The ugly truth about the HIV pandemic
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COMMENTS 
The impact of HIV and AIDS on children exposes the ugly truth that children are at the bottom of the ladder of social and economic priorities
Two weeks ago, I was visiting a small community centre on the outskirts of Mbabane, the capital of Swaziland. Outside the centre, greeting the visitor with vibrant singing, were all the students of the local primary school, 350 of them, row on row. The principal, a young woman, addressing the crowd, said that of the 350, some 250 were orphans!
I had encountered high orphan ratios before, but never 70%. I looked at those children, most of them clearly malnourished, wearing frayed and tattered uniforms, and thought of the tragic tenor of their young lives.
What distinguishes orphans whose parents have died of AIDS is the sheer torment of their childhood experience: they don't become orphans when their parents die, they become orphans while their parents are dying. They administer to sick mothers and fathers, over long periods of time - months, sometimes years - and then they stand in the huts and watch their parents die.
How do they ever get over the trauma? How do they ever regain their emotional equanimity? It is estimated that there are now 14 million children in sub-Saharan Africa orphaned by AIDS, expected to rise to 18 million by 2010.
Quite simply, it's a nightmare with which no country can begin to cope.
I think of the orphans every time I'm asked to write articles like this one. They illustrate one of the ugliest truths in the modern world, a truth which seems to remain immutable: children are always on the bottom rung of the ladder of social and economic priorities. It's as though the world has no conscience when it comes to kids. There's money galore for wars in Afghanistan and Iraq, there's money in every Western budget for the terrorist threat, but when it comes to children, the cupboard is bare.
Alas, it is ever thus. It's as though the Convention on the Rights of the Child, ratified by 189 out of 191 countries (only Somalia and the United States have failed to ratify), is but a hoax for children. When it comes to orphans, many factors conspire to make life wretched. We now know that fewer than 3% of all the orphans receive some kind of helpful intervention from the State.
Community-based and faith-based organisations - surrogate families, foster families, orphanages - desperately try in every possible way to absorb the orphan kids, but everyone is so poor, it's almost impossible to establish an ongoing relationship. Increasingly, between 40% and 60% of the orphans and vulnerable children in several southern African countries are being looked after by their grandmothers.
The grandmothers have emerged as the unsung heroes of Africa. They go through the agony of burying their own adult children, and then, at the age of 50, 60 or 70, they return to parenting again, often looking after five or 10 or more orphan grandchildren.
They have nothing: no food, no money for school fees or uniforms or textbooks, no guarantee of shelter. The school fees situation is a particular abomination.
The orphan children want nothing more than to go to school, for a sense of self-worth, for peer activity, for a school feeding lunch programme so that they'll have at least one meal a day. It's all denied them thanks to the twisted legacy of the World Bank and the International Monetary Fund, which exacted user fees as a condition of loans during the maliciously destructive period of so-called Structural Adjustment Programmes. The world has a lot to answer for.
And then, when the grandmothers die, the children are often left to survive in child-headed households, where the age of the child heading the household, and looking after the siblings can be as young as eight. HIV/AIDS has profoundly damaged the wholesome pattern of normal family relationships.
But that's only a part of the life of the children in the world of AIDS. There are also, of course, the children who are infected... some 2.3 million of them around the world - 700,000 new cases last year alone, with 570,000 deaths. The numbers are abstractions. Without treatment, 50% die before the age of two; 80% die before the age of five. It gives new meaning to the world 'carnage'.
It's a further commentary on the human condition that although we've had treatment for adults since 1996, it's literally only now, this very moment in time, that we're beginning to develop anti-retroviral drugs for children... drugs that can save and prolong their little lives. It's terribly painful to meet infected children, everywhere on the continent, who will surely die as they wait for paediatric drug formulations as yet unavailable.
And then there's perhaps the most repugnant reality of all: the absence of facilities to prevent transmission of the virus from mother to child; it's known as 'pMTCT'. Believe it or not, fewer than 10% of all the pregnant women in Africa have access to pMTCT. Yet, by administering the wonder drug Nevirapine to the mother during the birthing process, and providing the liquid equivalent to the newborn baby within 72 hours of birth, transmission of HIV can be cut in half.
We've lost hundreds of thousands of children, probably millions of children during the last decade, simply for lack of facilities for the prevention of mother-to-child transmission. How can it possibly be explained or justified?
But it gets worse. In the Western world, pregnant mothers who are HIV-positive routinely receive, instead of Nevirapine, full anti-retroviral therapy for the last several months of pregnancy. The transmission to the child is then reduced to roughly 1%! How's that for one of the more grotesque examples of the inequity between the developed and the developing worlds?
This overall situation for children in the world of HIV/AIDS is particularly pronounced when it comes to girls.
It's the girls who are pulled out of school to look after sick and dying parents. It's the girls who are forced into early marriage with older men, putting the girls at even greater risk of infection. It's the girls who, when orphaned and struggling for survival, engage in what we call 'transactional sex' - sex for a few pennies to keep body and soul together. We'll never know how many young girls have been infected in the process. And above all, it's the girls who are the targets of so much sexual violence.
Four of the eight Millennium Development Goals, scheduled to be reached by 2015, speak directly to the situation of young women and girls: cutting poverty in half, achieving parity between the sexes in primary school enrolment, approximating gender equality and subduing the pandemic of AIDS. Not one of them will be achieved in the high-prevalence countries of southern Africa.
There's something unconscionable about the way we've ignored the needs and rights and lives of children during the pandemic. Late last year, UNICEF announced a campaign to remedy the wanton neglect of the past.
They will address the treatment and prevention and care; they'll tackle the seething predicament of orphans; they'll attempt to roll out pMTCT across the continent. It's all totally admirable.
But it's late. We're all late. The entire international community is late. Who atones for the countless lives lost, and the excruciating pain and suffering felt by the children of Africa and beyond, as the world dithered?
Historians will write the epitaph. It will be short: 'Here lie crimes against humanity.'
(Stephen Lewis is the United Nations Special Envoy for HIV/AIDS in Africa. This article first appeared in Global Future, No 1, 2006.)
Third World Network Features, December 2006