AIDS Orphans and Vulnerable Children (OVC): Problems, Responses, and Issues for Congress
Released: 2005-11-18T00:00:00

Summary:
Since HIV/AIDS was discovered in 1981, more than 20 million people have lost their livesto the virus. According to the Joint United Nations Program on HIV/AIDS (UNAIDS), nearly 40million are currently living with HIV/AIDS, including nearly 2.2 million children under the age of15. In 2004, 4.9 million people acquired the virus, and 3.1 million died from AIDS. Sub-SaharanAfrica remains the most affected region with 25.4 million people living with HIV/AIDS at the endof 2004, 1.9 million of whom were children under the age of 15. The United States Agency forInternational Development (USAID), the United Nations Children's Fund (UNICEF), and UNAIDSestimate that at the end of 2003, 15 million children under the age of 18 had lost one or both parentsto AIDS, with the majority (82%) in sub-Saharan Africa. In just two years, from 2001 to 2003, theglobal number of children orphaned by AIDS increased from 11.5 million to 15 million. By 2010,it is expected that more than 25 million children will be orphaned by this deadly virus. Due to the10-year time lag between HIV infection and death, officials predict that orphan populations willcontinue to rise for a similar period, even after the HIV rate begins to decline. Experts say onlymassive spending to prolong the lives of parents could be expected to change this trend.
The impact of HIV/AIDS on children is just beginning to be explored. Not only are childrenorphaned by AIDS affected by the virus, but those who live in homes that have taken in orphans,children with little education and resources, and those living in areas with high HIV rates are alsoimpacted. Children who have been orphaned by AIDS may be forced to leave school, engage inlabor or prostitution, suffer from depression and anger, or engage in high-risk behavior that makesthem vulnerable to contracting HIV. Children who live in homes that take in orphans may see adecline in the quantity and quality of food, education, love, nurturing, and may be stigmatized. Impoverished children living in households with one or more ill parent are also affected, as healthcare increasingly absorbs household funds, which frequently leads to the depletion of savings andother resources reserved for education, food, and other purposes.
Congress passed P.L. 108-25 ("The United States Leadership Against HIV/AIDS,Tuberculosis, and Malaria Act of 2003") in the 108th Congress, which authorizes 10% of HIV/AIDSfunds to be used for children orphaned or made vulnerable by the virus. In the 109th Congress, H.R. 1408 , "Assistance for Orphans and Other Vulnerable Children in DevelopingCountries Act of 2005," passed the House and Senate on October 18, 2005, and October 25, 2005,respectively. Ultimately, the bill was enacted on November 8, 2005. The act, P.L. 109-95 ,established a monitoring and evaluation system to measure the effectiveness of related assistanceactivities; directed the appointment of a Special Advisor for Assistance to Orphans and VulnerableChildren within USAID; and required an annual report on project implementation. This reportexplores some of the challenges facing children affected by HIV/AIDS, outlines U.S. andinternational efforts to assist those children, and outlines some key issues that may be considered byCongress in the 109th session. This report will be updated.

subsections: section_title: Introduction
paragraphs: Since HIV/AIDS was discovered in 1981, more than 20 million people have lost their livesto the virus. Nearly 40 million people are currently living with HIV/AIDS, including nearly 2.2million children under the age of 15. Ninety-five percent of those living with HIV/AIDS reside indeveloping countries. Sub-Saharan Africa remains the most affected continent with 1.9 million ofthe 2.2. million infected children. (1) A joint study conducted by the U.S. Agency for InternationalDevelopment (USAID), the United Nations Children's Fund (UNICEF), and the Joint United NationsProgram on HIV/AIDS (UNAIDS) found that at the end of 2003, 15 million children under the ageof 18 had lost one or both parents to AIDS, with 12.3. million of them found in sub-SaharanAfrica. (2) 
Between 1990 and 2003, sub-Saharan Africa's population of children orphaned by AIDSincreased from less than 1 million to more than 12 million (3) . Due to the 10-year time lag between HIV infection and death,experts predict that without the availability of anti-retroviral medications orphan populations willcontinue to grow for at least two decades after a country has reached its peak HIV infection rate. In Uganda, for example, although the epidemic has been on a steady decline, from 14% in the late1980s to 4.1% in 2003, the number of orphans under the age of 15 continued to climb for 10 yearsafter the country's infection rate peaked. Experts report that the number of orphans is only nowexpected to decline in the country, from 14.6% of Ugandan children in 2001 to a projected 9.6% in2010. (4) Thailand, longhailed for having significantly reduced its HIV/AIDS rate, is still witnessing an increase in childrenorphaned by AIDS. In 1995, there were 63,000 children who had lost their parents to AIDS. In 2001,the number increased to 289,000, and in 2005, an estimated 380,000 are expected to lose theirparents to AIDS. (5) 
The term "AIDS orphans" is used in the title of this report to facilitate recognition of theissue. However, those that serve children affected by HIV/AIDS caution against the use of this termbecause they believe it further stigmatizes the children. Consequently, the terms "orphans andvulnerable children" (OVC), "children affected by AIDS," and "AIDS-affected children" will beused hereafter to refer to "AIDS orphans." (6) 
The growing population of children orphaned by HIV/AIDS is a concern, because had it notbeen for HIV/AIDS, the global percentage of orphans would be declining instead of increasing. Bythe end of 2003, 43 million children (12% of all African children) were orphaned in sub-SaharanAfrica, 12.3 million (32% of all African orphans) of those were due to AIDS. Although Asia had alower number of children orphaned by AIDS in 2001, 1.8 million (2.8% of all orphans), it had amuch larger overall orphan population than sub-Saharan Africa, with 65 million orphans. (7) Some have expressed concernthat Asia's relatively large population hides its significant population with HIV/AIDS. For example,although India had a seroprevalence. (8) rate of less than 1% at the end of 2003, 5.1 million people wereliving with HIV/AIDS at that time. (9) This is almost as many people who had the virus in South Africa(5.3 million) at the end of 2003, which had a seroprevalence rate of 21.5%. (10) 
Children living in high seroprevalence areas may see a decline in access to education or inthe quality of education. A 2000 study found that an HIV-infected teacher loses approximately sixmonths of professional working time before succumbing to the virus. (11) This has had a significantimpact on heavily affected countries such as Kenya, where teachers are dying faster than they canbe trained and replaced. Kenya faces the loss of 6,570 teachers annually due to HIV/AIDS, whichtranslates to 18 teacher deaths per day. (12) In the Central African Republic, almost as many teachers diedof AIDS as retired between 1996 and 1998. As a result, nearly two-thirds of the schools have closeddue to staff shortages. (13) Heavily affected communities produce lower crop yields due to a reduction in land use (those whoare ill with AIDS are often too weak to farm), and a decline in the variety of crops grown. Theinfrequent use of fertilizers in the fields often results in a decline in soil fertility, increases in pestsand diseases, and a decline of external production outputs, including cash crops. (14) As a result, countriessignificantly impacted by HIV/AIDS have experienced a rise in child mortality and a decline in thegains made in child survival over the past decade. For example, child mortality in Kenya was 205per 1,000 in 1960, and had fallen to 97 per 1,000 in 1990. However, due to HIV/AIDS the rateincreased to 122 per 1,000 in 2001. (15) 
The majority of children orphaned or made vulnerable by HIV/AIDS are living with asurviving parent, or within their extended family (often a grandparent). An estimated 5% of childrenaffected by HIV/AIDS worldwide have no support and are living on the street or in residentialinstitutions. Although most children live with a caretaker, they face a number of challenges,including finding money for school fees, food, and clothing. Experts contend that effectiveresponses must strengthen the capacity of families and communities to continue providing care,protect the children, and to assist them in meeting their needs. There are thousands of localizedefforts, many of them initiated by faith-based groups, to address the needs of children madevulnerable by AIDS. Proponents argue that supporting these "grassroots" efforts can be a highlycost-effective response, although additional mechanisms are needed to channel such resources. Theyfurther assert that additional resources are needed to expand the limited programs and to support thechildren who are on the street or in institutional care.
section_title: Most Recent Developments
paragraphs: The plight of children affected by HIV/AIDS is gaining increased congressional attention,particularly through the enactment of P.L. 108-25 , The United States Leadership Against HIV/AIDS,Tuberculosis, and Malaria Act of 2003 , which authorized 10% of global HIV/AIDS funds to be usedfor children orphaned or made vulnerable by the virus (OVC). In the 108th Congress, there wasconsiderable debate on how the funds should be allocated. Many pointed out that activities relatedto children affected by HIV/AIDS should be streamlined. Some wanted to create a coordinator forchildren orphaned and affected by HIV/AIDS in the AIDS Coordinator's Office of the StateDepartment. Still others argued that the scope of assistance should be expanded to include childrenwho are orphaned from other causes, as they are just as vulnerable as those orphaned by HIV/AIDS.In the 108th session, Congress considered four bills that targeted children orphaned and affected byHIV/AIDS, though none made it to full conference. 
In the 109th session, H.R. 1409 , Assistance for Orphans and Other VulnerableChildren in Developing Countries Act of 2005, passed the House and Senate on October 18, 2005and October 25, 2005, respectively. Ultimately, the bill was enacted on November 8, 2005. The act, P.L. 109-95 , authorized spending for orphan-related programs in FY2006 and FY2007; establisheda monitoring and evaluation system to measure the effectiveness of related assistance activities;directed the appointment of a Special Advisor for Assistance to Orphans and Vulnerable Childrenwithin USAID; and required an annual report on project implementation. 
section_title: Orphans and Other Children Made Vulnerable by HIV/AIDS: Challenges for Governments
paragraphs: The continued increase in international HIV rates is proving devastating for governmentsheavily affected by HIV/AIDS, not only because their most productive populations are beingdecimated, but also because the future of these countries and their children is at risk. Governmentswith significant populations of children orphaned and made vulnerable by HIV/AIDS may be facedwith a range of issues, including surging street children populations, a rise in child labor, childprostitution and other forms of exploitative work, vulnerability to crime, militias and terroristorganizations, a growing population of uneducated and unskilled laborers; and long-term foreign aiddependence. This section will explore some of these challenges, and the implications that they haveon affected countries.
subsections: section_title: Street Children and Exploitation
paragraphs: As HIV/AIDS rates continue to soar around the world and household poverty deepens,children are increasingly pressured to contribute financially to the household. The streets havebecome the place where children orphaned and made vulnerable by HIV/AIDS often turn tosupplement lost wages, find refuge, and sometimes to find an escape from stigma. While on thestreet, children can be exposed to rape, drug abuse, child labor, (16) including childprostitution, and other forms of exploitation, making them more vulnerable to contractingHIV/AIDS. Children as young as nine years old have been found to be engaged in sex work. (17) 
While no one seems to know how many children actually live on the streets worldwide, manyreports cite a UNICEF estimate of 100 million. (18) Country reports from a number of heavily affected nations allreport a significant increase in the number of children roaming the streets over the past ten years. The city of Blantyre, Malawi, has reportedly seen an 150% increase in the number of childrenroaming the streets since 2002, with 40 new children coming into the streets each month. (19) Tegucigalpa, the capitalof Honduras, has experienced an eightfold increase of street children in the last decade. (20) Kenya has becomeinfamous for its exploding population of street children, who are known for committing petty crimes,like stealing cell phones and wallets, mostly because they have no other means of survival. (21) 
A number of reports emphasize that the majority of children on the streets have families andhomes in which to sleep. However, most children go to the streets for about 12 hours to beg, work,or to seek food, and then return home to sleep. Children as young as two years old have been sentout by their parents to beg for food and money. (22) Whether the children live on the streets or spend the majorityof their days on the streets, experts are concerned about their vulnerability to terrorist organizationsand militias, crime, and HIV infection. A UNICEF worker in Kenya recently asked, "What kind ofadults does such an existence produce, if crime and violence become their survival strategies?" (23) 
Many analysts have expressed concern that the growing number of orphaned children andthose on the streets are increasingly rootless, uneducated, undernurtured and traumatized, makingthem ripe for recruitment for crime, military warlords and terrorists. Children as young as sevenyears old are among the 300,000 children fighting in wars around the world today. Some areparticularly concerned that orphans and other children affected by HIV/AIDS can become easyconscripts for warring factions, as they search for food, shelter, nurturing, and safety. A rebel fighterin Congo reportedly claimed that his militia pays the school fees for the children in his group, mostof whom are orphans. (24) Children's vulnerability to other forms of exploitation was illustrated in a study conducted by theInternational Labor Organization (ILO). The study found that in Zambia the majority of streetchildren and children involved in sex work were orphans. Another study in Ethiopia found that themajority of child domestic workers were orphans. It was found in Uganda that girls were especiallyvulnerable to sexual abuse while engaged in domestic work. (25) Scott Evertz, Director ofthe White House Office of AIDS Policy has said: 
More and more AIDS orphans are growing into youngadults with little or no adult supervision. Clearly this presents a security risk. We will have wholepopulations of them in much of the world, ripe for the picking by those individuals who would wantto engage the interests of young adolescents. Terrorists would find this an ideal breedingground. (26)
Although a number of social scientists have raised concerns about the growing number ofchildren orphaned and made vulnerable by HIV/AIDS, others feel that the prediction of rising crimerates and increased political instability is alarmist. (27) Those who dispute the linkage between social breakdown andincreased orphanhood cite a lack of evidence and a reliance on anecdotal data. Furthermore, theyargue that children have lived among extended family members for some time, particularly insouthern Africa, where a significant proportion of the population are migrant laborers. Those thatbelieve the family networks are strong and can support and adapt to the growing number of orphanspoint to a study conducted in Cape Town, South Africa, which found that before AIDS was a factor,at some point in their childhoods 18% of Africans surveyed were reared in households that wereheaded by neither their mother nor father. (28) The key point that critics underscore is that linking orphanhoodto increased crime or insecurity "prematurely labels orphaned children and youth as delinquents andcriminals before the necessary contextual research has been carried out." (29) Critics argue that this onlyfurthers the stigma that children orphaned and made vulnerable by HIV/AIDS already face.
section_title: Education and the Economic Impacts
paragraphs: Some social scientists are concerned that the growing number of children affected byHIV/AIDS could lead to a decrease of skilled laborers within a country, further destabilizing thenational economy and society at large. The issue is that an inefficient transfer of skills andscholarship leads to a decline in human capital, the body of knowledge, and ability found in apopulation. It is human capital that drives economic growth, some experts argue, and when that isthreatened so is the economic security of a nation. A 2003 World Bank report warned that "awidespread epidemic of AIDS will result in a substantial slowing of economic growth, and may evenresult in economic collapse." (30) The report argues that the effects of these weakenedknowledge-transmission processes are felt only over the longer run, as the poor education of childrentoday leads to the low productivity of adults in the future.
In many parts of the developing world, people rely on their own plots of land for the majorityof their food consumption and income. However, significant populations of engineers, miners,police, lawyers, and the like rely on skills gained through education and professional training forincome. Children who are affected by HIV/AIDS are less likely to be employed in these professions,as they have a lower chance of completing basic and secondary education. Without education andskills training, children orphaned and made vulnerable by HIV/AIDS are more likely to fall deeperinto the cycle of poverty and engage in high-risk behavior, which perpetuates the cycle of HIVtransmission. Ultimately, the affected countries might find it harder to overcome national povertyand become effective members of the international economy.
The economic challenges of children affected by HIV/AIDS occur in stages. The first stageoften begins when children realize that their parent has AIDS and is likely to die. They begin to fearfor their future, wonder who will care for them, and worry about how they will be able to stay inschool. Children are often pulled out of school to care for an ailing family member, or becausemeager household income is now spent on the sick. School fees, notebooks, and pencils becomeunaffordable and children begin to struggle to provide care and replace lost adult labor and income. At this stage, the quality of child-rearing is compromised, and many important lessons on life skillsand self-sufficiency are not taught, mostly because the parent(s) is too ill to transfer the knowledge. After one parent dies, most children continue to live with the surviving parent or a relative, but theyoften slide more deeply into poverty. For some, the next stage begins when they find themselves theheads of households. A young adolescent may be responsible for many siblings, some of whom maybe infants. Children who are the heads of households are in a difficult position not only because theymust now support their siblings with little to no education and/or employable skills, but also becausethey most likely have limited resources. In many cases much of the family's possessions may havebeen sold to care for the sick. Large numbers of orphaned children find themselves in homes thatcannot afford to pay school expenses and drop out to work in the household, fields, or on the street. Young children with minimal education or employable skills can be found doing work such asshining shoes, begging for money in the streets, bartending, selling food, and most often in the caseof girls, becoming domestic workers. Many observers believe that the desperation of these youngchildren makes them more vulnerable to abuse and exploitation, ultimately making them moresusceptible to contracting HIV.
section_title: Agricultural and Food Impacts
paragraphs: Stories of children going hungry or starving in areas that always had food, becauseHIV-infected parents who were farmers became too weak to till the fields are increasingly reportedacross Africa. Many traditional agrarian societies rely on women to produce food, particularly inAfrica, where 80% of subsistence farmers are women. (31) During times of famine these women know which wild grains,roots, and berries can be eaten when there are no crops. (32) The women also teach their children how to farm and surviveoff the land. As significant numbers of women of childbearing age fall ill due to HIV/AIDS, theybecome unable to transfer these skills to their children, both in times of famine and without. Thisis of particular concern in Africa, where 67% of all people infected with HIV/AIDS are women. (33) Farmers in the last stagesof AIDS usually produce little to no crop yields. Lower crop yields within households require thefamilies to spend more of their money on food, leaving less money for education and health care. Additionally, families affected by HIV often switch to a monocrop system or shift fromlabor-intensive corps, such as vegetables, to less labor-intensive crops, such as roots. Both changesimpact nutrition as the family has less access to a variety of nutritious foods because of a decline inproductivity and in purchasing power. 
The economic impact of HIV/AIDS on Africa's agricultural system is also being felt,particularly in Southern Africa, the region with the highest HIV/AIDS rates and from where muchof the continent's food products were exported. According to UNAIDS, the agricultural sectoraccounts for 24% of Africa's gross domestic product, 40% of its foreign exchange earnings, and 70%of its employment. Experts predict that AIDS will have killed one-fifth or more of agriculturalworkers in southern Africa by 2020. (34) A decline in productive yields is already being seen. In the early1990s many of the countries in the region exported their surplus grain production, while producingenough food to feed their own populations. In 2002, however, 15 million people faced hunger andstarvation in the region, and a number of the countries continue to struggle with hunger. 
Some of the countries in the region have become reliant on the World Food Program (WFP)to feed millions of residents. The Southern Africa Development Community (SADC) (35) projected a deficit of 3.22million tons of cereal in FY2002, and ultimately required between 3.6 and 4.6 million tons of cerealto meet the shortfall. (36) In 2003, WFP continued to seek support in its effort to feed 6.5 million people facing severe hungerin Zimbabwe, Mozambique, Swaziland, and Malawi. (37) The United Nations reported that in 2004, Lesotho, Malawi,Swaziland, and Zimbabwe still required assistance. Half of the population in Lesotho and 25% ofall Swazis are at risk of hunger or starvation until the next harvest in March 2005. In Malawi, some1.7 million people, mainly in the south, need assistance. It is estimated that 4.7 million peopledesperately need food assistance in Zimbabwe, mostly caused by a reduction in commercial maizeproduction (due to the land redistribution program) and sharp increases in food prices. The WorldFood Program (WFP) has expressed disappointment by the minimal response to the global appealfor $404 million for 2002-2005. To date, WFP has only received 2.5% (about US $10 million) tostave off hunger in southern Africa. (38) 
Household crop supply in the region has been further strained as neighboring families attemptto take in children who have lost their parents to AIDS. The long-term impact is of special concernas an increasing number of children are losing the opportunity to learn how to farm because theirparents have died an early death from AIDS. Some experts have expressed concern that in thelong-run African people will be unable to sustain themselves as they are forced to put off transferringlife skills to cope with HIV/AIDS. (39) In recognition of the long-term effects of AIDS on nutrition andfood security, WFP has announced that it is now a cosponsor of the Joint United Nations Programmeon HIV/AIDS (UNAIDS). (40) A significant part of its efforts will include integrating food aidwith education programs. (41) 
section_title: Stigma, Discrimination, and Depression
paragraphs: According to UNAIDS, stigma and discrimination continue to accompany the HIV/AIDSepidemic. Children are not immune from stigmatization. In cases of stigma, children begin to berejected early as their parents fall ill with AIDS. Some children may be teased because their parentshave AIDS, while others may lose their friends because it is assumed that proximity can spread thevirus. Harsh cases of discrimination have been reported in many countries, including India andTrinidad and Tobago, particularly for HIV-infected children. A UNAIDS study found thatHIV-related stigma is particularly high in India, where 36% of the respondents in a survey felt thatHIV-positive people should kill themselves, and the same percentage felt they deserved their fate. Another 34% reported that they would not associate with an HIV-infected person. (42) A recent story illustratedhow the desire to disassociate from HIV-positive people impacts children. Two HIV-positivechildren, who lost both of their parents to HIV/AIDS, were repeatedly barred from schools for twoyears in India. After the children and their grandfather protested in front of government buildings,one school finally accepted them. However, all 100 of their schoolmates were withdrawn by theirparents fearing infection by association. (43) Ultimately the government decided to pay for a private tutor sothat the children could learn at home. (44) Children were similarly shunned in Trinidad and Tobago whenthey were refused entry into schools for six months. One school has finally agreed to accept them,but refuses to give their names in order to avoid protests as have happened in the past. (45) 
Even children who are not HIV-positive may find themselves rejected and alone. This onlyadds to the feelings of anger, sadness, and hopelessness that they may feel after witnessing theirparents slowly and painfully die. One study in Kenya found that 77% of the children orphaned byAIDS said that they had no one outside of their families to "tell their troubles to." (46) The feeling of isolationcan be heightened if the orphaned children are separated from their siblings, as often occurs whenfamily members split up the child rearing duties. Another survey conducted in Kenya by the UnitedNations Development Programme (UNDP) found that 48% of the households with orphans reportedthat some of their family members were relocated to other communities. (47) Sibling separation can bedifficult for children as they often rely on each other to cope with the loss of their parents.
Children who are orphaned by AIDS often have a lower performance in school than childrenwho are not. The preoccupation with the illness or death of their parents, the isolation due to the lossof friends, and the undertaking of additional work that comes with caring for ill parents or supportingoneself after one's parents have died often make it difficult for orphaned children to concentrate inschool. It is common for teachers to report that they find orphaned children daydreaming, comingto school infrequently, arriving at school unprepared and late, or being non-responsive in theclassroom. Some teachers ignorant of the cause of the children's distress, are not sympathetic. Orphaned children have reported that unsympathetic teachers yelled at them, made fun of them, orput them out of the classroom. However, other orphaned children have reported that their teachershave been their primary support base at school. (48) 
Orphaned children can also experience discrimination and exploitation within their newhouseholds. Reports have emerged of orphaned children receiving less food, denied school fees, andforced to do more work. Exploitation remains an issue even in countries like Botswana, where thegovernment offers support to orphans. It has been reported that some caretakers, while offeringminimal care, are using children to benefit from the government orphan packages. (49) Children, especially girls,have also reported instances of sexual abuse in their new households. However, many may silentlyaccept it because they have nowhere else to turn for shelter or protection. (50) 
section_title: Gender Exploitation
paragraphs: The rapid spread of HIV/AIDS in many countries is fueled by gender inequities. Since girls tend tobe educated at lower rates than boys, some assert they are more likely to engage in survival sex. AUNAIDS survey found that of the estimated 2 million female sex workers in India, 20% were underthe age of 15 and nearly 50% were under 18. (51) In addition to the practice of exchanging sex for food, money,and clothing, as discussed earlier, young girls face a range of challenges that affect theirseroprevalence. While at school young girls may be raped by their peers or coerced into having sexwith their teachers. (52) Young girls are also vulnerable to sexual exploitation as they work, particularly as vendors anddomestic servants. A study in Fiji found that 8 in 10 young domestic workers reported having beensexually abused by their employers. (53) Young girls often engage in domestic work for food, clothingand shelter in impoverished areas. Sexual abuse by male relatives also remains a significantchallenge for girls, particularly for orphans. (54) Additionally, a widespread perception that virgins can cureHIV/AIDS has reportedly led to a significant rise in cases of rape among young girls. (55) One case that shocked theworld occurred in South Africa, where a five-month-old baby was raped by two men hoping to curethemselves of AIDS. (56) 
Recent data highlight how girls are particularly vulnerable to contracting HIV. UNICEFconducted a study with UNAIDS and WHO in 2002, and found that "two-thirds of all newlyHIV-infected 15-19 year olds in sub-Saharan Africa were female. [Further], in Ethiopia, Malawi,Republic of Tanzania, Zambia and Zimbabwe, for every 15-19 year old boy who is infected, thereare five to six girls infected in the same age group." (57) Sexual abuse and exploitation are not the only reasons that girlsand women have a higher HIV rate than their male counterparts in Africa. The upsurge in thenumber of girls who turn to older men to pay school expenses, protect themselves from the violence,or to escape poverty also contributes to the gender disparity in seroprevalence rates in sub-SaharanAfrica. Unfortunately, this practice places young girls at greater risk of contracting HIV, as the mencan often convince the young girls that protection is not necessary. A recent survey found thatbetween 12% and 25% of girls' partners in sub-Saharan Africa were at least 10 years older, and 25%of Kenyan men over 30 years old reported that their non-marital partners were at least 10 yearsyounger. (58) There area number of programs that seek to empower girls and young women, which contribute to HIV/AIDSprevention. (59) 
section_title: Responses to Impact
paragraphs: Children affected by HIV/AIDS need support in a wide range of areas, including economic,material, emotional, and legal protection. Although a number of organizations seeks to meet theneeds of children orphaned and made vulnerable by HIV/AIDS, local communities continue to bethe primary loci of support for these children. One USAID survey found that 74% of the timerelatives provided food for orphans and vulnerable children, and 19% of the time they relied on theirfriends for food. Religious groups were used the remainder of the time (7%), when needed. (60) 
subsections: section_title: Economic and Material Responses
paragraphs: This section discusses some of the initiatives that the United States and the internationalcommunity implement to serve the needs of the children affected by AIDS, and some of thechallenges that these programs face.
USAID supports a number of programs that offer material and other support to orphans andvulnerable children, mostly through its Child Survival and Health Fund (CSH) programs. Many ofthe programs use an integrated approach, which responds to more than one set of needs. Forexample, USAID uses a combination of funding sources (61) to support school feeding programs that reduce hunger,malnutrition, and disease while advancing basic education. (62) Similar programs thatcombine food and education aid have been instituted by the World Food Program (WFP) andUNICEF, (63) as well asby other international and local non-governmental organizations, such as Save the Children.
Since the majority of orphans and vulnerable children depend almost exclusively on theirfamilies and communities, some are advocating that organizations directly offer support to thosegroups. Suggested interventions include issuing stipends, financial assistance, or emergency supportfor families who care for orphans and vulnerable children and those that slip into completedestitution. Critics of this strategy have expressed concern that children can be exploited throughdirect stipends, such as has reportedly happened in Botswana. Although the country providesstipends, food aid, and pays school fees for its orphaned children, some caretakers are reportedlygiving the children substandard care. (64) Observers assert that empowering community groups to monitorthe care and support provided can minimize instances of exploitation. (65) Additionally, schoolfeeding programs and community cooperatives have been found to be effective strategies tosupplement the care that communities provide for vulnerable children, and minimize the likelihoodof abuse. Microfinance services are also seen by some as a promising way of enabling families whocare for orphans to support themselves. (66) 
section_title: Education and Skills Training
paragraphs: Attaining basic education and employable skills is an important part of preventing the spreadof HIV/AIDS and breaking the cycle of poverty. Education has a number of positive impacts,particularly for orphans and vulnerable children. Not only are those who are educated more likelyto have a higher income than those who are not, studies have also shown that the educated are alsoless likely to contract HIV and tend to have children later in life. Messages about HIV preventionare beginning to be integrated into school curricula to raise awareness about the disease among theyoung, a group that experiences an estimated 1,600 deaths daily. (67) HIV/AIDS awarenessremains very low among the young. According to a 2001 UNAIDS survey, 74% of young womenand 62% of young men aged 15-19 in Mozambique are unaware of any way to protect themselvesagainst HIV. Furthermore, half of the teenage girls surveyed in sub-Saharan Africa did not realizethat a healthy-looking person could be infected with HIV/AIDS. (68) 
Organizations are implementing a variety of approaches to increase access to educationamong orphans and vulnerable children. Some advocate implementing programs that offer bothtraditional and non-traditional responses, such as community schools, vocational training, andinteractive radio education. Community schools have been an attractive alternative to some becausesuch schools do not have user fees, uniform requirements, or related school expenses. Additionally,they utilize local teachers who often work on a voluntary basis, and are more affordable andaccessible to the poorest children because they are able to adapt to community needs (flexible hoursand harvest schedule). Some disadvantages of community schools are that they can be of a lowerquality than government schools and risk becoming a second tier for the poorest children. Additionally, volunteer teachers may leave the schools if offered a paid position, the quality ofeducation that they offer may be lower than that of paid teachers, and the community schools couldbe forced to close if donors decide to spend their funds elsewhere, since the schools rely on donorsfor infrastructure and material support. 
Vocational skills training, particularly farming skills training, is critical in areas whereparents have died before relaying knowledge of agricultural procedures. (69) In an effort to combatfamine in heavily affected areas, UNICEF has launched a program in Swaziland that offers trainingin farming to children orphaned by AIDS and affected by famine. (70) This program is intendedto help the children develop a source of income and combat famine that is affecting the region. Experts argue that vocational skills training programs can have additional benefits for girls. It ishoped that those who participate in vocational training will no longer be forced to rely on sex workto feed themselves and their siblings. (71) 
section_title: Protection and Legal Support
paragraphs: Children who are solely responsible for their siblings struggle not only to support thehousehold, but also to keep their homes. Property grabbing, a practice where relatives of thedeceased come and claim the land and other property, is reportedly a serious problem for widowsand child-headed households. Traditional law in many rural areas dictates that women and childrencannot inherit property. Property grabbing has a number of negative consequences particularly forgirls and women. Girls may experience sexual abuse and exploitation from their new caretakers;girls and women may be forced into the sex trade in exchange for shelter and protection, furtherincreasing the risk of contracting HIV. Some are concerned that the practice of property grabbingheightens the strain on extended families and increase the number of street children. 
In an effort to help parents prevent property grabbing, USAID supports organizations, suchas the Population Council and UNICEF, (72) which work with HIV-infected parents to plan for the future oftheir children through will-writing and other succession-planning initiatives. These initiativesencourage HIV-infected parents to disclose their HIV status to their children, appoint and trainstand-by guardians, create memory books (journals of lasting record of life together and familyinformation), and write wills before they die. (73) 
National legislation, at times, has minimized the effectiveness of succession programs. Thelegislative issues that AIDS-affected countries are beginning to face are often complex andinterlinked. For example, the single issue of inheritance rights may require governments to ensurethat each child has a birth certificate and national identification (which many children in developingcountries do not have), to strengthen the coordination and administration of their child services andsocial services departments that offer safety nets to children, to revisit property and trustee laws, andto reconsider who may legally represent minors. Laws in many rural countries follow traditionalcultural practices, which are based on the extended family structure. However, in the wake of theHIV/AIDS pandemic, they inadequately protect orphans and widows, as all adults in whole familiesmay have died. When the close family members die, children can be left in a precarious situation,as they may be forced to rely on distant relatives, who may be unknown. In many cases children areleft with their grandmothers, women who often have little legal power.
UNAIDS recently reported that 39% of countries with generalized HIV epidemics (countrieswith an HIV rate of more than 1%) have no national policy in place to provide care and support fororphans and vulnerable children, and 25% have no plans to develop such strategies. (74) National legislation thatwould establish and/or enforce inheritance rights of child- and widow-headed households could helpto curb the escalating street children population and minimize the practice among young girls andwomen of trading sex for security and shelter, ultimately contributing to HIV prevention. (75) 
The proliferation of property-grabbing has led some to call for an increase in orphanages. Supporters of increasing the use of orphanages argue that many communities are overwhelmed andcan no longer effectively care for children orphaned by AIDS. Children who live in orphanages haveaccess to education, food, shelter, and nurturing, which they may not be able to secure on their own,advocates of orphanages say. Some, including USAID, argue that orphanages do have their placein society, but that they should be used only in cases of last resort. Those who express caution aboutincreasing the use of orphanages to respond to the growing orphan population argue that poverty willbe the primary reason that parents place their children in institutions. Due to the high level ofpoverty in many areas, many parents send their children to orphanages simply because they areunable to support them. Research has shown that only 25% of children in institutional care do nothave any known relatives. (76) 
Supporters of community-based care argue that children who are raised in orphanages havea hard time being self-sufficient as adults because they do not learn life skills, do not havecommunity connections (a critical part of networking and job-seeking), have difficulty adapting tolife outside the orphanages, and develop a mentality that they will always be cared for. Ethiopia iscurrently implementing a country-wide reintegration program, after finding that orphanages were toocostly and unhealthy for the social and cultural development of the children. (77) Some caution thatorphanages can undermine community efforts to support orphaned children and separate them fromtheir families. Instead, they argue, efforts to support orphaned children should focus onstrengthening community networks and initiatives. In this view, community-based support can bothenable the children to stay within their communities, and enable donors to support more children,as the cost of supporting a child in an orphanage is substantially more than supporting a child withinits own community. (78) 
section_title: Psychosocial Interventions
paragraphs: The psychological impact of HIV/AIDS on children is often overlooked. Not only do manychildren who live in heavily affected areas contend with the death of one or both parents, but theyalso frequently face the death of younger siblings, aunts, uncles and other relatives. While there area number of programs that address the material needs of orphans and vulnerable children, there isless emphasis on helping children cope with the trauma associated with witnessing the deaths offamily members. The additional burden of caring for terminally ill relatives may send children intoshock leaving many of them with unanswered questions about their own mortality and future.
The psychological impact of HIV/AIDS on the young is often misunderstood, particularlyin the classroom. Children who are affected by HIV/AIDS may be frequently absent or tardy fromschool, find it hard to concentrate or unable to assume school-related expenses, such as school fees,uniforms, books and other school supplies. While teachers may have noticed that AIDS-affectedchildren tend to have lower performance in school, many apparently do not link the behavior withHIV/AIDS. As a result, some organizations are beginning to train teachers on how to identifygrief-related behavior. Teachers who have completed grief-identification training have reported thatthe sessions "opened their eyes to the reasoning behind what they had identified as misbehavior oforphaned students." (79) 
Programs are also being developed that enable children to play, a luxury to many orphans andvulnerable children. Children affected by HIV/AIDS often begin to assume adult responsibilities,such as earning wages, caring for the terminally ill, and cultivating the land, leaving them with littleto no time for recreational activities. These children may also be stigmatized and isolated, asignorance about the virus remains high. There are programs that offer Psychosocial support fororphans and vulnerable children, including peer support groups, recreational activities, andcounseling. (80) 
While psychosocial support for orphans and vulnerable children is important, the same typeof support is often overlooked for caretakers. Reports of grandmothers caring for a dozen childrenwith little to no income are not uncommon. The grandmothers are often exhausted and overworked. In many rural areas, senior citizens have no social security or retirement benefits. As a result,children under their care are more likely to be uneducated and malnourished. In response, caretakersand a variety of organizations have begun to develop programs that offer support to the caretakers. Grandmothers are beginning to form groups where they rotate supervision of children and allow eachother an hour of respite. Some are also developing support groups to discuss and find solutions totheir problems. Some non-governmental organizations offer stipends and financial support to thecaretakers and are training them to talk to the children about their grief. (81) 
section_title: Issues for Congress
paragraphs: Most often when governments of industrialized countries consider strategies to address theneeds of children affected by HIV/AIDS, they begin by examining their foreign aid programs. Whileforeign assistance programs are an important part of the effort, there are a wide range of other issuesthat are often overlooked. This section discusses a range of issues that impact efforts to helpchildren affected by HIV/AIDS, including how "AIDS orphans" are defined, how U.S. foreign aidprograms are implemented, and other related international initiatives. 
subsections: section_title: Targeting Assistance
paragraphs: Due to the high level of stigma still associated with HIV/AIDS, many who work in thedevelopment community avoid using the term "AIDS orphans." The term, some argue, only servesto further stigmatize and separate the children from the others in the community. Those who offersupport to communities affected by HIV/AIDS have found that the early programs, which focusedspecifically on children whose parents died of AIDS, often missed other vulnerable children, suchas those who are at high risk of becoming orphaned by AIDS (because their parents have HIV), thosewho live in households with children orphaned by AIDS, and those who may have been orphanedfrom other causes (like war or disease) are equally vulnerable. Additionally, in many communitiesit is often not known who has HIV/AIDS and who does not, due to struggling health careinfrastructures and minimal HIV/AIDS testing. As a result, many of the assistance networks,including UNICEF, UNAIDS, and USAID, develop programs that serve the needs of the mostvulnerable children in areas seriously affected by HIV/AIDS, many of whom are children orphanedby AIDS.
USAID's approach to assisting children orphaned and made vulnerable by HIV/AIDS hasposed a challenge for the U.S. Congress. USAID prefers not to create programs that exclusivelyserve children orphaned by HIV/AIDS. Representatives have stated that this approach would onlyserve to further isolate and stigmatize the children. As a result, the Agency supports the childrenthrough a number of interventions, which serve their needs, including educational support, schoolfeeding, and psychosocial support. Although this approach is one that is generally accepted amonginternational aid workers, it complicates Congressional efforts to monitor spending per program. P.L. 108-25 required that 10% of international HIV/AIDS funds be reserved for children orphanedand made vulnerable by HIV/AIDS. P.L. 108-199 , the FY2004 Consolidated Appropriations,supported the language. Neither USAID nor the Office of the Global AIDS Coordinator has beenable to detail exactly how much was spent on each program, such as school feeding, in large partbecause organizations implementing programs (including USAID-supported programs) use anintegrated approach. The programs respond to the needs of the most vulnerable children where theywork, rather than only assisting those whose parents have received an HIV/AIDS diagnosis. USAIDofficials underscore that this approach is also important, as many people in the most affectedcountries die without an HIV/AIDS diagnosis. Therefore, if it were to restrict services to thosechildren whose parents have officially died of AIDS, it might not meet its fiscal targets. Finally,USAID reports that it often combines funds from different accounts to address the sundry needs oforphans and vulnerable children, including Child Survival and Health Fund, (CSH), HIV/AIDSfunds for orphans and vulnerable children, Title II Food for Peace funds, and basic education funds. 
section_title: Foreign Assistance
paragraphs: Education and Poverty Programs. While fundingfor HIV/AIDS initiatives has dramatically increased in recent years, U.S. and international fundingfor other health programs, education and poverty-related programs have remained level anddecreased in some cases. Critics argue that this minimizes the effectiveness of HIV/AIDS programs,as many of the issues are interrelated. During a congressional hearing on the U.S. foreign operationsappropriations, USAID Administrator Andrew Natsios expressed concern that other programs suchas agriculture, which are vital in countering poverty and supporting health programs, are beingdecreased. (82) UNICEFestimates that over the past decade international education aid has fallen by 30%. As a result, 65million girls and 56 million boys did not attend school in 2002. The highest concentration ofuneducated children resides in Africa, also home of the highest number of children orphaned byHIV/AIDS. In 2002, the number of African children unable to attend school reportedly rose to 45million, up from 1990 levels of 41 million. (83) 
Collaboration. Although there are manyprograms that address the various needs of orphans, as illustrated in this report, some argue that thereis not enough collaboration among aid organizations on the ground. Some programs exclusivelyaddress the material needs of orphans, while others focus on their psychosocial needs, still othersfocus on empowering women and girls. Advocates argue programs could be more effective if therewere greater collaboration in their planning and implementation. USAID recognizes that the needsof orphans and vulnerable children are complex. In response, USAID integrates various aspects ofits development programs to meet the needs of these children, rather than implement a singleprogram exclusively for them. 
There has been an increasing amount of collaboration on the international level with USAID,UNICEF, UNAIDS, WHO, and the other international organizations that address the needs oforphans and vulnerable children. For example, the United Nations General Assembly SpecialSession (UNGASS) on HIV/AIDS developed a Declaration of Commitment on HIV/AIDS, to whichthe U.S. is a signatory. (84) Part of this commitment is that national policies would bedeveloped by 2003 and implemented by 2005, to build and strengthen government, community andfamily capacity to support children affected by HIV/AIDS. At the regional level, there have beena number of meetings in Africa that brought delegations together to agree on a common set of actionsand to measure progress towards them and the UNGASS goals. Additionally, in October 2003, anumber of international NGOs, faith-based institutions, governments, and other organizations metand agreed on a global strategic framework for the protection, care and support of orphans and otherchildren made vulnerable by HIV/AIDS at the first Global Partners Forum for Children Orphanedand Made Vulnerable by HIV/AIDS. This is a first step towards improving program effectiveness. However, collaboration efforts at the national and local level are often minimal or non-existent,critics say. As stated earlier, most of the needs of orphans and vulnerable children are met by theircommunities. Some argue that non-governmental organizations (NGOs) that operate at the locallevel need greater support and must be included in planning and implementation efforts. Additionally, including local and national NGOs may promote ownership and strengthens localcapacity.
Advocates for children affected by HIV/AIDS point out that efforts to respond to their needsare not commensurate to the scale of the problem. A number of options has been put forward toincrease the resources for AIDS-affected children. Some observes advocate establishing a Czar fororphans and vulnerable children to oversee U.S. efforts and to galvanize the global effort. Otheranalysts propose creating a senior orphan and vulnerable children position within the AIDSCoordinator Office. Still some say that the programs that address the needs of children should bestrengthened and better coordinated. Proponents of this position emphasize the importance ofintegrating the care, support, and treatment of HIV-infected children into HIV/AIDS treatmentprograms and those that prevent mother-to-child HIV-transmission.
The Global Fund to Fight AIDS, Tuberculosis, andMalaria. The magnitude of the HIV/AIDS crisis in seriously affected countries isfar too large, varied, and interrelated for any single body to address unilaterally and adequately.Those who believe that a productive response to this crisis requires greater cooperation point to theGlobal Fund as a model. (85) The Global Fund has at all levels representatives from the publicand private sectors. At the planning level, its board of directors is comprised of sevenrepresentatives from donor and developing countries, and a representative each from anindustrialized country NGO, a developing country NGO, the private sector, and a contributingfoundation. In the project design phase, the Country Coordinating Mechanism (CCM) or "nationalconsensus group" develops project proposals. The CCMs in each country include representativesfrom the government, NGO community, private sector, people living with HIV/AIDS, tuberculosisand/or malaria, religious and faith-based groups, academics, and the United Nations agencies. Thepractice of including all stakeholders in the planning and implementation of projects increases theireffectiveness and minimizes the likelihood of duplicating efforts, some claim. 
The Global Fund was unable to spend $87.8 million of the U.S. contribution in FY2004, asit did not receive sufficient matching funds. P.L. 108-25 required that U.S. contributions for fiscalyears 2004 through 2008 not exceed 33% of contributions from all sources. (86) The FY2005 ConsolidatedAppropriations provided $437.8 million to the Global Fund, including the $87.8 million. The fundsremain subject to the same 33% limitation. The total U.S. contribution through the end of FY2005has totaled more than $1.5 billion. Congress has consistently provided more than the Administrationrequested. The 33% requirement has caused a number of criticisms. Some believe that the UnitedStates should give more money to the Fund, as it has the structure and capability to use the moneyquickly. Some supporters of this idea also believe that the 33% requirement hinders the ability ofthe United States to give more. This policy, advocates claim, causes other nations who believe theUnited States has yet to give its fair share to hold back additional contributions. Critics of this viewpoint believe that the fiscal requirement encourages others to give more to the Fund. Proponentsargue that the United States is already the largest donor to the Fund, and should not be the primarycontributor. Furthermore some opponents of increasing U.S. contributions to the Fund havequestioned the absorptive capacity of the Global Fund, stating that it is spending the money tooslowly. (87) By December2004, the Fund had only disbursed $860 million of the $3.3 billion paid. (88) 
Anti-Retroviral Medication. Advocates argue thatif the most affected countries had greater access to anti-retroviral (ARV) medication there would bea decrease in the number of new orphans and other vulnerable children. Due to the cost and otherfactors, only 12% of the 5.8 million people immediately needing AIDS treatment in developingcountries have access to treatment. (89) According to WHO, only 325,000 of those with access totreatment in developing countries (700,000) live in sub-Saharan Africa, where 25.4 million peopleare currently living with the virus. (90) 
Preventing mother-to-child HIV transmission (PMTCT) is a critical part to reducing thegrowing number of orphans and vulnerable children (OVC) in developing countries, particularly forcountries with high seroprevalence rates among pregnant women, including Swaziland (39%),Botswana (32%), South Africa (24%), Kenya (22%), Namibia (18%), Zimbabwe (18%), and Malawi(18%). (91) Access tonevirapine, a relatively inexpensive single-dose drug that significantly reduces the HIV transmissionrate from mother to child, is virtually non-existent in many developing countries. In 2003, only anestimated 5% of pregnant women in Africa had access to drugs to prevent mother-to-child HIVtransmission, and only 8% globally were offered treatment. (92) It has been estimated that1,900 children are born with HIV every day in Africa alone. (93) 
Botswana, the first country in sub-Saharan Africa to develop a national anti-retroviraldistribution program, is the only developing country where nevirapine is readily available. Althoughit has a national distribution plan, there are barriers to widespread use of nevirapine and ARVs,including stigma and capacity challenges. At the end of 2002, 34% of pregnant women had accessto nevirapine in Botswana and 10,000 people were using ARVs. (94) The capacity challengesremain a significant challenge for countries that face the HIV/AIDS epidemic, as many of them,including Botswana have considerable shortages of health care workers. The President of Botswana,Festus Mogae, recently discussed this issue when he noted that Botswana struggles with "braindrain," as skilled health care professionals leave the government or country for more lucrativesalaries. (95) 
Botswana's slow ARV distribution has strengthened critics arguments that widespread ARVdistribution is not only hindered by high costs, but also by resource constraints. Some have statedthat health care infrastructures must first be strengthened before ARV distribution could be morerapidly scaled up. One area that has gained increasing attention is the shortage of trained Africanhealth care workers to offer ARV treatments. A UNAIDS report recently cited studies, whichestimated that between 19% and 53% of all government health employee deaths were caused byAIDS. (96) 
South Africa, a country that formerly rejected the widespread use of nevirapine or other ARVmedication, became the second country in sub-Saharan Africa to develop a national anti-retroviralprogram. It announced in August 2003 that its health ministry would begin a national distributionprogram. Though the country already offered nevirapine in some areas to pregnant women andemergency AIDS medication to rape survivors, the country leadership came under heavy criticismfor not developing an effective national ARV distribution plan. The announced plan sought toestablish a service point in each district within one year, and to make anti-retroviral medicationavailable to all South Africans and permanent residents at the municipal level within five years. (97) 
Uganda became the third country in sub-Saharan Africa to develop a national anti-retroviralprogram. It announced in December 2003 that its health ministry in partnership with USAID wouldlaunch a three-year program to provide anti-retroviral medication throughout the country. ThoughUganda has been hailed as an example of success for effectively bringing down its nationalseroprevalence rate, there are still more than 500,000 people living with HIV/AIDS in thecountry, (98) and nearlyone million (940,000) children orphaned due to HIV/AIDS. (99) 
The U.S. government has expanded its HIV/AIDS programs to include care and treatmentto people living with HIV/AIDS when Congress passed P.L. 108-25 , the "U.S. Leadership againstHIV/AIDS, Tuberculosis and Malaria Act of 2003." The law authorized the U.S. government tooffer ARV to at least 500,000 individuals by the end of 2004, and up to 2,000,000 by the end of2006. Some have criticized the U.S. government, as observers complain that it is moving too slowlyto implement the treatment programs. The Office of the Global AIDS Coordinator reports that bySeptember 2004, the President's Emergency Plan had supported ARV for 155,000 people. (100) Analysts note that ifthe Administration would work more closely with existing programs, greater results would beachieved.
Congress has already moved to increase access to treatment in the 109th session. H.R. 155 , Mother-to-Child Transmission Plus Appropriations Act for Fiscal Year 2005 ,introduced January 4, 2005, seeks to offer additional funding for MTCT-plus programs. Implemented through the Columbia University Mailman School of Public Health, this programprovides treatment to the entire family, as opposed to only the child and/or mother. H.R.155 appropriates $75 million for this effort in FY2005.
Access to ARVs for Children. Child advocates arecalling for more children to receive anti-retroviral therapy. UNAIDS estimates that only between15,000 and 20,000 children living with HIV/AIDS have access to treatment. The organizationbelieves that 660,000 of the 2 million children living with the virus need immediate care. Until1990, no antiretroviral (ARV) drug was specifically tested or approved for pediatric use. Only threeARVs are labeled for children under two, come in liquid form, and have WHO-approved genericversions available. The pediatric ARV drugs that are available are significantly more expensive thanadult versions -- branded pediatric ARV drug formulations cost between 50% and 90% more thanadult versions. (101) 
It is particularly challenging to treat infants and young children, as they are unable to swallowpills. This requires that they receive the drugs in liquid form, which has more stringent handling andstorage guidelines. Additionally, drug doses are based on children's changing weights and must berecalculated based on current weight or body surface area and then converted to the appropriatevolume based on the formulation strength. This process requires greater human resources, therecalculation of dosages at each visit, and fully-trained doctors. Liquid treatments are not availablein all ARVs, and the transition period from liquid to solid pills vary among medications. Whenliquid treatments are unavailable, providers would need to break adult tablets for lower doses orcrush pills into food or fluid. Proper dosage is hard to ensure using these methods. The currentshortage of health care practitioners in many developing countries, particularly in sub-SaharanAfrica, has posed considerable challenges in treatment efforts among adults. The more complexdemands and challenges of treating children has presented additional issues for affected countries.
Insufficient supplies of HIV testing kits are also a considerable problem in many of the mostaffected countries. For example, in 2004, 35% of HIV-positive babies in Nairobi, Kenya, died bytheir second birthday. The country had two specialized machines for detecting HIV in the country. Pediatric diagnostic equipment costs around $40,000 per unit in Kenya, while the cost of testing achild is about $55. In its 2004 Global Report, UNAIDS said 90,000 infants were exposed to HIVby birth and breast-feeding every year, at least 46,000 of them were infected and 60% died beforetheir second birthday. (102) 
section_title: Other Tools
paragraphs: Debt Relief. Some argue that the huge debtburden of developing countries, particularly those severely affected by HIV/AIDS, hinders theirability to develop an effective response to HIV/AIDS. Proponents of heavier debt relief argue thatmany countries, including those receiving debt relief, spend more money on debt payments than onsocial services. This money, they argue, could be used on other programs that are effective incombating the virus, such as supporting education and health infrastructures. (103) Oxfam estimates thatof the 26 countries participating in the Highly Indebted Poor Countries (HIPC) Initiative, half arestill spending 15% or more of government revenues on debt repayments. For example, Zambia isspending 30% more on debt repayment than on health. (104) Furthermore, HIV/AIDS is sinking these countries deeper intopoverty, making the debt repayments increasingly harder to pay.
There had been some congressional action on this issue in the 107th and 108th Congresses. H.R. 1567 , "Debt Cancellation for HIV/AIDS Response Act" in the 107th Congress, andin the 108th Congress H.R. 643 , "To Urge Reforms of the Enhanced Highly IndebtedPoor Countries (HIPC) Initiative," and H.R. 1376 , "To Improve the HIPC Initiative"were introduced. All three bills sought to expand debt relief efforts to countries heavily affected byHIV/AIDS. Similar legislation is expected to be introduced in the 109th session. Some areconcerned that debt reduction initiatives can be abused, and corruption will undermine debtreduction strategies. Furthermore, it has been argued that it is not debt repayments that are sinkingthese countries deeper into poverty but the lack of strong revenue sources. If some of these countrieswould revise their economic and social policies there would be less of a need for debt relief, criticssay. In an effort to limit the corruption and careless use of debt relief, international institutions, suchas the World Bank and UNAIDS, are working with countries to develop effective, transparent plansto incorporate HIV/AIDS efforts into debt reduction strategies. (105) 
Agricultural Subsidies. Countries heavilyaffected by HIV/AIDS need increased revenue to support crumbling health and educationinfrastructures, offer HIV/AIDS treatment, and develop comprehensive HIV/AIDS programs. Forexample, UNICEF recently reported that Kenya would need $70 million per year to support 1.2million Kenyan children affected by HIV/AIDS. (106) 
Some argue that agricultural subsidies hinder the economic growth of countries like Kenyathat are affected by HIV/AIDS, and consequently their ability to combat the epidemic. It is estimatedthat in 70% of developing countries agriculture is the main source of revenue for families, as wellas the national economy. (107) However, some have said that agricultural subsidies preventfarmers in agriculture-based economies from exporting their products to global markets, becausetheir unsubsidized prices are higher than the below-market prices of subsidized agricultural goods. The World Bank recently reported that agricultural subsidies in industrialized countries total $311billion a year, with sugar subsidies that are nearly equivalent to all exports from all developingnations at $6.4 billion. (108) The Bank estimated that if agricultural subsidies wereeliminated, agricultural and food exports from low and middle-income countries could rise by 24%,increasing rural income by about $60 billion. (109) Some use the World Bank report to argue that agriculturalsubsidies also undermine foreign aid efforts. The report estimates that agricultural subsidies areabout six times the amount of all foreign aid (110) with U.S. subsidies to cotton growers totaling $3.9 billion in2003, three times the amount of U.S. foreign aid to Africa. (111) Concurrently, criticsof agricultural subsidies are concerned that the subsidies also increase reliance on foreign aid,because subsidies encourage surplus production of agricultural goods that are ultimately exportedto poorer countries who are unable to produce domestic goods at a competitive price. They assertthat, consequently, people living in agriculture-based economies have less income to purchase basicnecessities, including food, heightening reliance on foreign aid. (112) 
In an effort to address agricultural trade issues, members of the World Trade Organization(WTO) agreed in Doha, Qatar, in 2001, to lower tariffs and other barriers to free and fair agriculturaltrade. The WTO Ministerial Conference in CancÃºn, Mexico, was to follow-up the agreement anddevelop concrete plans to revise the trade laws. (113) However, talks collapsed when developing countries andindustrialized nations could not agree on several issues. Since no progress was made, agriculturaltariffs and subsidies remain. The United States maintains that it will continue to work with countriesto develop strategies to gradually eliminate agricultural subsidies and other barriers to trade. (114)