the HIV/AIDS epidemic will result in large numbers of children being left in vulnerable circumstances;

the experience of children affected and orphaned by HIV/AIDS will generally be qualitatively different from that of other children; and

large-scale orphaning will result in large numbers of scarred and marginalised children who will be unable to become healthy, productive adults capable of contributing to and running healthy societies in the future.

Many children are not raised in ideal, stable family environments: Irrespective of HIV/AIDS, large numbers of children grow up in single-parent households, usually headed by women, and fathers are often absent. Levels of fosterage are high and the reality of children being sent away from their natal home in order to access care or resources is not new.

Orphanhood is a complex phenomenon: While orphaning is on the increase, and will have risen exponentially in most countries in the region by 2010, relatively few children would presently seem to be living in situations of extreme vulnerability. Indeed, although increasing numbers of orphans are beginning to place stress on traditional coping mechanisms such as the extended family, they are still remarkably intact and surprisingly small numbers of children have so far found themselves without the support they provide. Children are most likely to be orphaned during adolescence and often have a surviving parent, usually their mother.

It is often difficult to determine where the effects of HIV/AIDS begin and end: Many children in the region are going to be negatively affected by HIV/AIDS. Children may experience a range of impacts including economic need, reduced levels of care, poor health and nutrition, new responsibilities and work and school drop out, as well as psychosocial impacts such as abuse, trauma, stress and a loss of social connectivity. They may also be placed at greater risk of infection. The effects of the epidemic on children are, however, not only likely to vary considerably by age, but high levels of ambient poverty often makes it difficult to determine the causality of these effects. The conditions in many poor communities mean that few, if any, of these effects are specific to children affected by HIV/AIDS and it is impossible to isolate the effects of conditions that pre-date the death of a caregiver. It is also clear that HIV/AIDS increasingly affects almost everyone in severely affected communities, even households without HIV-positive members.

‘Affected ’ children are not habitually treated differently to ‘unaffected ’ children: Although some orphaned and fostered children are abused, mistreated, exploited or abandoned, most studies suggest that children are generally not treated differently by caregivers on the basis of their orphaned or fostered status. Measured largely in terms of educational enrollment, most evidence suggests that relatives often go to considerable lengths to meet the needs of the children in their care, including borrowing money through informal networks and selling their own assets.

Not all children are equally vulnerable: While some children are left in precarious circumstances as a result of parental illness and death, many children remain linked into support networks of various kinds. Children, such as those in child-headed households and street children, who at face value live in extremely vulnerable circumstances, often continue to benefit from some type of adult support. In some cases, child-headed households and street work may represent coping mechanisms developed in response to the HIV/AIDS epidemic.

Negative experiences do not necessarily result in negative psychosocial outcomes: While HIV/AIDS stands to exacerbate the multitude of risks faced by children in poor communities, children are often remarkably successful in overcoming such difficulties. The impact of risk factors is mediated by a range of factors, including personality and temperament, learned coping style, age of exposure, the availability of caring adults and social supports in their environment and, critically, opportunities for recovery afforded by achievements, new relationships, changing circumstances and the like. The implications of negative experiences are thus as much a result of the circumstances surrounding the experience, and the way it is interpreted, as the nature of the experiences per se; and it is estimated that only about one-third of children exposed to severe adversity will suffer negative psychosocial outcomes. Even where children do suffer negative effects as a result of their exposure to difficulties, studies suggest that they tend to show internalising rather than externalising symptoms in response to such impacts—depression, anxiety and withdrawal—as opposed to aggression and other forms of antisocial behaviour that may affect the security of communities and states.

Effective responses are being put in place: Despite difficulties posed by the epidemic, communities throughout Africa have begun to add additional layers to their community safety nets by providing material, educational, emotional and psychosocial support to children affected by HIV/AIDS. A number of local, national and regional level initiatives have also been developed which have successfully helped to mitigate the psychosocial impacts of the epidemic on children and fa mili es. Such initiatives are still relatively few in number and have been limited in their reach and impact, but both illustrate that valuable, cost-effective responses can be, and have been, put in place and provide valuable lessons for scaling up effective responses to the epidemic.