions.

3. B. Core Program Areas

Meeting the basic needs of children and youth is not only vital for ensuring their current well-being, but is also critical to their future. Basic or "core" needs include food/nutrition, shelter and care, protection, health care, psychosocial support, and education. Illness in the family or the loss of a parent or parents is extremely disruptive to children, and places them at a distinct disadvantage in obtaining the support necessary for their welfare and even at risk to life. Financial and material resources are often required to meet most of these needs, so economic strengthening is also often essential.

Working together, the U.S. Government in-country team and implementing partners need to ensure essential core support is available to identified OVCs. At the child level, the six core areas of a child?s life (food/nutrition, shelter and care, protection, health care, psychosocial support, and education) and the means to maintain them (economic strength) should be regularly monitored. Comprehensive, quality services should be then designed to meet each child?s specific needs. Please note, however, that this does not mean that each OVC program should provide all possible interventions for all OVCs. On the contrary, each partner should contribute according to its comparative advantage, and together with other providers, contribute to a well-coordinated and comprehensive set of interventions, regardless of the funding source or implementing partner. U.S. Government in-country staff should work closely with partners to determine what each program contributes in terms of program strengths, measurable results, and geographic coverage. The exact mix of care provided and the beneficiaries served will differ by location, according to existing community resources and the types and extent of a child?s vulnerabilities. The Emergency Plan encourages programs to support the development of a menu of core interventions that will guide community-led decisions on service delivery to orphans and other vulnerable children. The Emergency Plan will support processes that enable families and community members to make informed decisions regarding the mix and extent of core programs. The menu of core interventions should reflect service mapping that identifies coverage gaps and opportunities, and be coordinated with Government and civil-society programs, existing documents, and/or planned interventions consistent with the capacity and priorities of the Emergency Plan.

The following section briefly describes each core program area. A listing of examples of activities, broken down by Child, Caregiver, and Systems Levels that Emergency Plan funds can support, as well as some activities that do not fall under Emergency Plan funding, appear in Appendix II. Careful consideration of the appropriateness to the national and local context is paramount. Other interventions, beyond those listed here, will be given consideration for Emergency Plan funding on a case-by-case basis during the Country Operational Plan review and approval process. The Emergency Plan also encourages collaboration and leveraging with other international partners for comprehensive service delivery, as described above.

3. B. 1. Food and Nutritional Support
Food and nutritional are important components of OVC support. Malnutrition underlies more than one half of deaths in children under five in developing countries¹⁸, and the Emergency Plan works in many communities broadly affected by food insecurity. Food-security issues are extremely complex, and other organizations and international partners have strong comparative advantages in providing food assistance. Thus, a key precept of interventions supported by the Emergency Plan is to remain focused on HIV/AIDS. While the Emergency Plan funds can support food and nutrition for OVCs, ideally programs should leverage this support from other international or host-country partners, and it should be time-limited and conditional on the identification of more sustainable solutions. For additional information on the provision of food and nutritional support to OVCs, please see the Emergency Plan policy guidance, Use of Emergency Plan Funds to Address Food and Nutrition Needs of People Infected and Affected by HIV/AIDS¹⁹, and the Report to Congress, Food and Nutrition for People Living with HIV/AIDS.²⁰

3. B. 2. Shelter and Care
The HIV/AIDS epidemic overloads impoverished communities to the point where many children are left without suitable shelter or care. Those children who find themselves without a caregiver become highly vulnerable to abuse and stunted development.²¹ While institutional care might seem like a logical response to this situation, in some cases it can impede the development of sustainable solutions and often does not meet the complex needs of children.²² While there is sometimes a role for institutional arrangements, they are not optimal for child development, sustainability or cost-effectiveness. Given the number of OVCs, particularly in sub-Saharan Africa, and their complex needs, the most effective responses place families, households and communities at the center of interventions.

3. B. 3. Protection
The core values of this OVC guidance are rooted in the principles of child protection ? developing and implementing programs that place the best interests of the child and his or her family above all else. Thus, programs should include efforts to confront and minimize the reality of stigma and social neglect faced by OVCs, as well as abuse and exploitation, including trafficking, the taking of inherited property, and land tenure.

3. B. 4. Health Care

• 3. B. 4. a. General Health Needs of OVCs (including HIV/AIDS prevention)
  OVC programs must take active measures to meet the general health needs of children at every age level. Programs must disaggregate health requirements and interventions by the age groupings listed in section 2.B (infant, toddler, child and adolescent), as the health needs and recommended interventions differ significantly among these groups, and programs should facilitate access to primary health care for OVCs.
   
• 3. B. 4. b. Health Care for HIV-Positive Children
  Without appropriate treatment, over 50 percent of children born HIV-positive die within the first two years.²³ The Emergency Plan considers the provision of HIV-related health care to exposed or infected infants a high priority. When ill or suffering from the onset of AIDS, children supported under OVC programs should have timely access to appropriate ART. Programs should make available other health care for children born to HIV-infected mothers and known HIV-positive children, and related support either through direct access to health providers, or, preferably, with arrangements and referrals established with programs such as providers of interventions to prevent the transmission of HIV from mothers to their children (PMTCT), or specialized pediatric ART providers. Monitoring skin, weight and vital signs, periodic CD4 and/or HIV testing for children and youth, and pediatric ART and ART adherence interventions for HIV-positive OVC are among the essential health care required for HIV-positive children. For further information on this topic, please refer to the Guidance for a Preventative care Package for Children Aged 0-14 Year Old Born to HIV Infected Mothers²⁴ and to the Emergency Plan Report on Pediatric AIDS.²⁵
   
• 3. B. 4. c. Prevention of HIV
  Prevention of HIV is a priority health intervention in regions where the risk of infection is high. Programs should provide age-appropriate prevention activities to OVCs, including PMTCT intervention, as well as communication for behavior change targeted to appropriate age groups. OVC programs need to ensure vulnerable children get age-appropriate effective HIV prevention messages, including abstain, be faithful, and, as appropriate, correct and consistent use of Condoms (ABC), as well as avoiding injecting drugs and alcohol abuse. This is particularly true for programs that target adolescents and older youth. For additional guidance on the appropriate use of Emergency Plan funds to address preventive behaviors that help OVC avoid infection, please see the PEPFAR Guidance on Applying the ABC Approach to Preventing Sexually-Transmitted HIV Infections, 2005.²⁶

3. B. 5. Psychosocial Support
Healthy child development hinges greatly upon the continuity of social relationships and the development of a sense of competence. HIV/AIDS can undermine the fundamental human attachments essential to normal family life and child development. Children affected by HIV/AIDS suffer anxiety and fear during the years of parental illness, then grief and trauma with the death of a parent. Cultural taboos surrounding the discussion of AIDS and death often compound these problems. Children and their caregivers need love and emotional support, and the opportunity to express their feelings without fear of stigma and discrimination. Programs should provide children with support that is appropriate for their age and situation, and recognize that children often respond differently to trauma and loss. OVCs sometimes turn to drugs and alcohol as a means of coping with this trauma. Programs must provide support to avoid these counterproductive activities. In addition, U.S. Government Country Teams must also consider the emotional and psychosocial support for frontline national staff who are working with AIDS-affected communities. Many of those who are providing support to others are living with the trauma of HIV/AIDS in their own lives. Psychosocial counseling, rotational duties, and other interventions might be necessary to keep them from burn-out.

3. B. 6. Education and Vocational Training
Research on children and AIDS demonstrates that education can leverage significant improvements in the lives of orphans and other vulnerable children²⁷. Schools not only benefit the individual child, but can also serve as important resource centers to meet the broader needs of communities. Schools can provide children with a safe, structured environment, the emotional support and supervision of adults, and the opportunity to learn how to interact with other children and develop social networks. An education is the key to employability and can also foster a child?s developmentally important sense of competence. Countries and communities must identify the barriers to education (e.g., requiring a father to register a child, mandatory payments for uniforms, book or tuition fees) and define locally-appropriate strategies for attracting and keeping children, especially girls, in school. Programs must give special attention to the vulnerability of girls, by addressing the disproportionate levels of risk they face when leaving school at an early age. Schools must also be made safe for children, especially girls. In addition, vocational training is an important component of life preparation. Conversely, the lack of opportunity to learn a trade or the lack of a sponsor to enter vocational networks can threaten adolescents' long-term economic prospects.

Partnerships with the education sector provide an important opportunity to ensure that children affected by HIV/AIDS have access to education. Linkages with other programs such as U.S. government's basic education program or African Education Initiative (AEI) implemented through USAID can help expand educational opportunities. Education is an important area for leveraging on national and local levels.

3. B. 7 Economic Opportunity/Strengthening
OVCs and caretakers often experience diminished productive capacity and cash resources for necessary household purchases. Economic strengthening is often needed for the family/caregivers to meet expanding responsibilities for ill family members or to welcome OVCs into the household. Linking OVCs and their families with programs providing economic opportunities is often an important service. Look for programs that base their economic-strengthening activities on market assessments, and undertake joint efforts with organizations that have strong experience and a high level of expertise in this area. Food and fuel typically absorb the greatest share of household expenditures. Interventions that save household labor and expenses can relieve the burden of diminished capacity and perhaps allow families to allocate resources for more productive, remunerative uses. Maturing children and adolescents need to learn how to provide for themselves and establish sustainable livelihoods.

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