Appendix I: Examples of Eligible and Ineligible Activities for Core Program Areas

Below please find illustrative examples of interventions PEPFAR funds can support for children affected by HIV/AIDS. This list is not intended to be fully comprehensive.

1. Food and Nutritional Support
Food and nutritional support are usually the most costly of interventions needed by OVCs, and are certainly essential. Ensuring adequate food and nutrition requires interventions and coordination at many levels. Working with national Governments, communities and food agencies, the Emergency Plan intends to contribute to achieving food goals for OVCs, but in a way consistent with its mandate. Emergency Plan funds can support OVC food and nutritional support interventions at three levels. Please refer to the Report on Food and Nutrition for People Living with HIV/AIDS³⁰ for additional details. Examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Nutritional assessment and counseling;
• Weaning foods and other nutritional support for children under two years of age;
• Therapeutic and supplementary feeding of malnourished children based on anthropometric assessment and World Health Organization (WHO) guidelines; and
• Support to link children with other health and nutrition interventions provided by public or private health providers.

Caregiver or Family Level

• Training, course materials, and other program support for facility- and community-based counseling of families and caregivers on nutrition, diet and food preparation techniques.

Systems Level

• Development of policies and technical guidelines, training curricula and job aides for nutrition assessment and counseling;
• Working with appropriate national and District implementers to ensure targeting of OVCs for food and nutrition interventions and programs;
• Technical assistance and coordination with food industry to promote production of and access to nutritious foods, including fortified foods, for OVC; and
• Advocacy and resource mobilization for programs to address the nutritional needs of OVCs.

Emergency Plan funds for OVC cannot support:

• Strengthening the general administrative and management capacities of the food/agriculture sector that have deteriorated because of the impact of HIV/AIDS;
• School feeding programs for all school children; and
• Broad-based food-assistance and food-security programs

2. Shelter and Care
Working with communities, families and other international partners, Emergency Plan OVC programs should work to ensure no child goes without shelter, clothing, or basic personal hygiene. Yet, programs must meet these life-long needs through sustainable, community-based interventions consistent with and responsive to local circumstances. Partners who are working with OVCs affected by HIV/AIDS should work with other international partners, Governments, local authorities, NGOs, FBOs and CBOs to identify OVCs with unmet needs, and to offer, when required, temporary assistance. However, to encourage sustainable, effective solutions that support children who are without shelter or care, Emergency Plan programs should primarily intervene through referral and leveraging. Examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Assisting children and family members in identifying potential caregivers, prior to a parent?s death;
• Reintegrating children who are currently in institutional care through family tracing and fostering;
• Providing access to temporary shelter for children in transition; and
• Supporting child- or youth-headed households in maintaining their homes.

Caregiver Level

• Supporting family reunification and temporary shelter to take children off the streets;
• Supporting referrals and access to programs that provide incentives for adoption or the provision of foster care.

Systems Level

• Strengthening community-based programs that provide temporary shelter for children in transition and longer term shelter for those with no community option;
• Strengthening family-based care models for children (i.e., extended families, local adoption, and foster care);
• Developing innovative community responses to provide care in personalized settings when family options are not available (live-in schools, drop-in centers, etc.);
• Providing quality-assurance monitoring for institutionalized care; and
• Strengthening reintegration programs and providing training to accomplish family tracing for OVCs who are leaving institutional care.

3. Protection
In many countries where PEPFAR is working, the national government and international partners have introduced governance and legal reform. In keeping with the Emergency Plan?s focus on HIV/AIDS, partners who are supporting OVCs should find ways to incorporate youth-protection measures into ongoing or proposed reforms. Developing and implementing programs that place the best interests of children and their families above all else is a key value. All policy projects must have clearly delineated outcomes, e.g. an increase in number of registrations in X amount of time, etc. General policy work without specific outcomes should not be supported with PEPFAR resources. Examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Facilitating basic birth registration and identification necessary for long-term access to education, health care and social services;
• Providing community-based assistance to OVCs for inheritance claims;
• Strengthening child-headed households with the intent of promoting community support and prevent sibling separations; and
• Removing children from abusive situations into safe, temporary or permanent placements.

Caregiver Level

• Activities to support families and caregivers to better manage stress and improve parenting when they are in situations of chronic illness, are caring for multiple orphans, and have decreasing material resources; and
• Coaching caregivers to better access community and system-level support to which OVCs are entitled.

Systems Level

• Strengthening local community structures (such as Child Protection Committees) that carry accepted responsibility for monitoring and protecting OVCs;
• Providing training and support to frontline workers who are the "gatekeepers" ? those most likely to come into contact with OVCs, including local NGO field staff, local volunteers, police, emergency hospital workers, school counselors and nurses, and staff of child residential care facilities; assist police in how to constructively deal with OVCs who are in violation of the law.
• Networking with programs that confront incidents of child trafficking and sexual abuse;
• Improving mechanisms/systems to increase birth registration, improve access to basic social services, and facilitate inheritance claims;
• Policy development, such as technical assistance to local authorities on improving the investigation, reporting and follow-up on cases of rape, abuse, and neglect;
• Reviewing and assisting in the development and strengthening of child law and protection services and policies, including adoption;
• Communication or multi-media campaigns to support social norms that protect children and prevent child abuse and exploitation (e.g., increase reporting and legal action); and
• Activities to reinforce or change social norms to increase the practice of will writing, succession planning, and the enforcement of inheritance laws.

4. Health Care

a. General Health Needs of OVCs
OVC programs need to take active measures to meet the general health needs of vulnerable children at every age level. This often means making sure the caretakers bring the child to a clinic for health care. HIV care is also an important element for these children, as they might have been exposed to HIV and require testing and care. Emergency Plan resources for OVCs can be used to support the preventive and primary health care needs of children. To be cost-effective, however, interventions should rely largely upon existing health programs sponsored by Governments and international partners to ensure immunization coverage, maternal and health care (including antenatal and postnatal care, HIV testing, etc.). Examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Referrals and linkages to child health care, including, but not limited to, immunization, growth monitoring, malaria prevention and HIV testing, where appropriate; and
• Provision of support for survivors of sexual or physical abuse, including post-exposure prophylaxis (PEP) for rape victims, and education and messaging to prevent abuse.

Caregiver Level

• Training of caregivers to monitor children?s health and gain access to available health care when services are needed; and
• Training of caregivers and guardians on how to talk to children about abstinence and safe sexual behaviors and support healthy life decisions.

Systems Level

• Training of HIV counselors, home-based care providers, traditional healers, educational staff and staff of PMTCT and ART clinics to identify, monitor, and make referrals to health care and basic social services for children and clients' children;
• Work with public and private health care providers to integrate HIV elements and awareness of the special vulnerabilities of HIV-positive OVCs;
• Training of health workers in the WHO integrated infant and young child practices course or similar; and
• Bolstering the capacity of public and private health providers to improve the provision of immunizations, growth monitoring, bed-nets, malaria and tuberculosis meds, diarrhea control and treatment, and other basic prevention and care.

Emergency Plan funds for OVCs cannot support:

• Purchase of vaccines (or bulk formulation for vaccines) for immunization programs
• Contraceptives

b. Health Care for HIV- positive children
PEPFAR considers the provision of HIV-related health care to exposed or infected infants a high priority. Appropriate health care services for children born to HIV-infected mothers and known HIV-positive children are described in the Guidance for a Preventative Care Package for Children Aged 0-14 Years Old Born to HIV-Infected Mothers.³¹ Palliative care for HIV-positive children is outlined in HIV/AIDS Palliative Care Guidance #1: An Overview of Comprehensive HIV/AIDS Care Services.³² The Report to Congress on Pediatric AIDS³³ is also a reference for a discussion of ART for children.

c. Prevention of HIV
Prevention of HIV is a priority health intervention, particularly among adolescents, and especially in regions where the risk of infection is high. Please refer to the Guidance for Applying the ABC Approach to Preventing Sexually-Transmitted HIV Infections³⁴ for complete details.

5. Psychosocial Support
Healthy child development hinges greatly upon the continuity of social relationships. Programs should supply both children and their caregivers with emotional support, as well as support local staff that serve on the frontline. To respond to psychosocial needs, examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Gender-sensitive life skills and experiential learning opportunities for OVCs that build resilience and self-esteem;
• Activities that encourage the integration of OVCs into traditional support systems within the community in order to increase the social and psychological well-being of vulnerable youth (mentoring, apprenticeships, etc.);
• Improving links between children affected by HIV/AIDS and their communities;
• Referral to counseling where available and appropriate, particularly for HIV-positive youth; and
• Rehabilitation/re-integration for children who are living outside of family care.

Caregiver Level

• Strengthening the capacity of caregivers to listen to and talk with children;
• Access to family-centered activities that address the dynamics and stages of illness, treatment, and/or pending death (e.g., communication on the disclosure of HIV status, ART, succession planning, grief counseling); and
• Activities that help children to give expression to their feelings and perceptions of loss and help in the preservation of attachment and personal history, (e.g., art therapy, memory box methodologies, etc).

Systems Level

• Increasing communities? understanding of and action on the psychosocial needs of children and youth and the responsive roles community members can take to improve social or psychological wellness, including roles in schools and religious organizations;
• Providing training in age- and situation-appropriate communication;
• Strengthening local capacities to provide psychosocial support for distressed children (e.g., training of clinicians and community workers);
• Providing opportunities for networking, training, and reflection for frontline local staff who work with local partners in AIDS-affected communities; and
• Further investigation and refinement of culturally relevant measures to promote psychosocial well-being and factors that contribute to improved child welfare.

6. Education and Vocational Training
Increasingly, stakeholders in the fight against HIV/AIDS are recognizing and promoting the fact that education can bring about significant improvements in the lives of orphans and other vulnerable children. A growing body of research from sub-Saharan Africa makes clear the importance of timely, cost-effective interventions to secure access to primary and secondary education as well as livelihood training for children affected by HIV/AIDS.³⁵ Children orphaned in the region are much less likely to attend school, and can be unable to care and provide for themselves as a consequence. If school fees are the issue, international partners or communities can intervene to keep OVCs in school. Longer-term solutions, however, lie in mobilizing the community to establish fee-reduction for the disadvantaged, in providing direct support to schools for improving education (using non-AIDS funding), and negotiating scholarships for the needy. Collaboration with other programs, such as with the Education for All Initiative, is an important way of leveraging educational funds.³⁶ Programs often must address additional factors to enable children to attend school, such as care-taking responsibilities at home, or issues of stigma. Recognizing the importance of education, examples of potential interventions that PEPFAR programs may fund include the following:

Child Level

• Activities that encourage access to the formal education system for OVCs;
• Short-term, direct assistance to subsidize school-related costs (e.g., fees, books, uniforms) or to leverage cost-avoidance programs that lead to broader school access and completion and complement a long-term strategy for sustainability;
• Activities that encourage access for OVCs into early childhood development programs and services; and
• Activities that encourage access for OVCs to vocational training.

Caregiver Level

• Training and materials for health providers and caregivers on identifying vulnerable children and appropriate care procedures;
• Activities to monitor OVC status and to integrate OVCs into community social life; and
• Anti-stigma education, particularly education aimed at reducing the stigma faced by HIV/AIDS orphans.

Systems Level

• Community-mobilization efforts to keep orphans and other vulnerable children in school and/or to provide them with educational alternatives;
• Advocacy and technical support to provide school-based counseling services, flexible school schedules and school curricula that include life skills, business and household management, and agriculture training, plus establishing mechanisms to provide linkages with community-and faith-based organizations for referrals to school-based programs;
• Teacher training on how to address issues that often plague children from households affected by HIV/AIDS, such as how to identify children at risk and how to counsel and refer children; and
• Train parent-teacher associations in school communities to support and enable OVCs to remain in school, such as supporting fee waivers, tutoring and psychosocial support.

Emergency Plan funds for OVC cannot support:

• Strengthening the education system and general teacher training unrelated to the needs of orphans and other children made vulnerable due because of HIV/AIDS.
• Scholarships and other access interventions for non-HIV/AIDS OVCs.

7. Economic Opportunity/Strengthening
Economic strengthening is often needed for the family/caregivers to meet expanding responsibilities for ill family members or OVCs who join the household. Maturing children need to learn how to provide for themselves and establish sustainable livelihoods. PEPFAR encourages the use of OVC funds for economic-strengthening activities, as well as cooperation and joint efforts with organizations that have strong experience and a high level of expertise in this area. This is particularly appropriate for interventions focused on adolescents as well as caregivers. Economic strengthening interventions should be market-driven and contextually relevant. Examples of potential interventions that PEPFAR programs may fund include the following:

Child and Caregiver Level

• Vocational and technical training;
• Livelihood opportunities (e.g., income-generating activities, links with the private sector);
• Small-business development and activities to promote entrepreneurism among older HIV/AIDS OVCs and caregivers;
• Household economic-strengthening activities focused on increasing coverage of school-related expenses, such as incentive-driven, conditional grants and training for HIV/AIDS OVC caregivers;
• Support for drip-kit irrigation and use of drought-resistant crops with gardens for child-headed households;
• Purchasing of seeds and tools for household or community gardens for HIV/AIDS OVCs;
• Setting-up small-scale animal husbandry for HIV/AIDS-vulnerable households, especially in collaboration with efforts supported by other international partners;
• Household laborsaving devices; examples include improved charcoal cook stoves that use 50% less fuel than traditional stoves; improved pestles that reduce the amount of effort and time for women to pound grain into flour; and, high-density kitchen gardens that require little labor, but produce sufficient vegetables to meet household nutritional requirements.
• Activities that provide access to micro-finance, primarily opportunities to save, access credit, and, in some cases, access insurance;
• Community-based asset-building; and
• Establishing mechanisms to support community-based childcare.

Emergency Plan funds for OVCs cannot support:

• Any programs not directly supporting HIV/AIDS-affected OVCs.

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