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Psychology, Health & Medicine Vol. 15, No. 3, May 2010, 243–265

Children affected by HIV/AIDS: SAFE, a model for promoting their security, health, and development

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Theresa S. Betancourta*, Mary K.S. Fawzib, Claude Bruderleinc, Chris Desmondd and Jim Y. Kime a Franc¸ois-Xavier Bagnoud Center for Health and Human Rights, Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, MA 02115 USA; bDepartment of Global Health and Social Medicine, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, MA 02115 USA; cProgram on Humanitarian Policy and Conflict Research, Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, MA 02115 USA, d Franc¸ois-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, MA 02115 USA; eDartmouth College, Hanover, NH, USA

(Received 13 January 2010; final version received 14 January 2010) A human security framework posits that individuals are the focus of strategies that protect the safety and integrity of people by proactively promoting children’s well being, placing particular emphasis on prevention efforts and health promotion. This article applies this framework to a rights-based approach in order to examine the health and human rights of children affected by HIV/AIDS. The SAFE model describes sources of insecurity faced by children across four fundamental dimensions of child well-being and the survival strategies that children and families may employ in response. The SAFE model includes: Safety/ protection; Access to health care and basic physiological needs; Family/ connection to others; and Education/livelihoods. We argue that it is critical to examine the situation of children through an integrated lens that effectively looks at human security and children’s rights through a holistic approach to treatment and care rather than artificially limiting our scope of work to survival-oriented interventions for children affected by HIV/AIDS. Interventions targeted narrowly at children, in isolation of their social and communal environment as outlined in the SAFE model, may in fact undermine protective resources in operation in families and communities and present additional threats to children’s basic security. An integrated approach to the basic security and care of children has implications for the prospects of millions of children directly infected or indirectly affected by HIV/AIDS around the world. The survival strategies that young people and their families engage in must be recognized as a roadmap for improving their protection and promoting healthy development. Although applied to children affected by HIV/AIDS in the present analysis, the SAFE model has implications for guiding the care and protection of children and families facing adversity due to an array of circumstances from armed conflict and displacement to situations of extreme poverty. Keywords: child development; HIV; security

*Corresponding author. Email: theresa_betancourt@harvard.edu ISSN 1354-8506 print/ISSN 1465-3966 online Ó 2010 Taylor & Francis DOI: 10.1080/13548501003623997 http://www.informaworld.com


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Introduction: Children and HIV/AIDS The AIDS pandemic has dramatically altered the lives of children, families, and communities around the world. Of particular concern is the pandemic’s effect on children. Of the estimated 2.8 million people who died from AIDS in 2005, around half a million were children under the age of 15 (UNAIDS, 2005). In many parts of the globe, young people, particularly young women are at great risk of contracting the virus as soon as they become sexually active. Recent estimates indicate that half of all new HIV infections – approximately 7000 every day – are among young people between the ages of 15 to 24 (UNAIDS, UNICEF, & USAID, 2004). Without question, promoting the health and development of children requires more than just keeping them alive. Unfortunately, only a fraction of the children estimated to be made vulnerable due to HIV/AIDS actually received necessary services. To date, access to treatments that can prevent the transmission of HIV from mothers to children at birth remains far from reach in many low income countries (Perez et al., 2004). Access to pediatric antiretroviral treatment is less robust in most settings in which adults receive care (UNICEF, 2006a, 2006b). Beyond immediate medical care, systems of social protection and social welfare to appropriately support children orphaned or made vulnerable due to HIV/AIDS in their family remain weak or nonexistent in many low income countries (UNAIDS et al., 2004). Current progress in reducing vertical transmission of HIV to children globally is abysmal (DeGennaro and Zeitz, 2009). The HIV/AIDS pandemic has brought a new sense of urgency to the human security debate. Current estimates indicate that the pandemic’s effect on children is profound and on a dangerous trend. UNICEF currently estimates that more than 15 million children have been orphaned by the pandemic (80% of these in sub-Saharan Africa), a growing number expected to swell to over 25 million by 2010 (UNAIDS et al., 2004). The situation of orphans is only one part of the problem. An growing number of children are living with HIV infected parents and ill parents. These young people face numerous risks such as dropping out of school in order to provide care for sick relatives, as well as the psychological burden associated with witnessing the illness of a caregiver and in the worse instances, coping with death. Despite the considerable need for support and services, funding for HIV/AIDS affected children falls dramatically short. Certainly the President’s Emergency Plan for AIDS Relief as well as the Global Fund have made significant contributions to the picture of AIDS globally. Additionally, several large organizations such as the Bill and Melinda Gates Foundation, the Clinton foundation, and the Elizabeth Glazer Pediatric AIDS Foundation all have advanced treatment services available for HIV/AIDS infected children. Coalitions such as CCABA have provided tremendous advocacy on the issue, resulting in growing attention to the need to attend to children and families at the heart of the pandemic (Richter, 2008). Nonetheless, access to treatment remains far lower for children compared to adults in low resource settings (UNICEF, 2006a, 2006b). Despite availability of effective regimens and strategies to prevent vertical transmission of HIV to children, a majority of the pregnant women in resourcelimited settings who are HIV-positive (approximately two-thirds) do not have access to prevention of mother-to-child transmission (PMTCT) services. In addition, the PMTCT services that are provided tend to employ single-dose antiretrovirals to combat MTCT, despite consensus among organizations like


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UNICEF and WHO that more holistic and family-centered approaches are needed (Eyakuze et al., 2008). Further, many countries marked by high HIV prevalence are also characterized by many other forms of economic, political, and social instability. Health and developmental risks to children are particularly elevated in regions where the HIV/ AIDS pandemic is intermingled with other adversities such as armed conflict or extreme poverty as is the case in many parts of modern sub-Saharan Africa (Black, Morris, & Bryce, 2003). The direct and indirect effects of HIV/AIDS on children have increased with the globalization of trade, migration, and disease. Indeed, forces of globalization are often cited as vectors for the rapid spread of the pandemic from small isolated populations in the North to much larger segments of the population in the global South (Poku, 2005). When states and formal structures of authority fail to provide care and protection to HIV/AIDS affected communities, civilians, including children and their families, are forced into survival strategies to respond to their changing environments (Foster, 2006). In recognizing survival strategies, children can no longer be viewed merely as the victims of the pandemic. Increasingly, young people are taking on vital roles such as heads of households, caregivers to sick and dying family members, and community activists pressuring ineffective governments for change. Beyond the need for HIV care for infected children, we need to consider the broader spectrum of children affected by HIV/AIDS. In order to ensure the security, health and development of HIV/AIDS affected children, a comprehensive, familybased and integrated model of care is needed. The goal of this article is to discuss key components of such a model and its implications for policy and program implementation. This article is a follow up of a paper originally produced for the Human Security Network meeting in Amman, Jordan, 11–12 May 2001 with a focus on children in armed conflict. This prior work was developed with support from the Canadian Department for Foreign Affairs and International Trade (http:// www.humansecuritynetwork.org/docs/report_may2001_2-e.php). Human security and children Human security has gained increasing attention as a framework for understanding the broader factors that contribute to population health and well-being (Chen, 2004). Traditionally, the goal of security was the protection of state borders from external threats. This approach assumed that if the state was secure, the security of the population would consequently be assured. This traditional approach to security has been called into question in an era where weak or politically unstable states have actually contributed to significant sources of human insecurity and have failed in affording basic protections and services to their constituents. In addition, these states, often due to limited economic power, are more vulnerable to interventions by external factors that may result in even greater levels of insecurity, exploitation, and manipulation, particularly for vulnerable children and families. In his report of the Secretary-General on the Work of the Organization (2000), then-United Nations Secretary General, Kofi Annan noted: ‘‘The demands we face also reflect a growing consensus that collective security can no longer be narrowly defined as the absence of armed conflict, be it between or within


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States. Gross abuses of human rights, the large-scale displacement of civilian populations, international terrorism, the AIDS pandemic, drug and arms trafficking and environmental disasters present a direct threat to human security, forcing us to adopt a much more coordinated approach to a range of issues’’. (2000)

In the human security framework, individuals, not states, are the focus of security strategies. Human security seeks to protect the physical safety and integrity of people, rather than to defend state borders from external threats. Human security strategies are proactive; they stress prevention efforts and health promotion rather than charitable response, such as the overwhelming domination of the response to children affected by AIDS as one focused mainly on ‘‘AIDS orphans’’ while overlooking the much larger numbers of children affected more broadly by HIV. Human security is thus about the well-being of people, not of states. In this manner, the security of its people is also a measure and a determinant of state and global security, and a core indicator of the potential to foster human capital and move towards a more prosperous and equitable future. The rights of children and HIV/AIDS As children are in an ongoing process of growth, responding to their security needs involves protecting their healthy and successful development. This means that for children, human security strategies must not only protect the young from harm but also create the conditions for children to develop, thrive, and reach their optimal potential. The UN Convention on the Rights of the Child (CRC) is central to any discussion of children’s security (Shepler, 2005). The failure of some states and the international community to respect, protect, and fulfill the rights of children contributes to their insecurity. The CRC lays out the inherent rights and conditions necessary for human dignity and development of children. Using a human rights framework grounded in the CRC, children’s security is concerned with the conditions required for the survival, physical safety, and development of children at risk in the face of many forms of adversity from HIV/AIDS to humanitarian crises, natural disasters, and comprehensive social and economic breakdowns. A number of key articles from the CRC refer to such rights (United Nations, 1989).1 Without question, realizing the rights of children is about much more than ensuring their basic security needs. However, using the CRC as a guide, a human security approach to children affected by HIV/AIDS provides an important starting point for understanding the core threats to their life, survival, and development. Like the rights of the child, the key elements of children’s security in the face of the HIV/AIDS pandemic are interrelated and must be viewed holistically and from the ecological lens of the family and larger community system (Bronfenbrenner, 1979). For example, children orphaned or made vulnerable by HIV/AIDS may become vulnerable to sexual exploitation which can then result in physical and/or mental health problems (Brennan, Molnar, and Earls, 2007). Such difficulties may in turn undermine their chances of reaching their maximum developmental potential even if educational or other opportunities are made available. Despite the risks of sexual and physical violence facing children in both developed and developing countries (Lalor, 2004), children in many countries most affected by HIV/AIDS have no formal mechanisms for ensuring child protection or rehabilitative services. In cases of abuse or neglect, children often have nowhere to turn but to police who in some cases are themselves perpetrators of abuse


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(Human Rights Watch, 2005). In recent times, even the staff members of major international NGOs have been accused of sexual abuse of minors receiving humanitarian aid (United Nations, 2004). In low resource settings where government agencies dedicated to child protection and social services are nonexistent, children affected by HIV/AIDS are made further vulnerable due to poor legal protections or lack of essential state functions such as birth registries or child protective services. Without such protections, children are prey to a variety of discriminatory and abusive practices such as being denied property rights, facing stigma in receipt of health care, as well as facing discrimination hard labor and even physical and sexual abuse when placed in substandard or unregulated foster or institutional care (Human Rights Watch, 2005). The survival strategies that children and their families engage in serve as a reminder that young people are not just vulnerable recipients of aid, but rightsholders with evolving capacities and the agency to act on their behalf. In the face of adversity, young people and their families actively engage in both positive and negative survival strategies. A number of positive survival strategies can be observed. For instance, in regions where new medical technologies and ART have prolonged the life of primary caregivers, HIV/AIDS affected children continue to take on new roles in the family to assist the parent living with HIV (Campbell, Foulis, Maimane, & Sibiya, 2005; Human Rights Watch, 2005). The survival strategies employed by children and families to deal with the disease pandemic may also take negative, or at least more risky forms. In the wake of HIV/AIDS, many children are left to care for ailing parents or must prematurely assume roles as heads of households upon the death of caregivers. Girls in particular are at increased risk of dropping out of school in order to respond to family pressures caused by AIDS-related death or illness in their families (Human Rights Watch, 2005). The risk of sexual exploitation is particularly significant for female adolescents who may be left alone to cope with multiple social and economic pressures. Research in Zimbabwe has demonstrated that teenage females orphaned and made vulnerable by AIDS in their families had significantly higher rates of HIV infection, incidence of sexually transmitted infections (STI) symptoms, and teenage pregnancy in contrast to comparisons (Gregson et al., 2005). The situation of young girls who engage in risky sexual relationships to secure protection and meet economic needs illustrates how the fundamental needs of children are interrelated and should be addressed in a comprehensive manner. The ‘‘SAFE’’ model of child well-being and development Grounded in a human rights and developmental perspective on children, The SAFE model (Figure 1) argues that four dimensions of security are fundamental for the

Figure 1.

Interdependence of children’s security needs.


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well-being of young people facing adversity such as HIV/AIDS: Safety/protection; Access to health care and basic physiological needs; Family and connection to others; and Education, livelihoods, and hope for the future. Inattention to the interrelated nature of these core elements of children’s security undermines the prospects for millions of children both directly and indirectly affected by HIV/AIDS. The interdependence of children’s basic security needs are well illustrated by the following examples: When a child’s health and physiological needs are not met, their ability to attend school is compromised and their potential for personal development and vocational success undermined (Makame, Ani, & Grantham-McGregor, 2002). Similarly if children, unprotected by caregivers, face physical and economic insecurity, they may select dangerous survival strategies such as selling sex or living on the streets in order to secure basic needs of food, shelter, and protection and developing social connections. Banding together for protection can foster a sense of identity and community for young people when few other social alternatives exist, but it can also draw children into high risk behaviors that have implications for their future health and survival (Swart-Kruger & Richter, 1997). In the context of HIV/ AIDS, high-risk behaviors such as sexual risk taking and drug use can also increase a young person’s likelihood of becoming infected with the virus. However, in the absence of adequate responses to protect and provide for children made vulnerable by HIV/AIDS, such survival strategies may meet immediate needs, allowing children secure their basic needs for food, shelter, connection and a livelihood when few alternatives exist. Neglecting the interrelated nature of children’s security needs and rights can have serious security consequences for the viability of society as a whole as well as for the spread of the pandemic. This figure represents the interdependence of the security requirements of children. Children’s survival depends on physiological necessities, safety, communal relationships and opportunities for learning and securing a future livelihood. Children’s basic security needs are intimately linked to their social environment – their families and communities. The survival and healthy development of children in turn builds a healthier, more secure, and economically viable community. By acknowledging the interrelated nature of children’s security needs and rights, this model is just as concerned with maintaining healthy social relationships as providing for physiological and physical security. Dimension 1: Safety and protection Protecting children from violence, manipulation, and abuse is at the core of any protection strategy. Several studies in sub-Saharan Africa have linked physical, sexual, and structural violence to increased risk of HIV infection (Dunkle et al., 2004; Farmer, Nizeye, Stulac, & Keshavjee, 2006; Gregson et al., 2005; Maman et al., 2002). The increasing openness of global markets, permeability of borders, and pervasive corruption make abuses such as sex trafficking and child prostitution more difficult than ever to control. The world violence report has documented alarming rates of direct and indirect violence exposure among children and adolescents globally (World Health Organization, 2002). Direct exposure involves injury from communal or family violence as well as physical and sexual abuse. In many cases, the degree of a child’s exposure to violence may vary according to socioeconomic status, gender, age, and race/ethnicity. The WHO world violence report indicates that up to a third of girls in some countries


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reporting forced sex during their first sexual intercourse. A recent review by Lalor (2004) cites a study in Kenya by the African Medical and Research Foundation’s survey of over 10,000 females finding that 23.8% reported being ‘‘forced’’ and another 18% ‘‘tricked’’ into their first instance of sexual intercourse. Sexual abuse affects the lives of boys as well as girls. A study of street children in Mwanza in northern Tanzania indicated that a majority of boys had experienced anal sex as a ‘‘rite of passage’’ (Lalor, 2004). In this manner, particularly in regions with high HIV prevalence, young people, particularly young women are at great risk of contracting the virus as soon as they become sexually active. Recent estimates indicate that half of all new HIV infections – approximately 7000 every day – are among young people between the ages of 15 to 24 (UNAIDS et al., 2004). Sexual violence and HIV/AIDS Strong links exist between childhood sexual abuse and a number of risky behaviors which can increase vulnerability to HIV/AIDS. These include early age at first intercourse, frequent, short-term relationships, multiple partners, prostitution, drug, alcohol abuse, and unprotected sex (Cunningham, Stiffman, Dore, & Earls, 1994; Greenberg, 2001; Stock, Bell, Boyer, & Connell, 1997). A review of the literature on child sexual abuse in sub-Saharan African (Lalor, 2004) noted the lack of national surveys documenting the problem. The few studies available indicate that 5% of respondents report penetrative sexual abuse during childhood, but this number is likely to be an underestimate due to underreporting of sexual violence (Lalor, 2004). Reviews of the literature on the epidemiology of childhood sexual abuse in North American countries indicates lifetime prevalence estimates ranging from seven to 36% in females and three to 29% in males (Finkelhor, 1994). The little research that is available on sexual abuse and violence in subSaharan Africa points to similar mechanisms linking childhood sexual abuse and risk of HIV infection. For instance, a cross-sectional survey of women attending antenatal clinics in Soweto, South Africa correlated childhood sexual assault or forced first intercourse with increased sexual risk behaviors and earlier onset of physical/sexual partner violence as well as adult sexual assault by a non-partner (Dunkle et al., 2004). In Tanzania, Maman et al. (2002) found that HIV-positive women were much more likely to have experienced sexual violence and/or physical violence in their lifetime compared to their HIV-negative peers. Community violence Witnessing violence is associated with a number of emotional and behavioral consequences ranging from anxiety and depression to an increased tendency of delinquency (Buka, Stichick, Birdthistle, & Earls, 2001). In parts of the world that carry a large burden from HIV, from South African townships to Brazilian favellas, problems associated with the AIDS pandemic are compounded by violence and insecurity. When faced with such insecurity, children do not all remain passive victims. As their capacities evolve, children facing insecurity fashion their own survival or coping strategies. Negative survival strategies ultimately feed cycles of risky behavior and disadvantage. When a young person’s impulse to exert a sense of control cannot be fed via more positive alternatives


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such as the pursuit of an education or livelihood, disincentives to becoming involved in violence are far less. Experiences of and perpetration of violence during childhood is correlated with a host of high-risk behaviors including sexual risk taking, sexual violence, drug, and alcohol abuse. The result is greater overall insecurity in the child and youth population which can in turn fuel the spread of the pandemic.

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Protecting children from abuse and exploitation Article 19 of the UN CRC calls for the protection of children from abuse, neglect, and exploitation. The Convention condemns practices such as bonded child labor and child prostitution as fundamental threats to the life, survival, development, and well-being of children. The recent passage of the International Labor Organization (ILO) Convention on Child Labor marks significant progress in efforts to end the most dangerous forms of child labor. Many of the world’s working children face dangerous conditions and grave occupational hazards. Globalization feeds the increasing demand for child labor. Furthermore, political instability makes it much more difficult to enforce labor norms. Child labor has increased dramatically in response to economic restructuring in Central and Eastern Europe and the growth of service industries in the US and UK (UNICEF, 1997). In many African countries, families increasingly rely on their children’s labor because of political instability, lack of adult employment, and the scourge of HIV/AIDS. Children involved in exploitative labor practices, including those affected by HIV/AIDS, often experience physical and sexual abuse as well (Human Rights Watch, 2005). Children work in an attempt to cope with economic pressures, often exacerbated by caregiver illness and impairment, but child labor must be assessed in terms of its effects on the rights and security needs of children. When child labor threatens the physical and mental health of children, disrupts their education or the development of vocational skills, it threatens their immediate security and also the future security of their community by thwarting their potential. Dimension 2: Access to health care and basic physiological needs Health and physiologic needs are central to the security of children. The CRC details the child’s right to survival, life and development (Art. 6), health (Art. 24) and standard of living with particular attention to nutrition and housing (Art. 27) (United Nations, 1989). In many parts of the world these rights are continually threatened as the result of the HIV/AIDS pandemic. The pandemic is straining basic health and services infrastructures to provide food, water and shelter for children and their families. The susceptibility of young children to disease makes them particularly vulnerable to the collapse of health care services, food scarcity, and population displacement in times of disease pandemics. The research literature has indicated that there may be increased risks for mortality among children within the first six months of starting ARVs (Sutcliffe, year?). Malnourished children are among those shown to be at higher risk death within the first six months of starting ARVs. Nonetheless, children are underrepresented in populations receiving ART in almost every setting where treatment programs have been established (Kline, 2007). Children whose caregivers are affected by HIV/AIDS may also have poor access to health care due to stigma or to the


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depletion of family resources, which are often used to respond to morbidity and mortality in the family due to HIV/AIDS (Masanjala, 2007). Hunger and malnutrition Hunger and malnutrition are intrinsically linked to children’s security. Nutritional deficiencies significantly compromise a child’s ability to fight off disease. Childhood hunger and malnutrition are fundamental threats to the security of children as they undermine the conditions necessary for children to survive and attain maximum development and succeed in many areas of social and personal development from school attendance to cognitive development (Shonkoff & Phillips, 2000). The HIV/ AIDS pandemic has been linked to growing food insecurity in sub-Saharan Africa (DeWaal & Whiteside, 2003). AIDS alters the distribution of age and sex in a population demographic. High mortality rates among individuals in their most productive years have been shown to have a negative effect on the economic situation in high HIV prevalence areas resulting in greater food insecurity (Perez-Escamilla et al., 2007). UNICEF’s 1998 State of the World’s Children report termed hunger a ‘‘silent emergency’’ citing evidence from WHO that child malnutrition was implicated in over half of deaths to children in developing countries in 1995 (UNICEF, 1998). Although over the last three decades the rate of severe malnutrition has fallen globally, some areas of the world, particularly sub-Saharan Africa, has felt an increase in chronic food insecurity (Costello & White, 2001). This region also carries a disproportionate amount of the populations affected by HIV/AIDS. Access to health care In many regions affected by HIV/AIDS, health services systems are underdeveloped (Veenstra & Oyier, 2006). In fact, the HIV/AIDS pandemic presents a window of opportunity to strengthen sustainable health services systems as a component of a strategy to respond to the support and care of children affected by HIV/AIDS. Access to basic childhood immunizations, nutritional and growth monitoring and primary health care are fundamental to promoting health and reducing children’s susceptibility to disease. However, access to timely immunizations and primary care in many resource-limited settings is significantly limited (Partners in Health, 2006). For HIV-positive children, access to ART is lower than that for adults in developing countries. Finally limited PMTCT access globally has failed to prevent thousands of infants from acquiring HIV infection. It has been estimated that anywhere from 9 to 25% of HIV-positive pregnant women have access to PMTCT services (Bajunirwe & Muzoora, 2005; UNAIDS & World Health Organization, 2005); a grave situation that calls for immediate action.

Dimension 3: Family and connection to others The caregiving environment Children grow and develop in the context of relationships with others (National Scientific Council on the Developing Child, 2004). Recent scientific advances have detailed how early childhood experiences, including the quality of nurturing and attachment relationships, shape the developing architecture of the human brain


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(Shonkoff & Phillips, 2000). For children, relationships with caregivers are essential for survival and growth, as children move from a state of total dependence and develop the ability to care for themselves. The need for sustained social relationships, attachment to others, and a sense of belonging form the third core dimension of children’s security. As children grow, the nature of attachments that really matter for children must be qualified somewhat. Certainly, having an identified adult who is responsible for a child is important, but the quality of that connection and the love and support that a child receives from it are distinguishing characteristics (Ainsworth, 1979; Bowlby, 1969). To quote a renowned developmental psychologist, Urie Bronfenbrenner: ‘‘ . . . in order to develop normally, a child requires progressively more complex joint activity with one or more adults who have an irrational emotional relationship with the child. Somebody’s got to be crazy about that kid. That’s number one. First, last and always (1979).’’ Modern families can be very broad indeed encompassing biological mothers and fathers to siblings, aunties, uncles and grandparents. When others in the extended family or community develop close and caring relationships with children orphaned by AIDS, the health and social consequences have been demonstrated to be less grave than anticipated (Foster, 2006; Masmas et al., 2004a, 2004b; Ryder, Kamenga, Nkusu, Batter, & Heyward, 1994). In light of the AIDS pandemic, a shift from nuclear family supports to increased demands on extended family and community members is anticipated (Foster, 2006). Efforts to shore up these existing social safety nets must be given primary consideration in the planning, development and implementation of interventions to support and care for HIV/AIDS affected children (Foster, 2006). Helping families is about supporting and not supplanting families (Richter, 2008). The UNICEF Framework for Protection, Care and Support of Children Living in a World with HIV/AIDS (2004) notes that ‘‘without special support, communities affected by HIV/AIDS will not be able to carry out their basic impulse to respond to the needs of orphaned ‘children’’’. Institutionalization Children and adolescents develop within the framework of relationship to others. This awareness has led many to criticize the institutionalization of children in custodial settings such as orphanages. Yet in many high-prevalence countries where the pandemic has created large numbers of orphans, institutionalization continues to be used as a model of care by governments and NGOs alike. A number of social factors are predictive of the placement of HIV/AIDS affected children in institutional care. For example, a study in Porto Alegre, Brazil (Doring, Junior, & Stella, 2005) revealed that factors such as HIV positivity (Odds Ratio (OR) ¼ 4.6), death of mother (OR ¼ 5.9), losing both parents (OR ¼ 3.7), and having a nonwhite mother (OR ¼ 4.0) were all strong predictors of institutional placement. Insitutionalized children often experience far less individualized attention and care (Human Rights Watch, 2005). In the absence of alternatives, the nature of institutionalized care, particularly the degree to which a child receives warm and loving care, has a significant impact on their emotional health and development. Research on orphans in Eritrea indicated that institutions where the entire staff was involved in decision-making affecting the children, and where children’s self-reliance was encouraged through close interactions with staff, were much more effective in promoting the emotional well-being of


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children (Wolff & Fesseha, 1998). Children in comparable institutions where relationships with the staff were impersonal were more likely to suffer emotional distress (Wolff & Fesseha, 1998). Whenever no alternatives exist to institutionalizing children, attention must be paid to the nature of the care to ensure that it is designed to promote children’s security and well-being. Likewise, placing children in foster care alone cannot be seen as a simple solution to lack of immediate caregivers. Attention must be paid to the quality of love and support in sustained caregiving relationships, even in institutions, given their unfortunate reality.

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Grief and loss The loss of a primary caregiver is one of the most difficult challenges a child may face in their lives. The AIDS pandemic has resulted in unimaginable stress, change in life roles and opportunities as well as abject grief and loss for young people who experience the death of a primary caregiver. Research from Western sources on children affected by HIV/AIDS indicates that many children experience the greatest degree of emotional distress in the final phases of a caregiver’s illness. Several studies have indicated that if placed with a loving, stable home environment, particularly with extended family members already known to the child, most children demonstrate good psychosocial adjustment following parental death (Forehand et al., 1999). Some interventions have been piloted with HIV/AIDS affected children in an attempt to support their social and emotional adjustment. A model developed by Rotheram-Borus and colleagues (Lee & Rotheram-Borus, 2001) in the U.S. has been used to help caregivers and children cope with the stressors of parental HIV infection. Positive social and emotional outcomes of this intervention have been observed including reduced risk of emotional distress, reduced problem behaviors, conduct problems, lower family-related stressors and higher levels of self-esteem among adolescents in the intervention as compared to standard care (Lee & Rotheram-Borus, 2001; Rotheram-Borus, Stein, & Lin, 2001). Mental health in HIV/AIDS affected children Loving and supportive relationships with caregivers sustain life in early childhood and provide the foundations for social, emotional and moral development (Ainsworth, 1979; Bowlby, 1969). The AIDS pandemic has meant that ill caregivers and those who take on caregiving roles following parental death face competing economic and social pressures that can impair their ability to attend to the emotional needs of children also under stress. In many communities, the majority of the responses to children orphaned by AIDS to date has been undertaken by families supported by surrounding communities with little if any external support (Foster, 2006). As families struggle to address economic and placement concerns regarding HIV/AIDS affected children, mental health needs may get little attention. A few studies to date have documented increased risks of emotional and behavioral problems in HIV/AIDS affected children including depression, anxiety, and social withdrawal (Atwine, Cantor-Graae, & Bajunirwe, 2005). A study of children orphaned by AIDS in Tanzania documented that 34% had experienced suicidal thoughts in the past year (Makame et al., 2002). These findings indicate that there is likely a great deal of unmet need for mental health services among HIV/AIDS affected youth.


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Substance abuse The abuse of alcohol and drugs, particularly injection drug use are all associated with increased risk of HIV infection. Children affected by HIV AIDS may become involved in drug use at much younger ages (Hein, Dell, Futterman, RotheramBorus, & Shaffer, 1995; Naar-King et al., 2006). The use of drugs and alcohol has also been linked to mental health problems as well as problems in school and impairments in social functioning (CDC, 2008). Substance abuse presents an excellent portrayal of the dynamics discussed under the SAFE model. In this instance, a negative coping strategy (use of drugs or alcohol), in some cases to deal with issues like family loss or separation (connection to others) or life in a bad neighbourhood (safety/security) may lead a young person to cope by getting drunk or high. This negative survival strategy undermines their success and well being in all other basic dimensions of their security. For instance, social relationships may become even more strained or fail – or young people may perform poorly in educational or vocational training opportunities due to their use of substances. Migration and the disruption of social networks The death or illness of family members due to HIV/AIDS can necessitate migration of children away from communities where they have established support networks (Ansell & Young, 2004). Oftentimes, assistance for HIVAIDS affected children that is directed at communities may fail to consider these migration patterns. Research has documented that due to parental HIV infection, children already living with extended family for financial reasons may return home to care for dying relatives or upon parental death may relocate yet again to join the homes of extended family members (Ansell & Young, 2004). When family members take in children out of a sense of obligation, as is often the case with AIDS affected youth, they may receive different treatment or care compared to ‘‘biological’’ children in the same household (Human Rights Watch, 2005). These dynamics of migration as well as potential for discrimination of children taking into new households due to parental death or illness also merit close attention in the development of protection strategies, monitoring and support services. Child headed households In many countries in sub-Saharan Africa, orphans were traditionally cared for within the extended family. However, high mortality of young adults due to the pandemic has meant that the burden of orphan care is increasingly shifting to the very young and the very old (Drew, Makufa, & Foster, 1998). In some cases, older siblings or associates are assuming care for younger children (Foster et al., 1995; Human Rights Watch, 2005). This is one example of children engaging in survival strategies when formal mechanisms for care of orphaned children fail. As noted by Foster (1995), child-headed households may sometimes represent a temporary survival strategy that some families employ during transitions due to the death of primary caregivers and the logistical and economic adjustment that results. In this manner, the emergence of child headed households presents an example of positive and adaptive survival strategies that some families and children employ. Such responses should be recognized and supported by outside agencies, rather than


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viewed as an aberration that must be reversed by programmatic and policy action. Indeed the experience of child-headed households in post-conflict Rwanda indicated that a large proportion of young heads of households had faced theft, labor exploitation and both physical and sexual abuse (Brown, Thurman, & Snider, 2005). In the same study, many of these young heads of households reported being sexually active, yet few saw themselves at risk of HIV infection (Brown et al., 2005) In the light of the AIDS pandemic, survival strategies such as child-headed households need to be understood as a signal of underlying vulnerability. The efforts of young people to meet the basic needs for themselves and their siblings or household members need to be recognized and worked with rather than against. Street children HIV/AIDS is estimated to have resulted in twice as many street children as orphans (Heuveline, 2004). Life on the streets can provide alternative means for meeting basic physiological needs, income, protection and social relationships when such necessities are not met elsewhere. Research on street children indicates that homeless and abandoned children develop their own social networks to provide the emotional and instrumental support they need to survive (Swart-Kruger & Richter, 1997). These new survival methods, however, may involve high-risk behaviors and lifestyles that clash with traditional views of children in many societies (Ennew, 1995). As a result, street children are often seen as urban blight, rather than rightsholders trying to cope with social and economic pressures caused by the cascade of vulnerabilities that can be spurned by HIV/AIDS in the family. A rights-based and security approach to the situation of street children would weight the root cause, or ‘‘push’’ and ‘‘pull’’ factors (UNESCO, 2006) that make life on the streets a viable survival strategy for some children facing stressors associated with the AIDS pandemic.

In Focus: Street children and HIV AIDS in Accra Children who are drawn into dangerous survival strategies such as life on the street often engage in further high-risk behaviors that further compromise all core dimensions of their basic security and development from health to safety. For instance, a study of 1147 street children in Accra, Ghana indicated that most young people surveyed (mean age 16.1 years) were sexually active and had had their first sexual experiences while on the street and often with prostitutes (Anarfi, 1997). Most young people surveyed had multiple partners and rarely used condoms. Although 97% of boys and 88% of girls in this study had heard of AIDS, a quarter of those surveyed could not identify a single mode of transmission of the virus. Fifty-six percent of boys and 10% of girls identified sexual contact as a mode of HIV transmission. Young people interviewed were largely uninformed of the risk of sexually transmitted disease and HIV transmission, 83% knew about condoms but only 28% of the sample reported using them and 50% of the street children surveyed reported that condoms could not protect someone from getting AIDS. These findings suggest that children living on the streets to survive are at high risk for contracting and transmitting HIV and other STDs (Anarfi, 1997).


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A rights-based approach would address the basic needs street children have for protection, loving relationships, physiological needs/health care and livelihoods by presenting positive and healthier alternatives for so many young people engaged in this risky survival strategy. Dimension 4: Education, livelihoods, and hope for the future

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The fourth dimension of children’s security concerns their future and the opportunities available to them to reach their maximum potential. This last dimension links children’s security to their place and potential within the social environment. Early childhood intervention Scientific gains in neurobiology, the behavioral and social sciences and accumulated experiences from early intervention programs such as Head Start/Early Head Start Programs in US were captured in the IOM report From Neurons to Neighborhoods: The Science of Early Childhood Development (Shonkoff & Phillips, 2000). Most recently, the efforts of the National Scientific Council on the Developing Child have highlighted the vulnerability posed by early childhood exposures to toxic stress, alcohol and drugs and poor nutrition in negatively influencing long term developmental trajectories. Similarly, compromised caregiving relationships and toxic stress have been demonstrated to actually disrupt the architecture of the developing brain – limiting the developmental potential of many disadvantaged children (National Scientific Council on the Developing Child, 2004; Shonkoff & Phillips, 2000). In many countries afflicted by the AIDS pandemic, the problems of extreme poverty, insecurity and high HIV prevalence are compounded to create extreme conditions of risk for the growth, emotional, and cognitive development of children. In response, services characterized by multi-component early childhood interventions hold great promise for altering the developmental potential of children in even the poorest environments. Interventions that enrich early childhood environments and improve attachment and parenting relationships between child and caregivers (defined broadly) have been attributed to improved health, social, and economic outcomes in adulthood, particularly among disadvantaged children (Hawkins, Kosterman, Catalano, Hill, & Abbott, 2005). Experimental early childhood interventions have produced a range of positive health and social outcomes including improved school achievement, reduced risk of emotional and behavioral problems, fewer high risk behaviors (drug and alcohol abuse, sexual decision making, early pregnancy), reduced incidence of smoking, reduced antisocial behavior (less violent delinquency, fewer arrests), and positive economic outcomes such as less use of public assistance, higher earnings, greater effort at savings and increased home ownership (Hawkins et al., 2005; Reynolds & Temple, 1998; Schweinhart, Barnes, & Weikart, 1993). Recently, a number of early childhood intervention programs have been adapted and evaluated in developing countries (Engle et al., 2007). Building educational, health, child protection, and social services for children affected by HIV/ AIDS has the potential to strengthen service systems for all children in low resource settings, yet much of the service response remains fragmented and piecemeal. Despite new scientific advances and the development of important interventions for supporting healthy early childhood development in disadvantaged


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children, as exemplified by the Head Start Program in the US, or a number of the promising programs summarized in the recent review by Engle et al. (2007), the standards that are accepted for the developmental context and opportunities available to children in developing countries remain far too low. The fact is that in these settings, children are on a dramatically different developmental trajectory from square one (even prenatally). Early intervention programs have a great deal of potential for serving children and families affected by HIVAIDS in resource poor settings. Recently, the Services Learning Group of the Joint Learning Initiative on Children and HIV/AIDS (JLICA) explored the integration of early childhood intervention into initiatives for the PMTCT of HIV. The JLICA was a cross-sectoral, interdisciplinary exercise in collaboration with leading practitioners, policymakers, and scholars concerned with the well-being of children living in a world affected by HIV/AIDS. The initiative’s research tasks ranged across child survival, the role of families and communities, service provision, governance issues, and estimating the cost of an adequate response to children’s needs – as well as the cost of failure to act. JLICA’s goal was to protect and fulfil the rights of children affected by HIV/AIDS by mobilizing the scientific evidence base and producing actionable recommendations for policy and practice. The idea behind the integration of early childhood interventions with PMTCT is that programmatic responses need to be concerned with both preventing HIV transmission while also attending to the context and quality of early development and nurturance in the face of serious illness. Education In the modern global economy, even in the poorest countries, education is essential for the future advancement of children. Education is the primary means of securing the skills and qualifications necessary to achieve gainful employment, to compete and to succeed. Education also plays other important roles in children’s survival and well-being. Timely access to educational opportunities is extremely important for children affected by HIV/AIDS (Kelly, 2000). For children who have lost primary caregivers, education programs also serve as a form of protection since schools are safe places where their physical and mental well-being can be monitored and young people can pursue more developmentally appropriate pursuits. Active participation in school can also help stigmatized and isolated children develop social networks and broaden the social supports available to them via relationships with peers as well as school staff. Education and opportunities to develop vocational skills help children retain their sense of hope for the future. Reduced access to schooling among HIV/AIDS affected children, especially those whose schooling has been disrupted in order to care for ill and dying parents, can pose serious threats to their future well-being (Human Rights Watch, 2005; Lindsey, Hirschfeld, & Tlou, 2003). For instance, a study of 33 young girls in Botswana providing home-based care to family members living with HIV/AIDS documented that girls had often had to miss school in order to provide care (Lindsey et al., 2003). They also faced sexual abuse, exploitation and were struggling with social isolation and depression. Failing to improve the life chances of children to pursue an education or earn a livelihood increases the risk that they may engage in dangerous survival strategies including risky sexual behavior as well as the loss of


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human capital associated with poor achievement or the suffering associated with mental disorders as a consequence of abuse and expoitation. Economic development and HIV/AIDS AIDS disproportionately kills mature adults who would normally serve as primary household earners and carers of dependents. For example, in Uganda HIV seroprevalence in individuals 20–50 years of age is more than 20% (UNAIDS & World Health Organization, 2005). The economic and social consequences of adult morbidity and mortality due to HIV/AIDS are significant. For instance, in Zambia households affected by morbidity or mortality due to HIV/AIDS experienced a 30– 35% reduction in annual income (Mutangadora & Webb, 1998). Shifts in caregiving and economic demands cause by morbidity and mortality of mature adults due to HIV/AIDS often has the result of forcing children to take on roles as wage earners at much younger ages (Human Rights Watch, 2005). The policy community has investigated a number of strategies for providing economic support to HIVAIDS affected households. Strategies such as cash transfers and microdevelopment projects have been piloted in several high HIV prevalence regions, yet many models of economic support remain undocumented and under researched (Barnett & Whiteside, 2002). Models from other low resource countries, such as the PROGRESA model from Mexico, present potential new pathways that may be adapted to provide effective models of support to families and children affected by HIV/AIDS in resource-poor settings. PROGRESA was begun in 1997 as a national program to address extreme poverty and break the cycle of poverty in poor villages. The program offered social protection for poor families in the form of conditional cash transfers for a range of child health and educational activities reflective of the dimensions pertaining to health and education in the SAFE model. For instance, caregivers, usually mothers, were provided such incentives for prenatal care attendance, well baby visits and immunization and primary school enrolment of their young children. At its inception, PROGRESA extended benefits to some 2.6 million families across 50,000 rural villages in Mexico. In an innovative strategy of combining program evaluation with scale-up, the Mexican government rolled out program expansion using a randomized controlled design. Results of PROGRESA are impressive. Intervention children ages 0–35 months experienced a 39.5% reduction in illness (Gertler, 2004) compared to controls as well as improved outcomes in growth and nutrition. Program effects were observed to increase with length of time in the program, indicating a cumulative effect of the intervention (Gertler, 2004). Conclusions Key services issues for children affected by HIV/AIDS This article examines four core dimensions of children’s basic security of relevance to the effects of HIV/AIDS on families. The examples presented highlighted the importance of these dimensions, their interrelated nature, and how vulnerability in any one dimension can set into motion both positive and negative survival strategies. As the pandemic alters the nature of social and human experience worldwide, children’s security and the experience of childhood itself is undergoing major


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transformations in the shadow of AIDS. Despite a number of international instruments for promoting the rights of children and improving their protection, international and state efforts often fail to meet these basic security needs leaving children and families to fend for themselves. In light of this reality, children and their families must be viewed as agents acting on their own behalf, not merely ‘‘vulnerable’’ recipients of aid. They bear rights and responsibilities as key stakeholders in the struggle against the AIDS pandemic. Young people themselves, particularly adolescents, play a key role in developing responses and making choices that can either further spread of the pandemic or contribute to its reversal. Failure to ensure the core dimensions of children’s security and thus the health and well-being of young people increases the likelihood that children and their families will be propelled into the most perilous of survival strategies. However, the survival strategies children and their families must not be ignored for they can also present sources of strength to build upon protection and intervention programs. Where they take positive forms, such as the extended networks of households that pull together to share finances and care of children when families face illness or death, such survival strategies can form the building blocks for successful and sustained interventions that build on local strengths. Our commitment to children in light of the AIDS pandemic must go beyond simply providing for their physical survival. In particular, we must understand that the health and development of children occurs within relatedness to others and that in order to develop to their full potential, children must be safe from harm, have their basic needs for health, shelter and nutrition met while also having opportunities to better themselves through education, livelihoods and other mechanisms for maintaining a sense of the future. The interrelationships of the four dimensions of the SAFE model and the dynamics of positive and negative survival strategies have implications for the planning and implementation of services for HIV/AIDS affected children. First, the four interrelated dimensions of children’s security can provide a guide in planning integrated services for HIV/AIDS affected children. Operational agencies must consider the degree to which they are capable of providing quality services that improve the security of children across all four dimensions. In those instances where one agency cannot ensure holistic, comprehensive care, it is their obligation to consider partnerships which will ensure that all four dimensions are addressed. Sometimes the additional effort required to make referrals – and to ensure that the referral results in a stabilizing services – can go a long way in ensuring that investments made in one dimension – such as education – are not undermined by insecurity in another area of a child’s life – such as health and nutrition. Second, multi-sectoral, coordinated, integrated, and sustainable services are necessary. Unfortunately, our field has been marked by a tendency towards ‘‘silos’’ in programming. Funding is provided for sectorally confined programs – such as education or health – with no attention to their interrelated nature. To truly maximimize children’s security and wellbeing through a SAFE framework, comprehensive programming is the best case scenario. However, when such options are not possible under one coordinated point of service, cooperation, referral, and monitoring among service agencies is required. Even in low resource settings, some range of programs addressing each of these basic security needs can be assembled, yet coordinated and collective effort to much more rare. The services and supports to be assembled to ensure children’s security from a SAFE framework can come from


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both the formal and non-formal sectors. The non-formal community sector may actually be a very strong source of support and care, particularly in ensuring child safety or community-based child protection networks, as well as offering a resource for bolstering a young person’s sense of connection to others via volunteer and religious organizations or mentorship networks (Women’s Commission for Refugee Women and Children, 2004). Integrating services that attend to all basic security investments maximizes resources invested by communities, governments and international donors in the health and development of children and families. If we are truly to achieve the major millennium development goals related to reversing the scourge of HIV/AIDS and improving child health, such integrated approaches are of critical importance. Related to this is the fact that there is a tremendous knowledge-implementation gap in the provision of services to children affected by HIV/AIDS; only 3–5% of these children and youth have received any type of formal assistance outside of informal extended family and community-based support networks (Foster et al., 1995; JLICA). Although it is important to ensure that external resources for services do not supplant community-based support, there is clearly a significant need for outside assistance – and the additional financial and technical supports they provide to increase the technical and management capacity to integrate services across the core domains of children’s security. The SAFE framework also implies the need for a much more nuanced and insightful research agenda examining the power and potential pitfalls of holistic and family-centered programming. Funding and technical support are also required to conduct more formal applied research in this area. For instance, despite a wealth of information about the importance of each of these core domains of children’s security, and studies indicating their synergistic relationships, there is still very little research that systematically documents the economic and social gains that can result from such approaches. Despite numerous policy agencies arguing for holistic and integrated services for children and families affected by HIV/AIDs, trials examining child and family outcomes under comprehensive family-centered care versus ‘‘segmented delivery of only ART or PMTCT’’ are ‘‘virtually non-existent’’ (DeGennaro and Zeitz, 2009). Comprehensive and family-centered models that demonstrate approaches emulating the SAFE framework for the protection and care for children affected by HIV/AIDS will benefit tremendously from an improved evidence base that explicitly examines their interrelated nature. In addition, the idea that positive and negative survival strategies point to areas requiring additional protection (in the case of negative survival strategies) or a source of strength to build on for interventions (in the case of positive or adaptive coping). Formal evaluations and in-depth case studies can highlight these dynamics. Formal evaluations, including rigorous trials of interventions, can help to identify and refine comprehensive and family-centered programs to prepare them to go to scale as additional external resources became available. Expanded program efforts for HIV/AIDS affected children, families and communities must also be participatory and integrate meaningful input from beneficiaries in both program planning and the selection of targets for evaluation and accountability. Programmatic support for country-wide and regional initiatives will be needed and organizations that have a successful track-record in scale-up of HIV services can offer this type of technical assistance and training.


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Applying the SAFE model to analyze and promote children’s security in the face of the AIDS pandemic When addressing the source of children’s insecurity, funders and governments need to engage in a much more comprehensive assessment of the stability of these core dimensions of children’s security as a roadmap for prevention and intervention. Child development is a long-term process, and interventions to provide support and care for children affected by HIV/AIDS must be sustainable and take a long-term view. Donors and policy makers must recognize the interdependent nature of children’s basic security needs in funding and structuring programs to assist children and families affected by HIV/AIDS. Silo approaches to services for children are ineffective and counterproductive. Implementers must avoid separating or prioritising one dimension of services over others, and begin to favor of multisectoral, integrated, and sustainable responses. Policy makers must also ensure that the needs and rights of children are integrated into health systems reform as well as humanitarian responses to the pandemic (e.g. delegating funds to strengthen children’s security via establishing formal child protection services in low resource countries and strengthening agencies of health/mental health, education, social services and child protection along with the development of health systems). We must also support and promote the participation of youth in decisions that affect them by taking into consideration their evolving capacities and best interests as expressed in the CRC. In particular, we can provide for adolescents with opportunities to exercise their capacities to assess needs and plan health systems reform, prevention programs and interventions; program developers and advocates can consult young people and encourage their involvement in energizing health and social services reform and negotiating renewed child protection policies. The energies and capacities of adolescents must be channelled towards positive ends and providing input on decisions that affect them. Even at the policy level, young people can provide insight into the design of prevention, support and education programs. In addition, with sustained participation in all phases of response including prevention, treatment and long term planning is important. Youth and community advisory boards can help programs to do this. They may also help implementation agencies and governments to examine and respond to the pressures leading children to engage in high risk survival strategies such as risky sexual behavior or life choices that make them vulnerable to exploitation by others. Integrated responses to dangerous survival strategies, such as children living on the streets, in gangs or engaged in other criminal activity, must include buy-in from health, social services, juvenile justice, education and community leadership such as religious groups and in society at large. This includes developing gender-sensitive rehabilitative initiatives for girls affected by sexual exploitation and violence by promoting their right to safety, physical and mental health, their connection to supportive and healthy relationships, as well as providing opportunities to pursue self-sufficiency through education and skill building. At the grassroots level, we must promote capacity building, professional development and supervision in child protection among community organizations and nongovernmental organizations (NGO) addressing the security needs of children in especially difficult circumstances including those directly and indirectly affected by the AIDS pandemic. The emerging evidence base on child development clearly posits that it is not enough to simply provide services that address the physiological needs of


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children. Such efforts, while critical, must be complemented with comprehensive and integrated systems of support that address the multi-faceted dimensions comprising the livelihoods of children, their families and the communities in which they live. The SAFE model offers a theoretical framework for service providers to begin developing integrated interventions while beginning to articulate the synergistic benefits of comprehensive service delivery. Further research is needed to develop the evidence base on interventions which can help remediate the potentially deleterious effects of HIV/AIDS in the lives of affected children around the world. Acknowledgement

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The authors thank the Oak Foundation for their generous support of this project.

Note 1.

Any discussion of children’s security requires particular attention to several key CRC Articles. These include the child’s right to life and maximum survival and development (Art. 6), protection from all forms of violence (Art. 19) and exploitation (Arts. 34–36), the right to an adequate standard of living (Art. 27), and rights to health and education (Arts. 24 and 28). The CRC also underscores a child’s right to a name, a family and national identity as well as protection from unjust separation from one’s family including provisions for reunification (Arts. 7–10). The CRC also makes specific reference to the protection of children who are refugees (Art. 22) or otherwise affected by armed conflict (Art. 38) and to the rights of children to physical and psychological recovery and social reintegration (Art. 39).

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Children affected by HIV/AIDS: SAFE, a model ...  

Children affected by HIV/AIDS: SAFE, a model for promoting their security, health, and development Authors: Theresa S. Betancourt, Mary K.S...

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