1. Unite for Children, Unite against AIDS. Crises impact on children vulnerable to HIV UNICEF, ODI Conference The Global Economic Crises – including children in the economic response 9-10 November, 2009 Nicola Jones, Carlotta Tincati, Caroline Harper, Shreya Mitra, Jessica Espey Presented by Ken Legins Senior Advisor, HIV Policy and Evidence UNICEF

2. Outline 1.Framework to guide the linkages between HIV and the economic crises 2.Broad impacts and the special case for children and their mothers 1.How it impacts on children and mothers living with HIV 2.How it makes women and children more vulnerable to HIV 3.Case studies across epidemic types 4.Policy Recommendations for consideration

3. Framework

4. The world of HIV © Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

5. The world of income © Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

6. Total annual resources available for AIDS 1986-2007

7. Resource Availability for HIV, 2005-2008

8. Respondents expecting an adverse impact in the next twelve months on antiretroviral treatment (%) (comparison of April and July 2009 surveys)

9. Challenges posed by crises - financial The huge investment in treatment means that without new money there will be very little resources that can be directed toward prevention and it will be tough to increase treatment numbers. The pace of new infections also continues to outstrip the number treated. For every one person being put on a therapy regime, three people contract the disease. Trend is worrying because the majority of HIV positive people dont know their status (<40% and lower for high risk groups) and the majority of people who need treatment are not getting it (40-47% on treatment)

10. Why pay attention to children and HIV? 50% of all children living with HIV will die by their 2 nd birthday if they do not get ART. -

11. How is the crisis impacting on children living with HIV and their mothers Health Seeking Behaviour for PLWHAs Out of pocket expenses Travel Corruption (bribes for tests, etc). There are legitimate users fees and associate costs as well. Burden sharing – childs responsibilities increase Seek allopathic health care (witch doctors)

12. How is the crisis impacting on children living with HIV and their mothers: HH expenditure Health Expenditure Ratios (2006) Public Versus Private Expenditures Total expenditure s on health as % of GDP General government expenditure s on health as % of total government expenditure s General government expenditures on health as % of total expenditures on health Private expenditures on health as % of total expenditures on health Out-of- pocket expenditure s as % of private expenditure s on health External resources for health as % of total expenditures on health Botswana 7.117.876.523.527.55.8 Haiti 8.429.867.632.489.665.8 Lesotho 6.88.258.941.168.914.3 Mozambique 5.012.570.829.240.660.3 Namibia 5.410.566.733.315.721.1 Russia 5.310.863.236.881.50.1 South Africa 8.09.137.762.317.50.9 Swaziland 6.311.265.834.241.412.3 Thailand 3.511.364.535.576.60.3 Zambia 6.216.460.739.367.238.1 Zimbabwe9.38.948.751.350.317.3

13. How is the crisis impacting on children living with HIV and their mothers Social exclusion HIV+ migrants looking for jobs will not have the same access to health and protection services Exploitation and abuse, loss of homes and inheritance rights, potential to become street children and child trafficking were all recorded risks in South East Asia (Save the Children) Gender/Age Economic Risks - anticipated Women/girls are primary health care providers. In Africa over 90% of care of PLWHA is provided by women Women often consume less and poorer quality food in an effort to protect their families Children living with HIV need 100% more nutrition 80% less quantity of food in households affected by HIV in India / girls less

14. How is the crisis intensifying vulnerability to new infection Food consumption Dependence on asset selling, as poverty, HIV and malnutrition are are linked. There is a complex three-way relationship between malnutrition, the immune systems and infection, with malnutrition eliciting immune systems dysfunctions with in turn promote increased vulnerability of the host to infection, and the latter intensifying severity of malnutrition– Enwonwu (2006) Health seeking behaviour Access to testing – and throughout the cascade of PMTCT interventions

15. Percentage of pregnant women who received an HIV test in low- and middle- income countries by region, 2004-2008.

16. How is the crisis intensifying vulnerability to new infection Loss of livelihood and risky coping strategies Hazardous forms of work and the sex industry 58% of current Cambodian sex workers had entered the trade since the onset of the crisis. Impacts on Schooling Being in school exempts children from working in risky occupations. Gender/age dimensions Employment – coping strategies and female susceptibility 2 to 4.5 times higher infection rates for girls in Eastern and Southern Africa. Age Social exclusion of children affected by HIV and other vulnerable children

17. Respondents reporting or expecting an adverse impact on prevention and OVC programmes

18. Percentage of orphans and vulnerable children whose household received basic external support, 2005-2007

19. Applying the Model across different epidemics: Literature & interviews Macro: Decline in FDI / Declining Trade Volumes and Prices / Lower remittances / Declines in ODA Meso: Growth deceleration / Unemployment / Reduced Government Fiscal Space / Potential for cuts in health public expenditure (e.g. South Africa) and health private expenditure (e.g. Zambia mining companies) Micro: Increasing Transport Costs / Lower remittances / Unemployment

20. Thailand: Commercial sex-workers Macro: Growth contraction / Private Investment and consumption declines / Poorer volumes of trade / Decline in remittances Meso: Suspected HIV budget cuts as per 1997? / Unemployment Micro: Lower external HH inflows like remittances / unemployment / hazardous forms of employment like sex work / trafficking. Policy Response? - National Health Security Scheme - Children: Compulsory free basic education - Contributory and non-contributory social protection schemes, including unemployment benefit. Coverage for unemployment benefit was extended from 6 to 8 months as part of the government's stimulus package

21. Policy recommendations for consideration 1.Age and gender sensitive analysis An analysis of the risks women face has provided the basis for further analysis of women and children as living with HIV, care givers and at increased vulnerability. 2.Development of an AIDS sensitive, but not AIDS exclusive comprehensive package of protection measures which reflect context specific vulnerabilities. Context specific approaches: child grants, social insurance, etc. 3.Promote HIV as an entry point for health systems strengthening – improved access and coverage of MCH leading to impact and reduce inefficiencies in the current programmes. 4.Build back better – national policies must reflect the true capacity of civil society and to monitor the impact of the crises on their capacities so government responses can compliment.

22. Thank you!

23. Catastrophic out-of-pocket payments Out-of-pocket payments for health care pushed 2.6m Vietnamese into poverty in 1998. Increased poverty headcount by 23%

24. Russia: Intravenous Drug Users Macro: GDP contracting by c. 7.9% in 2009 (World Bank 2009) / Lower FDI / Lower trade / Falling commodity prices (price of Urals brand oil fell 70% in first 4 months of 2009). Meso: South-south remittances from Russia vulnerable (b/c of currency depreciation) / Unemployment up to 13% (World Bank 2009) / Real wages reduced by 2% (ibid). Micro: Poverty up to 17.4% (World Bank 2009) / Lower HH consumption (down 2.2% in Q1 09) / significant effects on out of pocket expenditure….

25. The trip F crisis will increase the Global poor between 53 and 64 million people in 2009 for those living on less than $2 and $1.25/day. Continued high prices of domestic food and fuel Challenge because no previous crisis. How to work with programmes to inform policy Addressing inefficiencies within social sectors HIV relationship to poverty

27. Crises specific impacts Budgets – national and household Pubic and private Outpacing of new infections with number of peoplw accessing drugs Inefficient use of resources (cuts on interventions for most at risk populations, including children MARA and MARPS)

28. Exacerbating pre-crisis conditions Absence of strategic national responses to address children affected by AIDS and other vulnerable children Ineffective health systems and knowledge about HIV testing, especially for parents Evidence base for working with MARA and MARPs is limited, but political will to address the needs of these populations is difficult

30. How is the crisis impacting on children living with HIV and their mothers: Factors causing or expected to affect the HIV and AIDS response across regions Regions 1/ 2/ APCaribbeanESAFECALAMENAWCAF Household income 27%100%55%50% 33%69% NGOs and CBOs capacity 27%67%64%50% 33%74% Food and nutrition 18%100%64%30%33%0%68% External Aid18%67%55%70%50%67%84% Government budget for HIV 27%67%64%60%50.033%68% Prices for ART0%67%18%50%17%0%32% User fees9%67%0%20%0% 16% Private sector0%67%27%30%0%33%58% Source: UNAIDS/World Bank survey