HIV/AIDS is a crisis of unprecedented magnitude in sub-Saharan Africa. Almost 80 percent of the 22 million deaths from AIDS since the beginning of the epidemic have occurred in Africa.10 Most of those have been concentrated in eighteen countries that make up only 5 percent of the population of the world. In most of the highly affected countries of eastern and southern Africa, AIDS has caused life expectancy to decline by over twenty years from already low levels.11 In the last ten years, AIDS has been a more potent killer by several orders of magnitude than all of the armed conflicts in Africa together.12 The AIDS epidemic is distinctive among lethal epidemics in that most of the lives it takes are of adults from twenty to forty years old. In Africa the vast majority of persons in this age group are parents, so AIDS has been responsible for orphaning millions of African children. About 25 million people are estimated to be living with HIV/AIDS in sub-Saharan Africa, of whom 3.8 million were infected in 2000 alone.13 Millions of new infections each year among young adults guarantee that high rates of orphaning will continue for years to come.
Mostly because of the stigma of AIDS, it is impossible to count children orphaned by AIDS using sample surveys or censuses. Estimates of the numbers of children orphaned by AIDS are extrapolated from statistics on AIDS-related deaths and demographic assumptions, which differ somewhat between the two main sources of projections, the United Nations and the United States Bureau of the Census. The United Nations estimated that by end 2000 about 13 million children under age fifteen years in sub-Saharan Africa would have lost their mother or both parents to AIDS.14 The Census Bureau estimates that there are currently about 15 million children under age fifteen who have lost at least one parent to AIDS in Africa and that by 2010 this number will be at least 28 million.15
By 2010, in five countries of eastern and southern Africa, over 30 percent of all children under age fifteen will be orphans, largely due to AIDS, according to the Census Bureau.16 By comparison, research suggests that in most developing countries about 2 percent of children under fifteen years were orphans before the era of AIDS.17 Experts in the U.N. and the Census Bureau agree that "the HIV/AIDS pandemic is producing orphans on a scale unrivaled in world history,"18 and that orphans as a percentage of the child population will continue to remain high in Africa for decades.
In heavily affected countries, for each child who has lost a parent to AIDS, there are one or two children of school age who are caring for an ill parent, acting as breadwinners for the household, or otherwise unable to attend school because of AIDS.19 Children who are not orphaned are also affected when orphans are brought into their homes or, obviously, when they themselves are infected. Thus, AIDS-affected children comprise a much larger population than just orphans.
The response of African governments to the AIDS epidemic has generally been grossly inadequate. Uganda, Kenya's neighbor to the west, is often cited as virtually the only African state in which government leaders recognized as early as the mid-1980s the threat of HIV/AIDS and acted to stop it. In 1986, spurred by outspoken leadership from President Yoweri Museveni, Uganda became the first country in Africa to collaborate with the World Health Organization Global Programme on AIDS to create an intersectoral national AIDS control program.20 In 1993, the first hard evidence of declining transmission rates in Uganda was published 21-a time when heads of state in the rest of Africa were still silent about the problem or mentioned it only to blame others for bringing it into their countries. In spite of early action on the part of the Ugandan government, Uganda still has over 1 million children orphaned by AIDS, and the epidemic has claimed millions of lives, including 110,000 in 1999 alone.22 This level of destruction is due to many factors, probably including the foothold that the epidemic already had in the country by 1986, the failure of even the greatest experts in the world at that time to understand its killing power, and the poverty and disintegration of social structures and basic services in Uganda following years of war. The successes in reducing rates of transmission in Uganda are most often attributed to the government's leadership and openness about the problem, the active role of civil society and religious leaders, and early donor support.23
Violations of civil and political rights have fueled HIV/AIDS' massive destruction in Africa. The subordinate status of women and their inability in many circumstances to negotiate safer sex or resist coerced sex is only one category of abuses. Women and girls may also face greater stigma than men in seeking services related to reproductive health and prevention and treatment of sexually transmitted infections. Gay men live a largely hidden life in many African countries, and this discrimination and marginalization contributes to their vulnerability to the disease and the inaccessibility of services for them. Prisoners in many countries are reportedly denied services and information to enable them to protect themselves. Injecting drug users and commercial sex workers are frequently marginalized and unable to assert their rights to protection. Sexual violence has been used systematically as a weapon of war and is particularly lethal where HIV/AIDS is prevalent. Any government's response to HIV/AIDS is incomplete without addressing these civil and political rights violations.
In the countries now hardest hit by HIV/AIDS, the extended family has traditionally been the source of support and care for orphans and other children needing special protection. In country after country, it has become clear that the extended family is now overextended and unable to provide its traditional level of protection and care for children deprived of a family environment. "In the body, HIV gets into the defensive system and knocks it out. It does that sociologically too. It gets into the extended family support system and decimates it," according to Geoff Foster, a pioneer in research on children affected by AIDS in Zimbabwe.24 As a researcher in Ethiopia has noted, the extended family, "a social safety net that accommodated orphaned children for centuries, is unraveling under the strain of AIDS."25
The deterioration of family support begins with the immediate family of the person with AIDS. John Williamson, author of some of the first and most authoritative analyses of the situation of AIDS-affected children, traces a pattern of weakening of the African family in the face of AIDS that has been confirmed in many investigations.26 When symptoms of AIDS appear, a breadwinner or parent becomes increasingly ill and unable to work. The combination of losing that person's income or daily household work and the financial burden of expensive medical treatments, even involving no antiretroviral drugs, leads to problems of food insecurity and other material need in the household. Children are withdrawn from school either to care for the sick person in the household, to care for young children, or to engage in income-generating activities (or some combination of the three). Increased poverty in the household also means reduced access to health services for all members, not just the person or persons living with AIDS. Williamson considers problems of inheritance for surviving widows and children, a common occurrence after death from AIDS occurs. He also notes that psychosocial distress following the death in the family is exacerbated by stigmatization on the part of the community and more distant relatives.
The situation of families affected by AIDS, as opposed to other conditions that result in orphans, was described succinctly by WHO and the United Nations Children's Fund (UNICEF) in 1994:
Many of the countries and communities hardest hit by HIV/AIDS in sub-Saharan Africa have in the era of AIDS suffered from war, natural disasters, increasing poverty, and the effects of widespread corruption. By the early 1990s, when the impact of AIDS began to be felt by the general population in most parts of eastern and southern Africa, community-level safety nets were already stretched. It is not surprising that caring for children affected by AIDS poses a major challenge. As one group of AIDS experts noted at an international conference,
Among the particular risks to children affected by AIDS in this difficult context, several have been noted consistently in a number of countries.
Risk of Having to Engage in Hazardous Labor
Street children, orphans living with poverty and stigma, children who have been deprived of their inheritance rights, and children with little prospect for realizing their right to education are all in need of special protection and are at very high risk of being victims of neglect, abuse and violence. HIV/AIDS in Africa contributes to all of these conditions.
In Kenya, HIV/AIDS is a national emergency. An estimated 2.1 million adults and children live with HIV/AIDS, representing about 14 percent of the sexually active population.41 Kenya has the ninth highest HIV prevalence rate in the world.42 UNAIDS estimates that about 500 persons died of AIDS each day in the country in 1999.43 Many experts in Kenya now use the figure of 600 deaths or more per day.44 U.S. Census Bureau projections indicate that by 2005, there will be about 820 deaths per day from AIDS in Kenya.45 About 75 percent of the deaths from AIDS in Kenya so far have occurred in adults aged eighteen to forty-five.46 HIV/AIDS remains shrouded in denial and silence in much of Kenya, which complicates discussions of policy and legal measures to address the problem as well as the delivery of services to those affected.
HIV/AIDS has ravaged Kenya during a period of dramatic increases in the rate of poverty. In 1972, it was estimated that about 3.7 million Kenyans lived in poverty (defined as an income level of less than U.S. $1 per day). Today that number is about 15 million, or about 52 percent of the population.47 Nyanza Province-which has the highest rate of HIV infection in the country, about 29 percent48 - also records the highest poverty rate, 63 percent, whereas in the early 1990s it was among the least poor regions.49
As in many countries, there is controversy in Kenya over the number of orphans. In 1999, the UN estimated that there were about 730,000 children under age fifteen in Kenya who had lost their mother or both parents to AIDS since the beginning of the epidemic, with about 550,000 of these children still living. A more recent estimate of about one million AIDS orphans currently living in the country has been widely accepted, including by many experts interviewed by Human Rights Watch.54 The Kenya National AIDS and Sexually Transmitted Disease Control Programme (NASCOP) estimates that there will be 1.5 million orphans under fifteen years by 2005, largely due to AIDS.55
Social services, including those on which children rely, are gravely affected by HIV/AIDS in Kenya. The Teachers Service Commission estimates a national shortage of about 14,000 teachers at the primary and secondary levels, attributable in large part to AIDS deaths among teachers.56 According to a high-level Ministry of Education official interviewed by Human Rights Watch, a school in Kenya might easily have seven of eighteen teaching positions vacant because of attrition due to AIDS.57
The care and treatment needs of persons with AIDS have overwhelmed health services in some parts of the country, causing reduced access to services generally, including basic child health and survival services.58 One study estimated that by 2000 expenditures made to care for AIDS patients in government health facilities would be about the equivalent of the entire 1993-94 Ministry of Health budget.59 It is only recently that, under pressure from nongovernmental organizations, the government has begun to take measures to improve access to antiretroviral drugs for the vast majority of persons with AIDS in the country for whom these drugs are unaffordable. In June 2001, over stiff opposition by pharmaceutical companies, the Kenyan Parliament passed the Industrial Properties Bill, which will allow the country to import and manufacture generic antiretroviral drugs.60 In addition, the Minister of Finance recently announced that tariffs on imported condoms would be removed to accelerate the fight against HIV/AIDS.61
Girls are especially affected by the AIDS epidemic in Kenya. The rate of HIV infection in girls and young women from fifteen to nineteen years old is about six times as high as that of their male counterparts in the most heavily affected regions,62 a pattern seen in many African countries. Although there are biological reasons why HIV transmission in this age group may be more efficient from male to female than in the opposite direction, biological reasons alone cannot account for a disparity this great. Several observers conclude that girls in this age group are catching the virus from older men, in many cases as a result of sex in which they engage to survive economically.63 One Kenyan girl in five reports that her first sexual experience is coerced or forced.64
Girls are more readily pulled out of school when someone in the household is ill with AIDS, as has been noted in other countries. Ministry of Education figures show that after four years of primary school in heavily AIDS-affected Nyanza Province, girls make up only 6 percent of those who are promoted to grade five.65 In Eastern Province, which has the lowest rate of HIV prevalence of Kenyan provinces, 42 percent of those passing into grade five are girls. The permanent secretary of the Ministry of Education attributed these disparities to AIDS and also noted that girls and boys passed through to grade five in roughly equal numbers twenty years ago before the epidemic's impact was felt.66 A recent detailed study carried out by the nongovernmental organization Population Communication Africa found that out of 72 children orphaned by AIDS on Rusinga Island in western Kenya, girls from AIDS-affected households were less likely to be in school than boys.67
Wife inheritance is practiced among some groups in Kenya, particularly the Luo in the national AIDS epicenter of Nyanza Province. This practice, whereby a widow is taken in marriage by the brother or other relative of her deceased husband, traditionally provided protections to the widow and her children who might otherwise find themselves bereft of the social and economic support of a family. In the era of HIV/AIDS, however, wife inheritance has been criticized by some government and community leaders as a means of spreading HIV.68 A study of AIDS-affected families on Rusinga Island concluded that "wife inheritance...is losing its former popularity due, perchance, to the risk of AIDS infection" but found that 77 percent of women widowed by AIDS still remarried, of whom half were inherited by the brothers of their husbands.69
The first case of HIV was diagnosed in Kenya in 1984,70 but concrete response on the part of the government came only years later. The Department for International Development (DFID), the British government aid ministry, noted that "Kenya has been notoriously slow to admit to its HIV/AIDS problem, to see it without an ethnic focus and to demonstrate high-level political commitment."71 The first national policy statement on AIDS came with the Kenyan parliament's adoption of its Sessional Paper no. 4 in 1997 which made recommendations for program implementation. In November 1999, President Moi declared HIV/AIDS a "national disaster," his first major public statement on the subject. 72 By then, an estimated one in every nine sexually active persons in the country was already infected. At about the same time, the government established an interministerial National AIDS Control Council (NACC) to develop strategies for controlling the spread of the disease.73
It is difficult to put a monetary figure on the Kenyan government's expenditures on HIV/AIDS because government-funded programs in many sectors touch directly or indirectly on the disease and its consequences. The government's most recent medium-term plan for dealing with HIV/AIDS proposes a budget of U.S. $30.7 million in government funds over five years.74 The government recently reported to the Kenyan parliament that it had allocated 140 million shillings, or about U.S. $1.87 million, for HIV/AIDS programs in the current fiscal year and that Kenya had received pledges of 7.6 billion shillings, or about U.S. $100 million, from various donors to continue AIDS work in the coming years; much of this aid is to be channeled through nongovernmental organizations rather than the government.75 The World Bank recently announced a loan on concessionary terms for U.S. $50 million over four years to combat AIDS.76 British official assistance in the area of HIV/AIDS was recently increased to 550 million shillings ($7.3 million) for the year with about $37 million pledged over five years.77 While external donors have recently been very responsive in the area of HIV/AIDS, in the last several years some donors and lenders, notably the International Monetary Fund and World Bank, have withdrawn their assistance to Kenya because of allegations of corruption and other concerns.78
10 U.N. Joint Progamme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS Epidemic: June 2000, (Geneva: United Nations, 2000).
11 UNAIDS, AIDS Epidemic Update, December 2000: Graphics (Geneva: United Nations, 2000). The countries with the ten highest reported rates of HIV infection in the world as of June 2000 were Botswana (adult prevalence of 36 percent), Swaziland (25.2 percent), Zimbabwe (25.1 percent), Lesotho (23.6 percent), Zambia (20 percent), South Africa (20 percent), Namibia (19.5 percent), Malawi (16 percent), Kenya (14 percent), and Central African Republic (13.8 percent). See tables in UNAIDS, Report on the Global HIV/AIDS Epidemic: June 2000, p. 124.
12 UNICEF Eastern and Southern Africa Regional Office, "The Silent Emergency" (annotated presentation and fact sheets, Nairobi, 2000).
13 Joint United Nations Progamme on HIV/AIDS (UNAIDS). AIDS epidemic update, December 2000. Geneva, 2000. For more information on methods of estimation of HIV/AIDS prevalence, see UNAIDS, Report on the global HIV/AIDS epidemic: June 2000, pp.115-116 Estimates of prevalence of AIDS in most African countries come from surveys of women seeking pre-natal services in selected or "sentinel" survey sites. This method has proven to be quite reliable in estimating national prevalence. Countries in which the epidemic is not in the general population but rather confined to high-risk groups use different methods of estimation.
14 UNAIDS, Report on the global HIV/AIDS epidemic: June 2000, p. 27.
15 Susan Hunter and John Williamson, Children on the Brink 2000, (Washington, DC: U.S. Agency for International Development, 2000).
16 Ibid., p. 20.
17 UNAIDS and UNICEF, Children Orphaned by AIDS: Front-line Responses from Eastern and Southern Africa (New York: United Nations, 1999), p. 3.
18 Hunter and Williamson, Children on the Brink, p. 1.
19 World Health Organization (WHO) and UNICEF, Action for Children Affected by AIDS: Programme Profiles and Lessons Learned (Geneva: United Nations, 1994), p. 5.
20 Mary Grace Alwano-Edyegu and Elizabeth Marum, "Knowledge is Power: Voluntary HIV Counselling and Testing in Uganda," UNAIDS Best Practice Series (Geneva: UNAIDS, 1999).
22 UNAIDS, "Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections: Uganda" (Geneva: United Nations, 2000).
23 Alwano-Edyego and Marum, "Knowledge is Power," p.8.
24 Association François-Xavier Bagnoud, Orphan Alert: International Perspective on Children Left Behind by HIV/AIDS (Boston: Association François-Xavier Bagnoud, 1999), p. 3.
25 Ibid, p.14.
26 Carol Levine and Geoff Foster, The White Oak Report: Building International Support for Children Affected by AIDS (New York: The Orphan Project, 2000), pp.24 - 27.
27 WHO and UNICEF, Action for Children, p.8.
28 Monitoring the AIDS Pandemic (MAP) Network, The Status and Trends of the HIV/AIDS Epidemics in the World (Cambridge, Massachusetts: François-Xavier Bagnoud Center for Health and Human Rights, 1998), p.20.
29 UNAIDS and UNICEF, Children Orphaned by AIDS, p.17.
30 UNAIDS, Report on the Global HIV/AIDS Epidemic: June 2000, pp.28-29.
31 Griffin Shea, "Future Bleak for Zimbabwe's AIDS Orphans," The Mail and Guardian (Johannesburg), September 25, 2000.
32 World Bank, Exploring the Implications of the HIV/AIDS Epidemic for Educational Planning in Selected African Countries: The Demographic Question (Washington, DC: The World Bank, 2000).
33 See, e.g., WHO and UNICEF, Action for Children, p.7; Association François-Xavier Bagnoud, pp.12-13.
34 WHO and UNICEF, Action for Children, p.42.
35 UNAIDS and UNICEF, Children Orphaned by AIDS, p.16.
36 "Crimes Against Humanity", Time, January 12, 2001, p.8.
37 Nhial Bol, "AIDS Orphans Throng the Streets," Inter Press Service, January 13, 1999.
38 Stefan Savenstedt, Gerd Savenstedt, and Terttu Haggstrom, East African Children of the Streets - a Question of Health (Stockholm: Save the Children - Sweden, 2000).
39 UNICEF Eastern and Southern Africa Regional Office, Child Workers in the Shadow of AIDS:Listening to the Children (Nairobi: UNICEF, forthcoming).
40 UNAIDS and UNICEF, Children Orphaned by AIDS, p.5.
41 National AIDS and STDs Control Programme (NASCOP), AIDS in Kenya: Background, Projections, Impact and Interventions, 5th ed. (Nairobi: Ministry of Health, 1999).
42 UNAIDS, Report on the Global HIV/AIDS Epidemic: June 2000, p.124. See prevalence rates of most affected countries in footnote 11.
43 UNAIDS. Epidemiological fact sheet on HIV/AIDS and sexually transmitted infections - Kenya (Geneva: UNAIDS, 2000).
44 See, e.g., a National AIDS Control Council official cited as saying that about 700 people die daily from the disease in Kenya, in Hannah Gakuo, "AIDS Awareness Project Launched," The Nation, May 3, 2001.
45 Jill Donahue, Susan Hunter, Linda Sussman, and John Williamsonm, "Children Affected by HIV/AIDS in Kenya -- An Overview of Issues and Action to Strengthen Community Care and Support: Report of a Combined USAID/UNICEF Assessment of Programming in Kenya for Children and Families Affected by HIV/AIDS" (Washington, DC: USAID, 1999), p.3.
46 NASCOP, AIDS in Kenya, p.14.
47 Government of the Republic of Kenya, "Interim Poverty Reduction Strategy Paper 2000-2003" (Nairobi: Government of the Republic of Kenya, July 13, 2000).
48 NASCOP, AIDS in Kenya, p. 7.
49 "Interim Poverty Reduction Strategy Paper 2000-2003," paragraph 2.3.
50 NASCOP, AIDS in Kenya, p. 32.
51 Ibid., p. 31.
52 Lori Bollinger, John Stover, and David Nalo, "The Economic Impact of AIDS in Kenya," (Washington, DC: Futures Group International, 1999), p.4.
54 "UNICEF Warns of Orphan Crisis in Kenya," International Planned Parenthood Federation News, December 1999.
55 NASCOP, AIDS in Kenya, p.24.
56 Kariuki Waihenya, "Teacher Shortage Biting", The Nation, April 16, 2001.
57 Human Rights Watch interview with W.K.K. Kimalat, permanent secretary of the Ministry of Education, Nairobi, March 5, 2001.
58 NASCOP, AIDS in Kenya, p. 26.
59 Cited in ibid., p. 27.
60 "Kenya's Parliament Passes AIDS Drugs Bill," Reuters, June 12, 2001.
61 "War on AIDS Gets Sh 146 Million Funding," The Nation (Nairobi), June 15, 2001.
62 NASCOP, AIDS in Kenya, p. 11.
63 See, e.g., Tony Johnston and Wairimu Muita, Adolescent Love in the Time of AIDS: A Kenyan Study (Nairobi: Population Communication Africa, 2001), pp. 48-52. This report notes that so-called sugar daddies are an important phenomenon and are not necessarily as old as middle age but are old enough to have some kind of income.
64 Tony Johnston, The Adolescent AIDS Epidemic in Kenya: A Briefing Book, rev. ed. (Nairobi: Population Communication Africa, 2000).
65 Human Rights Watch interview with W.K.K. Kimalat, permanent secretary of the Ministry of Education, Nairobi, March 5, 2001.
67 Tony Johnston, Alan Ferguson, and Caroline Akoth, A Profile of Adolescent AIDS Orphans (Nairobi: Population Communication Africa, 1999).
68 Stephen Buckley, "Wife Inheritance Spurs AIDS Rise in Kenya," The Washington Post, November 8, 1997; John Oywa, "Stop Widow Rituals, Says PC," The Nation (Nairobi), March 24, 2001.
69 Johnston, Ferguson, and Akoth, Profile of Adolescent AIDS Orphans, pp. 44-45.
70 NASCOP, AIDS in Kenya, p. 2.
71 Government of the United Kingdom, Department for International Development, Health and Population Department, "HIV/AIDS in Kenya - How Political Commitment Can Make a Difference," Stories from the Field Series (London: Government of the United Kingdom, April 2001).
72 Rosalind Russell, "Kenya Calls AIDS National Disaster, Bars Condoms News Alerts,"
73 Government of United Kingdom, "HIV/AIDS in Kenya,", p.1.
74 NASCOP, AIDS in Kenya, p. 54.
75 Odhiambo Orlale, "Sh 7.6 Billion Pledged for Fight Against AIDS," The Nation, April 18, 2001.
77 "UK Raises AIDS Funds to Kenya", The Nation, April 19, 2001.
78 "Kenya's Moi Lashes Donors on Corruption," The Mail and Guardian (Johannesburg), February 14, 2001.