AIDS Orphans and Vulnerable Children (OVC): Problems, Responses, and Issues for Congress

CRS Report for Congress
AIDS Orphans and Vulnerable Children (OVC):
Problems, Responses, and Issues for Congress
Updated November 18, 2005
Tiaji Salaam
Analyst in Foreign Affairs
Foreign Affairs, Defense, and Trade Division

Congressional Research Service ˜ The Library of Congress

AIDS Orphans and Vulnerable Children (OVC):
Problems, Responses, and Issues for Congress
Since HIV/AIDS was discovered in 1981, more than 20 million people have lost
their lives to the virus. According to the Joint United Nations Program on HIV/AIDS
(UNAIDS), nearly 40 million are currently living with HIV/AIDS, including nearly
2.2 million children under the age of 15. In 2004, 4.9 million people acquired the
virus, and 3.1 million died from AIDS. Sub-Saharan Africa remains the most
affected region with 25.4 million people living with HIV/AIDS at the end of 2004,
1.9 million of whom were children under the age of 15. The United States Agency
for International Development (USAID), the United Nations Children’s Fund
(UNICEF), and UNAIDS estimate that at the end of 2003, 15 million children under
the age of 18 had lost one or both parents to AIDS, with the majority (82%) in sub-
Saharan Africa. In just two years, from 2001 to 2003, the global 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 the
10-year time lag between HIV infection and death, officials predict that orphan
populations will continue to rise for a similar period, even after the HIV rate begins
to decline. Experts say only massive 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 children orphaned 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 also impacted. Children who have been
orphaned by AIDS may be forced to leave school, engage in labor or prostitution,
suffer from depression and anger, or engage in high-risk behavior that makes them
vulnerable to contracting HIV. Children who live in homes that take in orphans may
see a decline 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 health care increasingly absorbs household funds, which
frequently leads to the depletion of savings and other 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/AIDS funds 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 Developing Countries 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 assistance activities; directed the appointment of a Special Advisor for
Assistance to Orphans and Vulnerable Children within USAID; and required an
annual report on project implementation. This report explores some of the challenges
facing children affected by HIV/AIDS, outlines U.S. and international efforts to assist
those children, and outlines some key issues that may be considered by Congress in
the 109th session. This report will be updated.

In troduction ......................................................1
Most Recent Developments..........................................3
Orphans and Other Children Made Vulnerable by HIV/AIDS:
Challenges for Governments.....................................4
Street Children and Exploitation..................................4
Education and the Economic Impacts..............................6
Agricultural and Food Impacts....................................7
Stigma, Discrimination, and Depression............................9
Gender Exploitation...........................................11
Responses to Impact...............................................12
Economic and Material Responses...............................13
Education and Skills Training...................................14
Protection and Legal Support....................................15
Psychosocial Interventions......................................17
Issues for Congress...............................................19
Targeting Assistance ..........................................19
Foreign Assistance ...........................................20
Education and Poverty Programs.............................20
Collaboration ............................................20
The Global Fund to Fight AIDS, Tuberculosis, and Malaria........21
Anti-Retroviral Medication.................................22
Other Tools.................................................25
Debt Relief..............................................25
Agricultural Subsidies.....................................26

AIDS Orphans and Vulnerable Children
(OVC): Problems, Responses and Issues
for Congress
Since HIV/AIDS was discovered in 1981, more than 20 million people have lost
their lives to the virus. Nearly 40 million people are currently living with HIV/AIDS,
including nearly 2.2 million children under the age of 15. Ninety-five percent of
those living with HIV/AIDS reside in developing countries. Sub-Saharan Africa
remains the most affected continent with 1.9 million of the 2.2. million infected
children.1 A joint study conducted by the U.S. Agency for International Development
(USAID), the United Nations Children’s Fund (UNICEF), and the Joint United
Nations Program on HIV/AIDS (UNAIDS) found that at the end of 2003, 15 million
children under the age of 18 had lost one or both parents to AIDS, with 12.3. million
of them found in sub-Saharan Africa.2
Between 1990 and 2003, sub-Saharan Africa’s population of children orphaned
by AIDS increased from less than 1 million to more than 12 million3. Due to the 10-
year time lag between HIV infection and death, experts predict that without the
availability of anti-retroviral medications orphan populations will continue 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 late 1980s to 4.1% in 2003, the number of orphans under the age of 15
continued to climb for 10 years after the country’s infection rate peaked. Experts
report that the number of orphans is only now expected to decline in the country,
from 14.6% of Ugandan children in 2001 to a projected 9.6% in 2010.4 Thailand,
long hailed for having significantly reduced its HIV/AIDS rate, is still witnessing an
increase in children orphaned 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 their parents to AIDS.5

1 UNAIDS and World Health Organization (WHO), AIDS Epidemic Update: December 2004.
Geneva: 2004, p.1.
2 UNAIDS, UNICEF, and USAID, Children on the Brink 2004: A Joint Report of New Orphan
Estimates and a Framework for Action. New York City: 2004, p. 3.
3 Ibid, p. 10.
4 UNAIDS, Accelerating Action against AIDS in Africa, p. 24 [].
5 Stanmeyer, Anastasia, “AIDS in Asia: Cruel Epidemic Hits Kids Hard.” San Francisco
Gate, December 19, 2002 [].

The term “AIDS orphans” is used in the title of this report to facilitate
recognition of the issue. However, those that serve children affected by HIV/AIDS
caution against the use of this term because they believe it further stigmatizes the
children. Consequently, the terms “orphans and vulnerable children” (OVC),
“children affected by AIDS,” and “AIDS-affected children” will be used hereafter to
refer to “AIDS orphans.”6
The growing population of children orphaned by HIV/AIDS is a concern,
because had it not been for HIV/AIDS, the global percentage of orphans would be
declining instead of increasing. By the end of 2003, 43 million children (12% of all
African children) were orphaned in sub-Saharan Africa, 12.3 million (32% of all
African orphans) of those were due to AIDS. Although Asia had a lower number of
children orphaned by AIDS in 2001, 1.8 million (2.8% of all orphans), it had a much
larger overall orphan population than sub-Saharan Africa, with 65 million orphans.7
Some have expressed concern that 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 were
living 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 in the quality of education. A 2000 study found that an HIV-infected
teacher loses approximately six months of professional working time before
succumbing to the virus.11 This has had a significant impact on heavily affected
countries such as Kenya, where teachers are dying faster than they can be trained and
replaced. Kenya faces the loss of 6,570 teachers annually due to HIV/AIDS, which
translates to 18 teacher deaths per day.12 In the Central African Republic, almost as
many teachers died of AIDS as retired between 1996 and 1998. As a result, nearly

6 The issue of terminology is explored further in “Issues for Congress.”
7 The most recent report on children orphaned by AIDS, Children on the Brink 2004, only
offers updated data on children orphaned by AIDS in Africa. There is no updated
information on children orphaned by AIDS for the other regions. However, there are new
figures for the total number of orphans per region. In Asia, by the end of 2003, there were

87.6 million orphans.

8 Seroprevalence rate means HIV/AIDS rate.
9 UNAIDS and WHO, Epidemiological Fact Sheets: India. Geneva: 2004, p. 1.
10 UNAIDS and WHO, Epidemiological Fact Sheets: South Africa. Geneva: 2004, p. 1 at
[ h t t p : / / www. wh o . i n t / G l o b a l A t l a s / P D F F a c t o r y / H I V / E F S _ P D F s / E F S 2004_ZA.pdf].
11 Hepburn, Amy E., Primary Education in Eastern and Southern Africa: Increasing Access
for Orphans and Vulnerable Children in AIDS-Affected Areas, Terry Sanford Institute of
Public Policy, Duke University, June 2001, p. 12.
12, “A Lesson from AIDS among Teachers,” October 29, 2001
[ h t t p : / / www.a l l a f r i c a . c o m] .

two-thirds of the schools have closed due to staff shortages.13 Heavily affected
communities produce lower crop yields due to a reduction in land use (those who are
ill with AIDS are often too weak to farm), and a decline in the variety of crops
grown. The infrequent use of fertilizers in the fields often results in a decline in soil
fertility, increases in pests and diseases, and a decline of external production outputs,
including cash crops.14 As a result, countries significantly impacted by HIV/AIDS
have experienced a rise in child mortality and a decline in the gains made in child
survival over the past decade. For example, child mortality in Kenya was 205 per
1,000 in 1960, and had fallen to 97 per 1,000 in 1990. However, due to HIV/AIDS
the rate increased to 122 per 1,000 in 2001.15
The majority of children orphaned or made vulnerable by HIV/AIDS are living
with a surviving parent, or within their extended family (often a grandparent). An
estimated 5% of children affected by HIV/AIDS worldwide have no support and are
living on the street or in residential institutions. 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 effective responses 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 localized
efforts, many of them initiated by faith-based groups, to address the needs of children
made vulnerable by AIDS. Proponents argue that supporting these “grassroots”
efforts can be a highly cost-effective response, although additional mechanisms are
needed to channel such resources. They further assert that additional resources are
needed to expand the limited programs and to support the children who are on the
street or in institutional care.
Most Recent Developments
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 used for children orphaned or made
vulnerable by the virus (OVC). In the 108th Congress, there was considerable debate
on how the funds should be allocated. Many pointed out that activities related to
children affected by HIV/AIDS should be streamlined. Some wanted to create a
coordinator for children orphaned and affected by HIV/AIDS in the AIDS
Coordinator’s Office of the State Department. Still others argued that the scope of
assistance should be expanded to include children who 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
by HIV/AIDS, though none made it to full conference.

13 UNAIDS, Fact Sheets — HIV/AIDS and Development, at []; and
ILO, HIV/AIDS in Africa: The Impact on the World of Work, at [].
14 Food and Agriculture Organization of the United Nations (FAO) website, AIDS and
Agriculture in sub-Saharan Africa (June 1996), at [].
15 UNICEF, “State of the World’s Children 2003,” table 1, p. 85, at [].

In the 109th session, H.R. 1409, Assistance for Orphans and Other Vulnerable
Children in Developing Countries 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, authorized spending for orphan-
related programs in FY2006 and FY2007; established a 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 Children
within USAID; and required an annual report on project implementation.
Orphans and Other Children Made Vulnerable by
HIV/AIDS: Challenges for Governments
The continued increase in international HIV rates is proving devastating for
governments heavily affected by HIV/AIDS, not only because their most productive
populations are being decimated, but also because the future of these countries and
their children is at risk. Governments with significant populations of children
orphaned and made vulnerable by HIV/AIDS may be faced with a range of issues,
including surging street children populations, a rise in child labor, child prostitution
and other forms of exploitative work, vulnerability to crime, militias and terrorist
organizations, a growing population of uneducated and unskilled laborers; and long-
term foreign aid dependence. This section will explore some of these challenges, and
the implications that they have on affected countries.
Street Children and Exploitation
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 have become the place where children orphaned and made
vulnerable by HIV/AIDS often turn to supplement lost wages, find refuge, and
sometimes to find an escape from stigma. While on the street, children can be16
exposed to rape, drug abuse, child labor, including child prostitution, and other
forms of exploitation, making them more vulnerable to contracting HIV/AIDS.17
Children as young as nine years old have been found to be engaged in sex work.
While no one seems to know how many children actually live on the streets
worldwide, many reports cite a UNICEF estimate of 100 million.18 Country reports
from a number of heavily affected nations all report 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 children roaming the

16 For more information on international child labor, see CRS Report RL31767, Eliminating
International Child Labor: U.S. and International Initiatives, by Tiaji Salaam.
17 Human Rights Watch, In the Shadow of Death: HIV/AIDS and Children’s Rights in
Kenya, June 2001, at [].
18 Amnesty International Magazine, “Amnesty: On the Streets,” Accessed on October 7,

2003, at [].

streets since 2002, with 40 new children coming into the streets each month.19
Tegucigalpa, the capital of Honduras, has experienced an eightfold increase of street
children in the last decade.20 Kenya has become infamous 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 and homes 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 sent out by their parents to beg for food and
money.22 Whether the children live on the streets or spend the majority of their days
on the streets, experts are concerned about their vulnerability to terrorist
organizations and militias, crime, and HIV infection. A UNICEF worker in Kenya
recently asked, “What kind of adults 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 and those on the streets are increasingly rootless, uneducated, undernurtured
and traumatized, making them ripe for recruitment for crime, military warlords and
terrorists. Children as young as seven years old are among the 300,000 children
fighting in wars around the world today. Some are particularly concerned that
orphans and other children affected by HIV/AIDS can become easy conscripts for
warring factions, as they search for food, shelter, nurturing, and safety. A rebel
fighter in Congo reportedly claimed that his militia pays the school fees for the
children in his group, most of whom are orphans.24 Children’s vulnerability to other
forms of exploitation was illustrated in a study conducted by the International Labor
Organization (ILO). The study found that in Zambia the majority of street children
and children involved in sex work were orphans. Another study in Ethiopia found
that the majority of child domestic workers were orphans. It was found in Uganda
that girls were especially vulnerable to sexual abuse while engaged in domestic
work.25 Scott Evertz, Director of the White House Office of AIDS Policy has said:

19 Afrol News, “More Street Children as Malawi Food Crisis Deepens,” February 5, 2003,
at [].
20 Collymore, Yvette, “Migrant Street Children on the Rise in Central America,” Population
Reference Bureau, January-March 2002, at [].
21 Wax, Emily, “A Generation Orphaned by AIDS.” Washington Post, August 13, 2003.
22 UNICEF, A Study on Street Children in Zimbabwe, 2001, at [
evaldatabase/index_14411.html ].
23 Jingzhong, Wang, “AIDS Orphan Crisis Poses Grave Challenge to Africa,” Xinhua
General News Service, November 28, 2002.
24 Wax, Emily, “Boy Soldiers Toting AK-47s Put at Front of Congo’s War,” Washington
Post, June 14, 2003.
25 Department of State, “AIDS Orphans Crisis Looms, Action Needed, UNICEF Says,”
Washington File, November 27, 2002, at [].

More and more AIDS orphans are growing into young adults with little or no
adult supervision. Clearly this presents a security risk. We will have whole
populations of them in much of the world, ripe for the picking by those
individuals who would want to engage the interests of young adolescents.
Terrorists would find this an ideal breeding ground.26
Although a number of social scientists have raised concerns about the growing
number of children orphaned and made vulnerable by HIV/AIDS, others feel that the27
prediction of rising crime rates and increased political instability is alarmist. Those
who dispute the linkage between social breakdown and increased orphanhood cite a
lack of evidence and a reliance on anecdotal data. Furthermore, they argue that
children have lived among extended family members for some time, particularly in
southern Africa, where a significant proportion of the population are migrant
laborers. Those that believe the family networks are strong and can support and
adapt to the growing number of orphans point 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 were headed by
neither their mother nor father.28 The key point that critics underscore is that linking
orphanhood to increased crime or insecurity “prematurely labels orphaned children
and youth as delinquents and criminals before the necessary contextual research has29
been carried out.” Critics argue that this only furthers the stigma that children
orphaned and made vulnerable by HIV/AIDS already face.
Education and the Economic Impacts
Some social scientists are concerned that the growing number of children
affected by HIV/AIDS could lead to a decrease of skilled laborers within a country,
further destabilizing the national economy and society at large. The issue is that an
inefficient transfer of skills and scholarship leads to a decline in human capital, the
body of knowledge, and ability found in a population. It is human capital that drives
economic growth, some experts argue, and when that is threatened so is the economic
security of a nation. A 2003 World Bank report warned that “a widespread epidemic
of AIDS will result in a substantial slowing of economic growth, and may even result30
in economic collapse.” The report argues that the effects of these weakened
knowledge-transmission processes are felt only over the longer run, as the poor
education of children today leads to the low productivity of adults in the future.

26 Gibson, William E., “AIDS Crisis Spurs US into Action,” South Florida Sun-Sentinel,
June 23, 2002.
27 Bray, Rachel, “Predicting the Social Consequences of Orphanhood in South Africa,”
Centre for Social Science Research (CSSR) Working Paper 29, February 2003.
28 Nattrass, Nicoli, “AIDS and Human Security in Southern Africa,” Centre for Social
Science Research (CSSR) Working Paper 18, November 2002, p. 9.
29 Bray, Rachel, “Predicting the Social Consequences of Orphanhood in South Africa,”
Centre for Social Science Research (CSSR) Working Paper 29, February 2003, p. 9.
30 Bell, Clive, Shanta Devarajan, and Hans Gersbach, “The Long-Run Economic Costs of
AIDS: Theory and Application to South Africa” (Washington: World Bank, June 2003), p.

6, at [].

In many parts of the developing world, people rely on their own plots of land for
the majority of 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 for income. 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 and
skills training, children orphaned and made vulnerable by HIV/AIDS are more likely
to fall deeper into the cycle of poverty and engage in high-risk behavior, which
perpetuates the cycle of HIV transmission. Ultimately, the affected countries might
find it harder to overcome national poverty and become effective members of the
international economy.
The economic challenges of children affected by HIV/AIDS occur in stages.
The first stage often begins when children realize that their parent has AIDS and is
likely to die. They begin to fear for their future, wonder who will care for them, and
worry about how they will be able to stay in school. Children are often pulled out of
school to care for an ailing family member, or because meager household income is
now spent on the sick. School fees, notebooks, and pencils become unaffordable 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 skills and 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 they often slide more deeply into
poverty. For some, the next stage begins when they find themselves the heads of
households. A young adolescent may be responsible for many siblings, some of
whom may be infants. Children who are the heads of households are in a difficult
position not only because they must now support their siblings with little to no
education and/or employable skills, but also because they most likely have limited
resources. In many cases much of the family’s possessions may have been sold to
care for the sick. Large numbers of orphaned children find themselves in homes that
cannot 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 as shining shoes, begging for money in the streets,
bartending, selling food, and most often in the case of girls, becoming domestic
workers. Many observers believe that the desperation of these young children makes
them more vulnerable to abuse and exploitation, ultimately making them more
susceptible to contracting HIV.
Agricultural and Food Impacts
Stories of children going hungry or starving in areas that always had food,
because HIV-infected parents who were farmers became too weak to till the fields
are increasingly reported across Africa. Many traditional agrarian societies rely on
women to produce food, particularly in Africa, where 80% of subsistence farmers are
women.31 During times of famine these women know which wild grains, roots, and

31 World Economic Forum, “African Food Security: A Role for Public-Private Partnership,”
December 6, 2003, at [].

berries can be eaten when there are no crops.32 The women also teach their children
how to farm and survive off the land. As significant numbers of women of
childbearing age fall ill due to HIV/AIDS, they become unable to transfer these skills
to their children, both in times of famine and without. This is of particular concern
in Africa, where 67% of all people infected with HIV/AIDS are women.33 Farmers
in the last stages of AIDS usually produce little to no crop yields. Lower crop yields
within households require the families 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 from labor-intensive corps, such as
vegetables, to less labor-intensive crops, such as roots. Both changes impact
nutrition as the family has less access to a variety of nutritious foods because of a
decline in productivity 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 much of the continent’s food products were exported. According to
UNAIDS, the agricultural sector accounts 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 agricultural workers in
southern Africa by 2020.34 A decline in productive yields is already being seen. In
the early 1990s many of the countries in the region exported their surplus grain
production, while producing enough food to feed their own populations. In 2002,
however, 15 million people faced hunger and starvation 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 3.22 million tons of cereal in FY2002,
and ultimately required between 3.6 and 4.6 million tons of cereal to meet the
shortfall.36 In 2003, WFP continued to seek support in its effort to feed 6.5 million
people facing severe hunger in 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% of
all Swazis are at risk of hunger or starvation until the next harvest in March 2005.
In Malawi, some 1.7 million people, mainly in the south, need assistance. It is

32 De Waal, Alex, “What AIDS Means in Famine,” New York Times, November 19, 2002.
33 World Economic Forum, “African Food Security: A Role for Public-Private Partnership,”
December 6, 2003, at [].
34 UNAIDS, 2004 Report on the Global AIDS Epidemic: Executive Summary. Geneva:

2004, p. 10, at [].

35 SADC comprises the nations of Angola, Botswana, Democratic Republic of Congo
(DRC), Lesotho, Malawi, Mauritius, Mozambique, Namibia, Seychelles, South Africa,
Swaziland, Tanzania, Zambia, and Zimbabwe.
36 “Food Crisis in Southern Africa,” SafAIDS News, vol. 10, no. 2 (June 2002), p. 10, at
[ h t t p : / / www.s a f a i d s .or g. zw] .
37 “Food Aid Needs in Southern Africa Remain Massive,” WFP News Release, November

4, 2003, at [].

estimated that 4.7 million people desperately need food assistance in Zimbabwe,
mostly caused by a reduction in commercial maize production (due to the land
redistribution program) and sharp increases in food prices. The World Food Program
(WFP) has expressed disappointment by the minimal response to the global appeal
for $404 million for 2002-2005. To date, WFP has only received 2.5% (about US
$10 million) to stave off hunger in southern Africa.38
Household crop supply in the region has been further strained as neighboring
families attempt to take in children who have lost their parents to AIDS. The long-
term impact is of special concern as an increasing number of children are losing the
opportunity to learn how to farm because their parents have died an early death from
AIDS. Some experts have expressed concern that in the long-run African people will
be unable to sustain themselves as they are forced to put off transferring life skills to
cope with HIV/AIDS.39 In recognition of the long-term effects of AIDS on nutrition
and food security, WFP has announced that it is now a cosponsor of the Joint United
Nations Programme on HIV/AIDS (UNAIDS).40 A significant part of its efforts will
include integrating food aid with education programs.41
Stigma, Discrimination, and Depression
According to UNAIDS, stigma and discrimination continue to accompany the
HIV/AIDS epidemic. Children are not immune from stigmatization. In cases of
stigma, children begin to be rejected early as their parents fall ill with AIDS. Some
children may be teased because their parents have AIDS, while others may lose their
friends because it is assumed that proximity can spread the virus. Harsh cases of
discrimination have been reported in many countries, including India and Trinidad
and Tobago, particularly for HIV-infected children. A UNAIDS study found that
HIV-related stigma is particularly high in India, where 36% of the respondents in a
survey felt that HIV-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 illustrated how the desire to
disassociate from HIV-positive people impacts children. Two HIV-positive children,
who lost both of their parents to HIV/AIDS, were repeatedly barred from schools for
two years in India. After the children and their grandfather protested in front of
government buildings, one school finally accepted them. However, all 100 of their

38 UN Office for the Coordination of Humanitarian Affairs (OCHA), Southern Africa: More
than food aid needed for recovery. February 10, 2005. See [].
For additional reading on hunger and HIV/AIDS, also see OCHA, The Impact of AIDS on
Agriculture. October 22, 2004. See
[ ht t p: / / www.sahi ms .net / a r c hi ve / Br i ef cases/ 2004/ r e g_br i e f m] .
39 de Waal, Alex, “What AIDS Means in a Famine,” New York Times, November 19, 2002.
40 U.S. Department of State, Washington File, “World Food Program to Cosponsor U.N.
HIV/AIDS Program,” October 16, 2003.
41 This issue is further discussed below in the “Responses to Impact” section.
42 Aggleton, Peter, Shalini Bharat, and Paul Tyrer, India: HIV and AIDS-related
Discrimination, Stigmatization and Denial (Geneva: UNAIDS, 2001), p. 8.

schoolmates were withdrawn by their parents fearing infection by association.43
Ultimately the government decided to pay for a private tutor so that the children
could learn at home.44 Children were similarly shunned in Trinidad and Tobago
when they 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 only adds to the feelings of anger, sadness, and hopelessness that they may feel
after witnessing their parents slowly and painfully die. One study in Kenya found
that 77% of the children orphaned by AIDS said that they had no one outside of their
families to “tell their troubles to.”46 The feeling of isolation can be heightened if the
orphaned children are separated from their siblings, as often occurs when family
members split up the child rearing duties. Another survey conducted in Kenya by the
United Nations Development Programme (UNDP) found that 48% of the households
with orphans reported that some of their family members were relocated to other
communities.47 Sibling separation can be difficult 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 children who are not. The preoccupation with the illness or death of their
parents, the isolation due to the loss of friends, and the undertaking of additional
work that comes with caring for ill parents or supporting oneself after one’s parents
have died often make it difficult for orphaned children to concentrate in school. It
is common for teachers to report that they find orphaned children daydreaming,
coming to school infrequently, arriving at school unprepared and late, or being non-
responsive in the classroom. 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, or put them out of the classroom.
However, other orphaned children have reported that their teachers have been their
primary support base at school.48

43 Philip, John, “India-AIDS-Schools: Indian School Ostracized after Admitting HIV-
Positive Children,” Agence France-Presse, March 2, 2003.
44 “No School for India AIDS Victims,” BBC Online, March 5, 2003, at
45 Posted on AIDS Education Global Information System (AEGIS), reported by Richards,
Peter, “Rights-Trinidad and Tobago: Children with AIDS Continue to Be Shunned,” Inter
Press Service, June 3, 1999, [].
46 Human Rights Watch, “In the Shadow of Death: HIV/AIDS and Children’s Rights in
Kenya, Human Rights Watch Publications, vol. 13, no. 4(A) (June 2001), p. 17, at
[ reports/2001/kenya/].
47 Ayieko, M. A., “From Single Parents to Child-Headed Households: The Case of Children
Orphaned by AIDS in Kisumu and Siaya Districts,” UNDP Study Paper 7, 1998, pp. 7 and

14, at [].

48 UNAIDS, “Investing Our Future: Psychosocial Support for Children Affected by
HIV/AIDS,” UNAIDS Case Study, July 2001, p. 30, at [

Orphaned children can also experience discrimination and exploitation within
their new households. Reports have emerged of orphaned children receiving less
food, denied school fees, and forced to do more work. Exploitation remains an issue
even in countries like Botswana, where the government offers support to orphans.
It has been reported that some caretakers, while offering minimal 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 silently accept it because they have nowhere else to turn for
shelter or protection.50
Gender Exploitation
The rapid spread of HIV/AIDS in many countries is fueled by gender inequities.
Since girls tend to be educated at lower rates than boys, some assert they are more
likely to engage in survival sex. A UNAIDS survey found that of the estimated 2
million female sex workers in India, 20% were under the 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 their
seroprevalence. While at school young girls may be raped by their peers or coerced
into having sex with their teachers.52 Young girls are also vulnerable to sexual
exploitation as they work, particularly as vendors and domestic servants. A study in
Fiji found that 8 in 10 young domestic workers reported having been sexually abused
by their employers.53 Young girls often engage in domestic work for food, clothing
and shelter in impoverished areas. Sexual abuse by male relatives also remains a
significant challenge for girls, particularly for orphans.54 Additionally, a widespread
perception that virgins can cure HIV/AIDS has reportedly led to a significant rise in

48 (...continued)
49 UN Office for the Coordination of Humanitarian Affairs, “Botswana: AIDS Orphans
Exploited,” October 8, 2003, [].
50 Suffering in Silence: The Links between Human Rights Abuses and HIV Transmission to
Girls in Zambia, a Human Rights Watch report released in November 2002, discusses the
sexual vulnerabilities of young girls, at [
zambia/zambia1202.pdf ].
51 UNAIDS, “Children and Young People in a World of AIDS, “ [].
52 Human Rights Watch Press Release, “South Africa: Sexual Violence Rampant in
Schools,” March 27, 2001, at [].
See also Scared at School: Sexual Violence Against Girls in South African Schools, Human
Rights Watch Publications, at [].
53 UNICEF, “Gender, Sexual and Reproductive Health — Including HIV/AIDS and Other
STIs,” in Gender and Relationships: A Practical Action Kit for Young People, p. 84, at
54 For more information on some of the gender-based violence that contributes to the rapid
spread of HIV/AIDS, see Human Rights Watch, “Suffering in Silence: The Links between
Human Rights Abuses and HIV Transmission to Girls in Zambia.” Similar stories can be
found in many countries. See, for example, at [
za mbia1202.pdf].

cases of rape among young girls.55 One case that shocked the world occurred in
South Africa, where a five-month-old baby was raped by two men hoping to cure
themselves of AIDS.56
Recent data highlight how girls are particularly vulnerable to contracting HIV.
UNICEF conducted a study with UNAIDS and WHO in 2002, and found that “two-
thirds of all newly HIV-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, there are five to six girls infected in the
same age group.”57 Sexual abuse and exploitation are not the only reasons that girls
and women have a higher HIV rate than their male counterparts in Africa. The
upsurge in the number 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-Saharan Africa. Unfortunately, this practice
places young girls at greater risk of contracting HIV, as the men can often convince
the young girls that protection is not necessary. A recent survey found that between

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 years younger.58 There are a number of programs that seek to
empower girls and young women, which contribute to HIV/AIDS prevention.59
Responses to Impact
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 the needs of children orphaned and made vulnerable by
HIV/AIDS, local communities continue to be the primary loci of support for these

55 Kaiser Family Foundation, “Rise in Child Rapes in Zambia Traced to AIDS Cure Myth,
Some Say,” December 22, 2003, at [].
56 Johnston, Jenny, “South Africa’s Secret Horror,” The Mirror, February 8, 2003.
57 UNAIDS, UNICEF, and WHO, Young People and HIV/AIDS: Opportunity in Crisis.

2002, at [].

58 UN Integrated Regional Information Networks, “The Sugar Daddy Phenomenon,” July

24, 2003, at [].

59 See Hughes-d’Aeth, Armand, “Evaluation of HIV/AIDS Peer Education Projects in
Zambia.” Pergamon: Evaluation and Program Planning 25 (2002), 397-407, at
[]; African Microenterprise AIDS
Initiative, “Preventing the Spread of AIDS by Empowering Women in Africa,” at
[]; Ellis, Susan, Dobriansky
Promotes Women’s Empowerment in Botswana, U.S. Department of State, November 18,
2003, at []; USAID, “Angola Female
Literacy Center-Horizonte Azul,” at [];
“Khmer HIV/AIDS NGO Alliance Offers HIV/AIDS Awareness to Women in Cambodia,”
see at []; UNICEF, “What Are UNICEF
Strategies for Addressing Girls’ Education?,” at [
index_strategies.html ].

children. One USAID survey found that 74% of the time relatives provided food for
orphans and vulnerable children, and 19% of the time they relied on their friends for
food. Religious groups were used the remainder of the time (7%), when needed.60
Economic and Material Responses
This section discusses some of the initiatives that the United States and the
international community implement to serve the needs of the children affected by
AIDS, and some of the challenges that these programs face.
USAID supports a number of programs that offer material and other support to
orphans and vulnerable children, mostly through its Child Survival and Health Fund
(CSH) programs. Many of the programs use an integrated approach, which responds
to more than one set of needs. For example, USAID uses a combination of funding
sources61 to support school feeding programs that reduce hunger, malnutrition, and
disease while advancing basic education.62 Similar programs that combine food and
education aid have been instituted by the World Food Program (WFP) and
UNICEF,63 as well as by other international and local non-governmental
organizations, such as Save the Children.
Since the majority of orphans and vulnerable children depend almost
exclusively on their families and communities, some are advocating that
organizations directly offer support to those groups. Suggested interventions include
issuing stipends, financial assistance, or emergency support for families who care for
orphans and vulnerable children and those that slip into complete destitution. Critics
of this strategy have expressed concern that children can be exploited through direct
stipends, such as has reportedly happened in Botswana. Although the country
provides stipends, food aid, and pays school fees for its orphaned children, some
caretakers are reportedly giving the children substandard care.64 Observers assert
that empowering community groups to monitor the care and support provided can
minimize instances of exploitation.65 Additionally, school feeding programs and

60 UNICEF presentation at USAID-sponsored “Orphans and Vulnerable Children: Technical
Consultation,” November 3-5, 2003, Washington, D.C., at [].
61 School feeding programs can be supported by a combination of programs, including Title
II Food for Peace Funds, Child Survival and Health Funds, and basic education funds.
62 For more information on USAID programs that seek to address the needs of children
affected by HIV/AIDS see USAID Project Profiles: Children Affected by HIV/AIDS, at
[ gl oba l _ h e a l t h/a ids/Publications/docs/cabaproj ectprofile
63 For more information on WFP programs that integrate food aid and education see
“Widening the ‘Window of Hope’ Using Food Aid to Improve Access to Education for
Orphans and Vulnerable Children in sub-Saharan Africa,” at [
aboutwfp/downloads /2003/0309_AIDS_Wide ning_Window.pdf].
64 U.N. Office for the Coordination of Humanitarian Affairs, “Botswana: AIDS Orphans
Threatened by Exploitation,” October 9, 2002, at [].
65 A number of national programs encourage community empowerment, such as Farm

community cooperatives have been found to be effective strategies to supplement the
care that communities provide for vulnerable children, and minimize the likelihood
of abuse. Microfinance services are also seen by some as a promising way of
enabling families who care for orphans to support themselves.66
Education and Skills Training
Attaining basic education and employable skills is an important part of
preventing the spread of 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 likely to have a higher income than those who
are not, studies have also shown that the educated are also less likely to contract HIV
and tend to have children later in life. Messages about HIV prevention are beginning
to be integrated into school curricula to raise awareness about the disease among the
young, a group that experiences an estimated 1,600 deaths daily.67 HIV/AIDS
awareness remains very low among the young. According to a 2001 UNAIDS
survey, 74% of young women and 62% of young men aged 15-19 in Mozambique are
unaware of any way to protect themselves against HIV. Furthermore, half of the
teenage girls surveyed in sub-Saharan Africa did not realize that a healthy-looking
person could be infected with HIV/AIDS.68
Organizations are implementing a variety of approaches to increase access to
education among orphans and vulnerable children. Some advocate implementing
programs that offer both traditional and non-traditional responses, such as community
schools, vocational training, and interactive radio education. Community schools
have been an attractive alternative to some because such 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 and
accessible to the poorest children because they are able to adapt to community needs
(flexible hours and harvest schedule). Some disadvantages of community schools are
that they can be of a lower quality than government schools and risk becoming a
second tier for the poorest children. Additionally, volunteer teachers may leave the

65 (...continued)
Orphans Support Trust (FOST), a program in Zimbabwe that aims to increase the capacity
of farming communities to respond to the orphan crisis and ensure that systems are in place
to protect and care for OVC. See []. UNICEF
also supports a community empowerment program in Swaziland. U.N. Office for the
Coordination of Humanitarian Affairs, “Swaziland: Community Provides ‘Shoulder to Cry
On’,” December 11, 2003, at []. Palmyrah Workers Development
Society is a community-based program that seeks to promote HIV/AIDS awareness.
66 White, Joanna, Facing the Challenge: NGO Experiences of Mitigating the Impacts of
HIV/AIDS in Sub-Saharan Africa, University of Greenwich: 2002. This book offers
examples of microcredit and other strategies that support community efforts to care for
children made vulnerable by HIV/AIDS.
67 Article found on Factiva website, citing Nyasato, Robert and Samuel Otieno, “HIV/AIDS:
Over 1,600 Minors Die Daily,” Africa News Service, May 13, 2002.
68 UNAIDS, “Children and Young People in a World of AIDS,” August 1, 2001, at
[] .

schools if offered a paid position, the quality of education that they offer may be
lower than that of paid teachers, and the community schools could be forced to close
if donors decide to spend their funds elsewhere, since the schools rely on donors for
infrastructure and material support.
Vocational skills training, particularly farming skills training, is critical in areas
where parents have died before relaying knowledge of agricultural procedures.69 In
an effort to combat famine in heavily affected areas, UNICEF has launched a
program in Swaziland that offers training in farming to children orphaned by AIDS
and affected by famine.70 This program is intended to 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 is hoped
that those who participate in vocational training will no longer be forced to rely on
sex work to feed themselves and their siblings.71
Protection and Legal Support
Children who are solely responsible for their siblings struggle not only to
support the household, but also to keep their homes. Property grabbing, a practice
where relatives of the deceased come and claim the land and other property, is
reportedly a serious problem for widows and child-headed households. Traditional
law in many rural areas dictates that women and children cannot inherit property.
Property grabbing has a number of negative consequences particularly for girls 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, further increasing the risk of contracting HIV. Some are concerned
that the practice of property grabbing heightens the strain on extended families and
increase the number of street children.
In an effort to help parents prevent property grabbing, USAID supports
organizations, such as the Population Council and UNICEF,72 which work with HIV-
infected parents to plan for the future of their children through will-writing and other
succession-planning initiatives. These initiatives encourage HIV-infected parents to
disclose their HIV status to their children, appoint and train stand-by guardians,

69 For examples of programs that involve youth and support microenterprise efforts, see
Horizons, “Microfinance and Households Coping with HIV/AIDS in Zimbabwe: An
Exploratory Study,” June 2002, []; Horizons,
“Involving Youth in the Care and Support of People Affected by HIV and AIDS,” July 2003,
at [].
70 UN Integrated Regional Information Networks, “Swaziland HIV/AIDS Orphans Taught
to Farm,” July 29, 2003, at [].
71 Chase, Marilyn, “Saying No to ‘Sugar Daddies’”, Wall Street Journal, p. B1, February 25,


72 To learn more about Population Council and UNICEF HIV/AIDS programs, see
[] and [

create memory books (journals of lasting record of life together and family
information), and write wills before they die.73
National legislation, at times, has minimized the effectiveness of succession
programs. The legislative issues that AIDS-affected countries are beginning to face
are often complex and interlinked. For example, the single issue of inheritance rights
may require governments to ensure that each child has a birth certificate and national
identification (which many children in developing countries do not have), to
strengthen the coordination and administration of their child services and social
services departments that offer safety nets to children, to revisit property and trustee
laws, and to reconsider who may legally represent minors. Laws in many rural
countries follow traditional cultural practices, which are based on the extended
family structure. However, in the wake of the HIV/AIDS pandemic, they
inadequately protect orphans and widows, as all adults in whole families may 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 are left with their grandmothers, women who often have little
legal power.
UNAIDS recently reported that 39% of countries with generalized HIV
epidemics (countries with an HIV rate of more than 1%) have no national policy in
place to provide care and support for orphans and vulnerable children, and 25% have
no plans to develop such strategies.74 National legislation that would establish and/or
enforce inheritance rights of child- and widow-headed households could help to curb
the escalating street children population and minimize the practice among young girls
and women of trading sex for security and shelter, ultimately contributing to HIV
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 and can no longer effectively care for children
orphaned by AIDS. Children who live in orphanages have access 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
place in society, but that they should be used only in cases of last resort. Those who
express caution about increasing the use of orphanages to respond to the growing
orphan population argue that poverty will be the primary reason that parents place
their children in institutions. Due to the high level of poverty in many areas, many
parents send their children to orphanages simply because they are unable to support

73 Horizons, “Succession Planning in Uganda: Early Outreach for AIDS-Affected Children
and Their Families,” at [].
74 UNAIDS, “Progress Report on the Global Response to the HIV/AIDS Epidemic, 2003,”
[ h t t p : / / www.unai d s.or g/ h t ml / p ub/ T opi cs/ UNGASS2003/ UNGASS_Repor t _2003_en_pdf
75 See Human Rights Watch, “Double Standards: Women’s Property Rights Violations in
Kenya,” March 2003, at [].

them. Research has shown that only 25% of children in institutional care do not have
any known relatives.76
Supporters of community-based care argue that children who are raised in
orphanages have a hard time being self-sufficient as adults because they do not learn
life skills, do not have community connections (a critical part of networking and job-
seeking), have difficulty adapting to life outside the orphanages, and develop a
mentality that they will always be cared for. Ethiopia is currently implementing a
country-wide reintegration program, after finding that orphanages were too costly and
unhealthy for the social and cultural development of the children.77 Some caution
that orphanages can undermine community efforts to support orphaned children and
separate them from their families. Instead, they argue, efforts to support orphaned
children should focus on strengthening community networks and initiatives. In this
view, community-based support can both enable 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 within its own
Psychosocial Interventions
The psychological impact of HIV/AIDS on children is often overlooked. Not
only do many children who live in heavily affected areas contend with the death of
one or both parents, but they also frequently face the death of younger siblings, aunts,
uncles and other relatives. While there are a number of programs that address the
material needs of orphans and vulnerable children, there is less emphasis on helping
children cope with the trauma associated with witnessing the deaths of family
members. The additional burden of caring for terminally ill relatives may send
children into shock 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,
particularly in the classroom. Children who are affected by HIV/AIDS may be

76 “Report on Meeting on African Children without Family Care,” Windoek, Namibia,
November 30, 2002.
77 For more on Ethiopia’s reintegration program, see Jerusalem Association of Children’s
Home (JACH), [
78 For more information on the orphanages debate, see Desmond, Chris, and Tim Quinlin,
“Costs of Care and Support,” in Literature Review: The Economic Impact of HIV/AIDS on
South Africa (University of Natal: Health Economics and HIV/AIDS Research Division
[HEARD]), 2002), p. 35; Save the Children, “A Last Resort: The Growing Concern about
Children in Residential Care,” [
images/last_res.pdf]; Lacey, Marc, “For Children Left Behind, a Place to Feel at Home,”
New York Times, November 18, 2002; AIDS Orphans and Vulnerable Children in Africa:
Identifying the Best Practices for Care, Treatment and Prevention, Hearing before theth
Committee on International Relations House of Representatives, 107 Cong., Second sess.,
April 17, 2002, Serial 107-84, at [


frequently absent or tardy from school, 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-affected children tend
to have lower performance in school, many apparently do not link the behavior with
HIV/AIDS. As a result, some organizations are beginning to train teachers on how
to identify grief-related behavior. Teachers who have completed grief-identification
training have reported that the sessions “opened their eyes to the reasoning behind
what they had identified as misbehavior of orphaned students.”79
Programs are also being developed that enable children to play, a luxury to
many orphans and vulnerable 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 little to no time for recreational activities.
These children may also be stigmatized and isolated, as ignorance about the virus
remains high. There are programs that offer Psychosocial support for orphans and
vulnerable children, including peer support groups, recreational activities, and
While psychosocial support for orphans and vulnerable children is important,
the same type of support is often overlooked for caretakers. Reports of grandmothers
caring for a dozen children with 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, caretakers
and 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 each other an hour of respite. Some are also
developing support groups to discuss and find solutions to their problems. Some
non-governmental organizations offer stipends and financial support to the caretakers
and are training them to talk to the children about their grief.81

79 UNAIDS, “Investing in Our Future: Psychosocial Support for Children Affected by
HIV/AIDS,” UNAIDS Case Study, July 2001, at [].
80 The Salvation Army has a number of programs which support OVC, one Masiye camp
offers skills training, psychosocial support and recreational activities for OVC. See [http://]. Tsungirirai offers a range of programs for
OVC, including psychosocial support. See []. For
more information on USAID psychosocial programs for OVC, see [http://www. gl obal_health/aids/Tech Ar eas/ChildrenAffected/cabafactsheet.html ].
81 HelpAge International serves to support disadvantaged older people worldwide. For
information on its programs that support elderly HIV/AIDS caretakers, see [http://]. Hope Worldwide
offers support for adults and children, including support for caretakers to avoid burnout; see
[ ht t p: / / r i ca.hopewor l dwi de.or g/ wor l d/ af r i ca/ s ect i ons/ pr ogr ams/ si ya wel a .ht m] .

Issues for Congress
Most often when governments of industrialized countries consider strategies to
address the needs of children affected by HIV/AIDS, they begin by examining their
foreign aid programs. While foreign assistance programs are an important part of the
effort, there are a wide range of other issues that are often overlooked. This section
discusses a range of issues that impact efforts to help children affected by HIV/AIDS,
including how “AIDS orphans” are defined, how U.S. foreign aid programs are
implemented, and other related international initiatives.
Targeting Assistance
Due to the high level of stigma still associated with HIV/AIDS, many who work
in the development community avoid using the term “AIDS orphans.” The term,
some argue, only serves to further stigmatize and separate the children from the
others in the community. Those who offer support to communities affected by
HIV/AIDS have found that the early programs, which focused specifically on
children whose parents died of AIDS, often missed other vulnerable children, such
as those who are at high risk of becoming orphaned by AIDS (because their parents
have HIV), those who live in households with children orphaned by AIDS, and those
who may have been orphaned from other causes (like war or disease) are equally
vulnerable. Additionally, in many communities it is often not known who has
HIV/AIDS and who does not, due to struggling health care infrastructures 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 most
vulnerable children in areas seriously affected by HIV/AIDS, many of whom are
children orphaned by AIDS.
USAID’s approach to assisting children orphaned and made vulnerable by
HIV/AIDS has posed a challenge for the U.S. Congress. USAID prefers not to create
programs that exclusively serve children orphaned by HIV/AIDS. Representatives
have stated that this approach would only serve to further isolate and stigmatize the
children. As a result, the Agency supports the children through a number of
interventions, which serve their needs, including educational support, school feeding,
and psychosocial support. Although this approach is one that is generally accepted
among international 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 orphaned and 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 been able to detail exactly
how much was spent on each program, such as school feeding, in large part because
organizations implementing programs (including USAID-supported programs) use
an integrated approach. The programs respond to the needs of the most vulnerable
children where they work, rather than only assisting those whose parents have
received an HIV/AIDS diagnosis. USAID officials underscore that this approach is
also important, as many people in the most affected countries die without an
HIV/AIDS diagnosis. Therefore, if it were to restrict services to those children 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 of orphans and vulnerable children, including Child Survival and
Health Fund, (CSH), HIV/AIDS funds for orphans and vulnerable children, Title II
Food for Peace funds, and basic education funds.
Foreign Assistance
Education and Poverty Programs. While funding for HIV/AIDS
initiatives has dramatically increased in recent years, U.S. and international funding
for other health programs, education and poverty-related programs have remained
level and decreased 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 operations appropriations, USAID
Administrator Andrew Natsios expressed concern that other programs such as
agriculture, which are vital in countering poverty and supporting health programs, are
being decreased.82 UNICEF estimates that over the past decade international
education aid has fallen by 30%. As a result, 65 million girls and 56 million boys did
not attend school in 2002. The highest concentration of uneducated children resides
in Africa, also home of the highest number of children orphaned by HIV/AIDS. In

2002, the number of African children unable to attend school reportedly rose to 4583

million, up from 1990 levels of 41 million.
Collaboration. Although there are many programs that address the various
needs of orphans, as illustrated in this report, some argue that there is not enough
collaboration among aid organizations on the ground. Some programs exclusively
address the material needs of orphans, while others focus on their psychosocial
needs, still others focus on empowering women and girls. Advocates argue programs
could be more effective if there were greater collaboration in their planning and
implementation. USAID recognizes that the needs of orphans and vulnerable
children are complex. In response, USAID integrates various aspects of its
development programs to meet the needs of these children, rather than implement a
single program 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 of orphans and vulnerable children. For example, the United
Nations General Assembly Special Session (UNGASS) on HIV/AIDS developed a
Declaration of Commitment on HIV/AIDS, to which the U.S. is a signatory.84 Part
of this commitment is that national policies would be developed by 2003 and
implemented by 2005, to build and strengthen government, community and family
capacity to support children affected by HIV/AIDS. At the regional level, there have
been a number of meetings in Africa that brought delegations together to agree on a
common set of actions and to measure progress towards them and the UNGASS

82 For further discussion on U.S. health programs funding trends, see CRS Report RL31433,
U.S. Global Health Priorities: USAID’s Global Health FY2003 Budget, by Tiaji Salaam.
83 Donnelly, John, “Funding Lack Keeps Millions Out of School, UNICEF Says,” Boston
Globe, December 12, 2003.
84 UNGASS Declaration on HIV/AIDS can be downloaded from [].

goals. Additionally, in October 2003, a number of international NGOs, faith-based
institutions, governments, and other organizations met and agreed on a global
strategic framework for the protection, care and support of orphans and other children
made vulnerable by HIV/AIDS at the first Global Partners Forum for Children
Orphaned and 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 their communities. Some argue that non-
governmental organizations (NGOs) that operate at the local level need greater
support and must be included in planning and implementation efforts. Additionally,
including local and national NGOs may promote ownership and strengthens local
Advocates for children affected by HIV/AIDS point out that efforts to respond
to their needs are not commensurate to the scale of the problem. A number of
options has been put forward to increase the resources for AIDS-affected children.
Some observes advocate establishing a Czar for orphans and vulnerable children to
oversee U.S. efforts and to galvanize the global effort. Other analysts propose
creating a senior orphan and vulnerable children position within the AIDS
Coordinator Office. Still some say that the programs that address the needs of
children should be strengthened and better coordinated. Proponents of this position
emphasize the importance of integrating the care, support, and treatment of HIV-
infected children into HIV/AIDS treatment programs and those that prevent mother-
to-child HIV-transmission.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria. The
magnitude of the HIV/AIDS crisis in seriously affected countries is far 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 the Global Fund as a model.85 The Global Fund has at all levels
representatives from the public and private sectors. At the planning level, its board
of directors is comprised of seven representatives from donor and developing
countries, and a representative each from an industrialized country NGO, a
developing country NGO, the private sector, and a contributing foundation. In the
project design phase, the Country Coordinating Mechanism (CCM) or “national
consensus group” develops project proposals. The CCMs in each country include
representatives from the government, NGO community, private sector, people living
with HIV/AIDS, tuberculosis and/or malaria, religious and faith-based groups,
academics, and the United Nations agencies. The practice of including all
stakeholders in the planning and implementation of projects increases their
effectiveness 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, as it did not receive sufficient matching funds. P.L. 108-25 required that
U.S. contributions for fiscal years 2004 through 2008 not exceed 33% of

85 The Global Fund is a funding entity that partners governments, civil society, the private
sector, and affected communities to fight three of the world’s most devastating diseases:
HIV/AIDS, tuberculosis, and malaria.

contributions from all sources.86 The FY2005 Consolidated Appropriations provided
$437.8 million to the Global Fund, including the $87.8 million. The funds remain
subject to the same 33% limitation. The total U.S. contribution through the end of
FY2005 has totaled more than $1.5 billion. Congress has consistently provided more
than the Administration requested. The 33% requirement has caused a number of
criticisms. Some believe that the United States should give more money to the Fund,
as it has the structure and capability to use the money quickly. Some supporters of
this idea also believe that the 33% requirement hinders the ability of the United
States to give more. This policy, advocates claim, causes other nations who believe
the United States has yet to give its fair share to hold back additional contributions.
Critics of this view point believe that the fiscal requirement encourages others to give
more to the Fund. Proponents argue that the United States is already the largest
donor to the Fund, and should not be the primary contributor. Furthermore some
opponents of increasing U.S. contributions to the Fund have questioned the
absorptive capacity of the Global Fund, stating that it is spending the money too
slowly.87 By December 2004, the Fund had only disbursed $860 million of the $3.3
billion paid.88
Anti-Retroviral Medication. Advocates argue that if the most affected
countries had greater access to anti-retroviral (ARV) medication there would be a
decrease in the number of new orphans and other vulnerable children. Due to the
cost and other factors, only 12% of the 5.8 million people immediately needing AIDS89
treatment in developing countries have access to treatment. According to WHO,
only 325,000 of those with access to treatment in developing countries (700,000) live90
in sub-Saharan Africa, where 25.4 million people are currently living with the virus.
Preventing mother-to-child HIV transmission (PMTCT) is a critical part to
reducing the growing number of orphans and vulnerable children (OVC) in
developing countries, particularly for countries with high seroprevalence rates among
pregnant women, including Swaziland (39%), Botswana (32%), South Africa (24%),91
Kenya (22%), Namibia (18%), Zimbabwe (18%), and Malawi (18%). Access to
nevirapine, a relatively inexpensive single-dose drug that significantly reduces the
HIV transmission rate from mother to child, is virtually non-existent in many
developing countries. In 2003, only an estimated 5% of pregnant women in Africa
had access to drugs to prevent mother-to-child HIV transmission, and only 8%

86 P.L. 108-25, United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act
of 2003, as amended, Section 202.
87 For more on the Global Fund, see [], and CRS Report
RL31712, The Global Fund to Fight AIDS, Tuberculosis, and Malaria: Background and
Current Issues, by Raymond W. Copson and Tiaji Salaam.
88 WHO, ‘3x5’ Progress Report, December 2004, p. 26. See [].
89 Ibid, p. 49.
90 Ibid.
91 Figures in this paragraph were taken from the Joint United Nations Programme on
HIV/AIDS (UNAIDS), Progress Report on the Global Response to the HIV/AIDS Epidemic,

2003; and UNAIDS, A Joint Response to HIV/AIDS, 2003, at [].

globally were offered treatment.92 It has been estimated that 1,900 children are born
with HIV every day in Africa alone.93
Botswana, the first country in sub-Saharan Africa to develop a national anti-
retroviral distribution program, is the only developing country where nevirapine is
readily available. Although it 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 access to nevirapine in Botswana
and 10,000 people were using ARVs.94 The capacity challenges remain 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 “brain drain,” as skilled health care professionals leave the
government or country for more lucrative salaries.95
Botswana’s slow ARV distribution has strengthened critics arguments that
widespread ARV distribution is not only hindered by high costs, but also by resource
constraints. Some have stated that health care infrastructures must first be
strengthened before ARV distribution could be more rapidly scaled up. One area that
has gained increasing attention is the shortage of trained African health care workers
to offer ARV treatments. A UNAIDS report recently cited studies, which estimated
that between 19% and 53% of all government health employee deaths were caused
by AIDS.96
South Africa, a country that formerly rejected the widespread use of nevirapine
or other ARV medication, became the second country in sub-Saharan Africa to
develop a national anti-retroviral program. It announced in August 2003 that its
health ministry would begin a national distribution program. Though the country
already offered nevirapine in some areas to pregnant women and emergency AIDS
medication to rape survivors, the country leadership came under heavy criticism for
not developing an effective national ARV distribution plan. The announced plan
sought to establish a service point in each district within one year, and to make anti-
retroviral medication available to all South Africans and permanent residents at the
municipal level within five years.97

92 WHO, ‘3x5’ Progress Report, December 2004, p. 32, at [].
93 Dabis, François, and Ehounou René Ekpini, “HIV/AIDS and Maternal and Child Health
in Africa,” The Lancet, vol. 359 (June 15, 2002), p. 2097, at [].
94 Kaiser Family Foundation, “Financial Times Weekend Magazine Examines Botswana’s
Antiretroviral Drug Program,” October 14, 2003, at [
95 Kaiser Family Foundation, “Botswana Losing Skilled Workers for HIV/AIDS Programs
to Non-governmental Groups, President Mogae Says,” November 13, 2003, at
[ h t t p : / / www.ka i s er net wor k.or g/ dai l y_r epor t s / r ep_i m?hi n t = 1&DR_ID=20838] .
96 UNAIDS, 2004 Report on the Global AIDS Epidemic: Executive Summary. Geneva:

2004, p. 10, at [].

97 For the text of South Africa’s national ARV plan, see [].

Uganda became the third country in sub-Saharan Africa to develop a national
anti-retroviral program. It announced in December 2003 that its health ministry in
partnership with USAID would launch a three-year program to provide anti-retroviral
medication throughout the country. Though Uganda has been hailed as an example
of success for effectively bringing down its national seroprevalence rate, there are
still more than 500,000 people living with HIV/AIDS in the country,98 and nearly one
million (940,000) children orphaned due to HIV/AIDS.99
The U.S. government has expanded its HIV/AIDS programs to include care and
treatment to people living with HIV/AIDS when Congress passed P.L. 108-25, the
“U.S. Leadership against HIV/AIDS, Tuberculosis and Malaria Act of 2003.” The
law authorized the U.S. government to offer ARV to at least 500,000 individuals by
the end of 2004, and up to 2,000,000 by the end of 2006. Some have criticized the
U.S. government, as observers complain that it is moving too slowly to implement
the treatment programs. The Office of the Global AIDS Coordinator reports that by
September 2004, the President’s Emergency Plan had supported ARV for 155,000
people.100 Analysts note that if the Administration would work more closely with
existing programs, greater results would be achieved.
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 program provides 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 are calling for more
children to receive anti-retroviral therapy. UNAIDS estimates that only between
15,000 and 20,000 children living with HIV/AIDS have access to treatment. The
organization believes that 660,000 of the 2 million children living with the virus need
immediate care. Until 1990, no antiretroviral (ARV) drug was specifically tested or
approved for pediatric use. Only three ARVs are labeled for children under two,
come in liquid form, and have WHO-approved generic versions available. The
pediatric ARV drugs that are available are significantly more expensive than adult
versions — branded pediatric ARV drug formulations cost between 50% and 90%
more than adult versions.101

98 U.N. Office for the Coordination of Humanitarian Affairs, “Uganda: Programme launched
to boost ARV treatment capacity,” December 29, 2003, at [].
99 UNAIDS, UNICEF, USAID Joint Report, Children on the Brink 2002: A Joint Report on
Orphan Estimates and Program Strategies, November 2002, at [].
100 U.S. Department of State, The President’s Emergency Plan for AIDS Relief:
Compassionate Action Provides Hope Through Treatment Success. January 26, 2005.
Office of Global AIDS Coordinator website [].
101 “Ensuring Access to ARVs for Kids: A Challenge of Logistics.” Global Health Council.
See []/

It is particularly challenging to treat infants and young children, as they are
unable to swallow pills. This requires that they receive the drugs in liquid form,
which has more stringent handling and storage guidelines. Additionally, drug doses
are based on children’s changing weights and must be recalculated based on current
weight or body surface area and then converted to the appropriate volume based on
the formulation strength. This process requires greater human resources, the
recalculation of dosages at each visit, and fully-trained doctors. Liquid treatments
are not available in all ARVs, and the transition period from liquid to solid pills vary
among medications. When liquid treatments are unavailable, providers would need
to break adult tablets for lower doses or crush pills into food or fluid. Proper dosage
is hard to ensure using these methods. The current shortage of health care
practitioners in many developing countries, particularly in sub-Saharan Africa, has
posed considerable challenges in treatment efforts among adults. The more complex
demands 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 most affected countries. For example, in 2004, 35% of HIV-positive babies in
Nairobi, Kenya, died by their 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 a child is about $55. In
its 2004 Global Report, UNAIDS said 90,000 infants were exposed to HIV by birth
and breast-feeding every year, at least 46,000 of them were infected and 60% died
before their second birthday.102
Other Tools
Debt Relief. Some argue that the huge debt burden of developing countries,
particularly those severely affected by HIV/AIDS, hinders their ability to develop an
effective response to HIV/AIDS. Proponents of heavier debt relief argue that many
countries, including those receiving debt relief, spend more money on debt payments
than on social services. This money, they argue, could be used on other programs
that are effective in combating the virus, such as supporting education and health103
infrastructures. Oxfam estimates that of the 26 countries participating in the
Highly Indebted Poor Countries (HIPC) Initiative, half are still spending 15% or
more of government revenues on debt repayments. For example, Zambia is spending
30% more on debt repayment than on health.104 Furthermore, HIV/AIDS is sinking
these countries deeper into poverty, making the debt repayments increasingly harder
to pay.

102 U.N. Office for the Coordination of Humanitarian Affairs, “Kenya: Babies suffer lack of
pediatric testing kits.” October 26, 2005. See [].
103 Clark, Marie, “Debt Relief Will Spur AIDS Plans,” Philadelphia Inquirer, May 30, 2003.
104 Debt Relief and the HIV/AIDS Crisis in Africa: Does the Heavily Indebted Poor
Countries (HIPC) Initiative Go Far Enough?, Oxfam Briefing Paper 25, at
[ ].

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, and in the 108th Congress H.R. 643, “To Urge Reforms of the
Enhanced Highly Indebted Poor 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 by HIV/AIDS. Similar legislation is
expected to be introduced in the 109th session. Some are concerned that debt
reduction initiatives can be abused, and corruption will undermine debt reduction
strategies. Furthermore, it has been argued that it is not debt repayments that are
sinking these countries deeper into poverty but the lack of strong revenue sources.
If some of these countries would revise their economic and social policies there
would be less of a need for debt relief, critics say. In an effort to limit the corruption
and careless use of debt relief, international institutions, such as the World Bank and
UNAIDS, are working with countries to develop effective, transparent plans to
incorporate HIV/AIDS efforts into debt reduction strategies.105
Agricultural Subsidies. Countries heavily affected by HIV/AIDS need
increased revenue to support crumbling health and education infrastructures, offer
HIV/AIDS treatment, and develop comprehensive HIV/AIDS programs. For
example, UNICEF recently reported that Kenya would need $70 million per year to106
support 1.2 million Kenyan children affected by HIV/AIDS.
Some argue that agricultural subsidies hinder the economic growth of countries
like Kenya that are affected by HIV/AIDS, and consequently their ability to combat
the epidemic. It is estimated that in 70% of developing countries agriculture is the
main source of revenue for families, as well as the national economy.107 However,
some have said that agricultural subsidies prevent farmers in agriculture-based
economies from exporting their products to global markets, because their
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 $311 billion a year, with sugar subsidies that are nearly
equivalent to all exports from all developing nations at $6.4 billion.108 The Bank
estimated that if agricultural subsidies were eliminated, agricultural and food exports
from low and middle-income countries could rise by 24%, increasing rural income109
by about $60 billion. Some use the World Bank report to argue that agricultural

105 UNAIDS, “AIDS, Poverty Reduction, and Debt Relief”. 2001, [
en/in+focus/topic+areas/debt+relief.asp]; World Bank, “AIDS, Poverty Reduction, and
Debt Relief,” 2001, at [].
106 Kaiser Family Foundation, “Kenya Needs $70M Annually to Assist Children Affected
by HIV/AIDS, UNICEF Says,” July 2, 2003, at
[ h t t p : / / www.ka i s er net wor k.or g/ dai l y_r epor t s / r ep_i m?hi n t = 1&DR_ID=18590] .
107 National Center for Policy Analysis, “Phasing Out Agricultural Subsidies.” Daily Policy
Digest, September 29, 2003, at [].
108 Berhelsen, John, “Asia’s Take on Cancun,” Asia Times, September 13, 2003. See
[ h t t p : / / i a t i mes/ Gl obal _ Economy/ EI13Dj ml ] .
109 World Bank, “Cutting Agricultural Subsidies: World Bank Chief Economist Urges Cuts

subsidies also undermine foreign aid efforts. The report estimates that agricultural
subsidies are about six times the amount of all foreign aid 110 with U.S. subsidies to
cotton growers totaling $3.9 billion in 2003, three times the amount of U.S. foreign
aid to Africa.111 Concurrently, critics of agricultural subsidies are concerned that the
subsidies also increase reliance on foreign aid, because subsidies encourage surplus
production of agricultural goods that are ultimately exported to poorer countries who
are unable to produce domestic goods at a competitive price. They assert that,
consequently, people living in agriculture-based economies have less income to
purchase basic necessities, 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 agricultural trade. The WTO Ministerial Conference in
Cancún, Mexico, was to follow-up the agreement and develop concrete plans to
revise the trade laws.113 However, talks collapsed when developing countries and
industrialized nations could not agree on several issues. Since no progress was made,
agricultural tariffs and subsidies remain. The United States maintains that it will
continue to work with countries to develop strategies to gradually eliminate
agricultural subsidies and other barriers to trade.114

109 (...continued)
in Rich Country Agricultural Subsidies,” November 20, 2002, at
[ h t t p : / / www.wor l dba nk.or g] .
110 Nicholas Stern, Senior Vice President of the World Bank, first reported the findings at
the Munich Lectures on Economics at the Center for Economic Studies in Munich, Germany
on November 19, 2002. The speech, “Dynamic Development; Innovation and Inclusion” can
be found at [].
111 World Bank, “Cutting Agricultural Subsidies: World Bank Chief Economist Urges Cuts
in Rich Country Agricultural Subsidies,” November 20, 2002, [].
112 United Nations Development Programme, Human Development Report: Policy, Not
Charity: What Rich Countries Can Do to Help Achieve the Goals, chap. 8, p. 156,
113 For more on the WTO Cancun Meeting, see [
itp/wto/default.htm] .
114 Zoellick, Robert, “America Will Not Wait for the Won’t-Do Countries,” Financial
Times, September 22, 2003.