Evidence base for children affected by HIV and AIDS in low prevalence and concentrated epidemic countries: applicability to programming guidance from high prevalence countries

Figures & data

Table 1. Quality of the documentation of studies in the evidence base on children affected by HIV and AIDS in low prevalence and concentrated epidemic countries.

		Strength of documentary evidence
Type of study	Number of studies (n(%))	Good	Fair	Poor
Situation	256 (62%)	137	56	63
Intervention	103 (25%)	54	30	19
Situation + intervention	54 (13%)	23	20	11
Total	413 (100%)	214 (52%)	106 (26%)	93 (23%)
Source: Quality Assurance Project (QAP, 2008).
Note: One study on methodology was excluded.

Table 2. Selected strong and moderate evidence on situations and interventions related to increased vulnerability of children affected by HIV and AIDS.

Priority challenge	Selected findings on situation and interventions	Description of evidence base
Health and health Care	• Situation: Healthy HIV-infected mothers reduce risk of mortality of their young children, both HIV-infected and uninfected – Strong evidence from Burkina Faso, Ivory Coast (Newell, Coovadia, & Cortina-Boraja, 2004) • Situation: Children in HIV and AIDS-affected households have comparable morbidity to similar children in unaffected households – Moderate evidence from Cambodia, India (Alkenbrack, Chettra, & Forsythe, 2004; Pradhan, Sundar, & Singh, 2006) • Situation: Children in affected households make fewer health care visits than children in unaffected households – Moderate evidence from Benin, China, India (Gestion d'entreprise en culture Africaine [GECA], Ministère de la Famille de la Protection Sociale et de la Solidarité, Projet Plurisectoriel de Lutte contre le VIH et SIDA, et al., 2005; Jianhua, Chun, & Kangmai, 2006; Loudon, Bhaskar, & Bhutia, 2007; Verma, Salil, & Mendoca, 2002)	Several studies with strong and moderate design but limited geographical coverage
Nutrition	• Situation: Affected children reside in food-insecure households more often than unaffected children – Moderate evidence from China, Senegal (Jianhua et al., 2006; Niang & van Ufford, 2007) • Intervention: Community-based education and supplementary programs improve nutritional status – Moderate evidence from Guinea (Kadio, Kaba, & Blackett-Dibinga, 2005)	Most studies focus on HIV-infected children, with limited assessment of other affected children; limited geographic coverage
Socioeconomic	• Situation: Affected households are economically worse off than unaffected households and express concerns about meeting basic needs – Strong evidence from Burkina Faso, Cambodia, China, India, Thailand, Chad (Abbott Labs Fund, 2002; Alkenbrack et al., 2004; Jianhua et al., 2006; Pradhan et al., 2006; Safman, 2004; Wyss, Hutton, & N'Diekhor, 2004) • Situation: Children living in affected households have increased workforce participation relative to similar children living in unaffected households – Moderate evidence from Cambodia, India (Alkenbrack et al., 2004; Pradhan et al., 2006)	Consistent, strong findings on situation; limited evidence on interventions that target additional vulnerabilities related to HIV and AIDS in the household
Education	• Situation: School enrollment among younger affected children is comparable to unaffected children, but older affected children appear less likely to be enrolled in school – Strong evidence from Cambodia, China, India, PR Lao (Alkenbrack et al., 2004; Jianhua et al., 2006; Pradhan et al., 2006; UNICEF & Save the Children Foundation [SCF], 2007) • Situation: Effect of orphanhood on school enrollment is mixed – Moderate evidence from Niger, Ghana, Chad, Benin, Nigeria (Ainsworth & Filmer, 2002; Case, Paxson, & Ableidinger, 2004)	Inconsistent findings across countries but relatively broad geographic coverage; large focus on orphans; few studies on interventions
	• Situation: Caretakers face difficulties ensuring school attendance due to several economic factors Moderate evidence from (Human Rights Watch [HRW], 2005; Jianhua et al., 2006; New ERA Team, 2006; Pradhan et al., 2006; Safman, 2004; UNICEF, 2002) • Intervention: Education provides protection against HIV infection – world Moderate evidence from (Global Campaign for Education [GCE], 2004; World Bank, 2002)
Psycho-social support	• Situation: Some affected children are more vulnerable to psychological problems than similar unaffected children – Strong evidence from USA, China, India, Western Europe (Brandt, 2005; Hough, Brumitt, & Templin, 2003; Jianhua et al., 2006; Lester, Rotheram-Borus, & Lee, 2006; Loudon et al., 2007; Nostlinger, Bartoli, & Gordillo, 2006; Pelton & Forehand, 2005) • Intervention: Psychosocial services improve psychological well-being of children living with HIV-infected parents – Moderate evidence from United States (Pivnick & Villegas, 2000; Rotheram-Borus, Lee, & Leonard, 2003) • Situation: Family, parent, and caretaker functioning are most important predictors of HIV and AIDS-affected children's psychosocial well-being – Strong evidence from USA, Western Europe (Bauman, Foster, & Silver, 2006; Nostlinger et al., 2006) • Situation: Vulnerability due to HIV and AIDS differs across ages – Moderate evidence from Western Europe, USA (Brandt, 2005; Nostlinger et al., 2006; Ostrom, Serovich, & Lim, 2006)	Consists largely of industrialized countries with strong study design, with scarce information across sub-groups of affected children
Protection	• Situation: Additional HIV and AIDS-related vulnerabilities relate to confidentiality, discrimination, and medical consent Moderate evidence from (Jackson, 2006a, b; Sealy-Burke, 2005a, b) • Intervention: Small programs have successfully helped families affected by HIV and AIDS gain access to services within their rights – Moderate evidence from South East Asia, Senegal (Borthwick, 2004; Samaras, 2004) • Situation: Legal frameworks often make no specific mention of children affected by HIV and AIDS – Moderate evidence from India, multi-country Caribbean (Jackson, 2006a; Sealy-Burke, 2005a)	Almost exclusively qualitative evidence, much of it not specific to children affected by HIV and AIDS, but related to all children
Placement	• Situation: Children born to HIV-positive mothers and HIV-infected children face increase risk of abandonment – Moderate evidence from Russia, Thailand, Vietnam, Eastern Europe (Borthwick, 2004) • Situation: Families and children's homes (including orphanages) are more reluctant to assume care for HIV-infected children – Moderate evidence from Russia, India (HRW, 2005; Rau & Lee, 2005) • Intervention: Institutional care should be the last resort for HIV-affected children – several industrialized countries, Strong evidence from Russia, Eastern Europe, PR Lao (Frank, Klass, Earls & Eisenberg, 1996; Tobias, 2000; UNICEF & SCF, 2007)	Solid cross-regional evidence of where children are living, limited evidence of additional vulnerabilities, no information on effective interventions to remove additional barriers to placement for children affected by HIV and AIDS
Stigma and discrimination	• Situation: Affected children anticipate, fear, and experience stigma and discrimination in communities, public services, and caretaking situations, although this may not reflect experiences of all affected children – multi-country Moderate evidence from Asia, Cambodia, Scotland, Benin, India, Thailand, China (Borthwick, 2004; Carswell, Ramage, & Richmond, 2005; Cree, Kay, & Tisdall, 2004; GECA et al., 2005; Loudon et al., 2007; Safman, 2004; Save the Children UK [SCF/UK], 2006a; Verma et al., 2002) • Interventions: Anti-retroviral treatment – Brazil, Haiti (Abadia-Barrero & Castro, 2006; Castro, 2005), visibility and participation – Moderate evidence from Haiti, China (Loudon, 2006; SCF/UK, 2006a), and anti-stigma information – Thailand (Henessey, 2001) improve acceptance and inclusion of affected children	Large moderate evidence base with modest geographic representation; some findings on relevant interventions, although not strong study designs
^aThis table consolidates findings from a review of the evidence base on children affected by HIV and AIDS in low prevalence and concentrated epidemic countries (QAP, 2007).

Table 3. Consolidation of recommendations for high prevalence countries into three programming principles.

Recommendations as outlined in JLICA LG1 summary^a,b	Programming principles
• Improve the prevention of HIV infection among adults and children • Expand treatment of adults and children living with HIV • Adopt family-focused approaches to HIV and AIDS prevention, treatment, and care	#1: Family-centered preventive efforts, treatment, and care
• Focus on families to support children affected by HIV and AIDS • Support extended families	#2: Family-focused support to ensure capacity to care for and protect HIV and AIDS-affected children
• Implement income transfer programs	#3: Sustaining economic livelihood of HIV and AIDS-affected households
^aJoint Learning Initiative on Children and HIV and AIDS (JLICA) (2008).
^bA seventh recommendation (build partnerships between the state and civil society for comparative advantages) was not included in this review given limited relevant findings in the evidence base in low prevalence and concentrated epidemic countries.

Pradhan , B. , Sundar , R. and Singh , S. 2006 . Socio-economic impact of HIV and AIDS in India , New Delhi , , India : National AIDS Control Organization (NACO), Ministry of Health and Family Welfare, Government of India, United National Development Programme, and the National Council of Applied Economic Research .

 Google Scholar

GCE (Global Campaign for Education) . 2004 . Learning to survive: How education for all would save millions of young people from HIV/AIDS . Brussels , , Belgium : GCE .

 Google Scholar

World Bank . 2002 . Education and HIV/AIDS: A window of hope . Washington , DC : Author .

 Google Scholar