An Unintended Catastrophe: The outcome of 20 million AIDS orphans without social service support is a tragedy in the making
The 19th International AIDS Conference, which concludes today in Washington, has highlighted some genuine signs of progress against the global HIV pandemic—chief among these, the campaign to prevent mother-to-child-transmission (PMTCT) of HIV. Yet the very success of this public health initiative has created dilemmas of its own—and raises profound ethical questions that the international community has barely begun to ponder.
To the concerned public and the policymakers who represent them, preventing unborn children from contracting their mother’s HIV/AIDS infection looks like a total no-brainer. The programs are inexpensive, relatively easy to implement, last for only a few months, and usually provide a concrete, positive outcome—an infant free of infection. The efficacy of these programs is impressive: MTCT HIV falls from 20 to 50 percent during pregnancy, delivery, and breastfeeding to under 5 percent.
And that is the intended result of such programs. There is, however, an unintended or invisible result as well. Over the last decade, PMTCT programs have swelled the ranks of AIDS orphans by allowing uninfected children to live long enough to watch one or both of their parents die from AIDS.
In 2009, in its most recent reckoning, UNAIDS estimated that there were more than 16 million children worldwide who have been orphaned because of the HIV/AIDS-related deaths of their parents—a figure nearly equal to the population of Australia. The overwhelming majority of these children live in sub-Saharan Africa, with Nigeria alone accounting for an estimated 2.5 million AIDS orphans; South Africa, 1.9 million; and Tanzania,1.3 million. Kenya and Uganda were estimated then to have 1.2 million AIDS orphans each—and all these totals have only been rising over the past few years.
South Africa probably offers the most accurate HIV/AIDS data of any sub-Saharan country. According to estimates for South Africa, the number of AIDS orphans as a percentage of total orphans has increased from virtually zero in 1990 to more than 75 percent today. South Africa has made notable advances in adult HIV/AIDS treatment program coverage over the past several years. Even so, the Actuarial Society of South Africa estimates that this proportion of AIDS orphans will continue to grow to almost 82 percent by 2025. By these estimates and projections, over a fifth of South Africa’s children are already AIDS orphans—and that fraction will continue to rise in the years immediately ahead.