AIDS 25 years later: The ongoing tragedy for children

“When HIV/AIDS enters a household by infecting one or both parents, the very fabric of a child's life falls apart.” – United Nations Children's Fund (UNICEF) (1) On June 5, 1981, Morbidity & Mortality Weekly Report published a report of Pneumocystis carinii pneumonia in five previously healthy, young men in Los Angeles, California, USA (2) – and so began the AIDS saga. That first report gave no hint of the huge impact AIDS would have not only on health, but also on the political, social, cultural and economic fabric of so many countries. AIDS has dictated history, reshaping the demographics of the world's population. Twenty-five years after this seminal report, we now recognize HIV/AIDS as one of the great global public health challenges. The toll is breathtaking: an estimated 25 million lives lost, equivalent to two-thirds of the entire population of Canada, with a further 40.3 million people living with HIV infection in 2005, 2.3 million of whom are children and many of whom will die (3). In several countries, the improvements in child survival achieved in the 1980s through immunization programs and clean water supplies have been reversed by this epidemic. In Canada, there is now hope for those living with HIV/AIDS. Recent advances in HIV treatment using potent combinations of antiretroviral therapy (ART) have dramatically shifted HIV infection from a death sentence to a manageable chronic disease (4). Many children born with this disease are now physically healthy and living into adulthood. Education and behavioural intervention strategies have led to a decline in the rate of new infection in some, but not all, of our at-risk populations. Perinatal transmission has become extremely rare (5). Almost all pregnant women now receive care that includes HIV screening and, where indicated, prophylaxis following guidelines developed by Susan King, a long-time champion for the prevention of HIV infection in children and care of infected children (6). In contrast to this picture of hope, the reality of HIV/AIDS in many developing countries is grim. The number of persons living with HIV has continued to increase in all regions of the world except the Caribbean (3). An estimated 1800 children are infected every day. While access to ART for adults in resource-poor countries has improved somewhat in the past few years, very few children have access to ART or even to the simplest antibiotics; 1400 children die every day (7). Children who are not infected are still affected by this epidemic. HIV/AIDS continues to unrelentingly slay the young adult population in many countries – smashing their economies, destroying the ability of countries to feed themselves, devastating their education and health care systems, and, most critically for children, shattering families. The effects of HIV/AIDS pervade every aspect of these children's lives: their emotional well-being, physical security, mental development and overall health (1,7). In sub-Saharan Africa, the HIV/AIDS epidemic has already orphaned a generation of children, and it is projected that by 2010, 18 million African children younger than 18 years of age will be orphans as a result of this single cause (1,7) as the onslaught of HIV/AIDS continues unchecked. There are nine-year-old children acting as parents for younger siblings, grandmothers caring for the children of their children, children and youth living on the street – all with limited resources and no hope for a better tomorrow. Schooling for many children and youth has become an unaffordable luxury. The improvements in poverty and literacy levels made over the past generation are rapidly falling away. Prevention of HIV transmission and effective treatment for HIV/AIDS can halt this downward spiral, but the impact of the current HIV/AIDS epidemic will linger for decades because of its consequences on this generation of children. While orphanages may seem to be the answer to the orphan problem at first glance, thoughtful scrutiny suggests otherwise (8,9). Orphanages are not an inherent and valued part of many cultures. They take significant resources from already overstretched economies, and they remove children from their familiar surroundings and culture, as well as further stigmatize children who already carry a heavy burden (9). A recent study (10) in rural Zimbabwe, a country where one in four adults is HIV positive and one in five children is an orphan, suggested a more thoughtful approach. On the basis of interviews with community-based orphan caregivers, this group noted the importance of providing even limited financial assistance, such as fees for schooling (10). Other suggestions included development of community programs to identify and support children in need, evaluation and strengthening of individual families' capacity to provide orphan care, development of programs to help youth – especially young girls – to leave the street, and initiation and support of orphan placement in the home community when family members cannot manage (8,10). With assistance, programs for ART for HIV-infected children and for support of orphans in their community are possible – both giving hope for a better tomorrow. However, the question remains: are we in the developed world ready to provide the needed support to make these hopes a reality (11), or will we fall short? The lives of these children depend on all of us reaching out to help to make these dreams come true.

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