Whilst many orphans are 'adopted' by extended families, poverty serves to cut off many options for children and forces them into a life of menial work, drug-dealing and prostitution writes Russell Davies

The hiv/aids pandemic continues toravage communities all over the world, having perhaps its most severe impact on highly vulnerable children, depriving them of parents, and in some cases, condemning them to a premature death from the moment of birth.

The most recent UNAIDS statistics estimate that around 42 million people worldwide are now HIV positive, 3.2 million of them are under the age of 15, and in 2002 alone, 3.1 million lost their lives to the virus - 610,000 of whom were children. The virus continues to spread at an alarming rate with five million people newly infected in 2002, of whom 800,000 were children. Though accurate figures are not available, UNICEF estimates that at least 13 million children have lost either one or both parents to HIV/Aids, though only between 10 and 15 per cent are themselves HIV positive.

The challenges faced by an orphan in any circumstance are immense, particularly if they have been old enough to bond with the parents before death. Whilst other relatives or friends may assume a guardianship role, it is never the same as a natural parent, the most "significant other" in any child's life. Children experience deep seated feelings of grief and loss, especially where they have witnessed the dying process and shared in the palliative care. For many Aids orphans, the transition to orphanhood is hardly managed at all - they receive little communication about what is happening, they are not prepared emotionally, legal provisions regarding transfer of assets or welfare entitlements are not made, and practical arrangements for their ongoing welfare are not considered.

By far the most severely affected region is sub-Saharan Africa, where HopeHIV works with local partners in nine countries to deliver a range of programmes for children orphaned by HIV/Aids.

The problem is exacerbated in this region by many factors. Whilst many orphans are "adopted" by extended families, poverty serves to cut off many options for children and force upon them a host of undesirable scenarios. Overcrowding, poor sanitation, malnutrition, inability to pay school fees, appalling or even non-existent health services and high crime rates are just some of the effects of poverty. Many children, particularly those who are the heads of their households, are forced out of school prematurely to try to support both themselves and their younger siblings. This can take the form of very menial low paid employment, or more commonly, prostitution or drug dealing. These are then further complicated by other external issues such as conflict, drought and sexual abuse.

Recent visits to Zimbabwe, where communities are being devastated by drought, food shortages and political intimidation; northern Uganda, where rebel violence has forced thousands of people from their villages into internal displacement camps, and Kibera; a slum inhabited by around one million people in central Nairobi, have highlighted for me the especially desperate plight of some orphans.

Most of sub-Saharan Africa's major cities have huge numbers of street children, a high proportion of whom are Aids orphans, many fleeing to the city from remote rural areas in search of employment. Whilst some of our project partners and many others are seeking to engage with these children, the costs of reuniting them with families and communities of origin, especially to areas with problematic road access, is almost prohibitive. Many find their way into institutional care and ultimately recidivist cycles of drug and alcohol abuse, prostitution, homelessness and street crime. That is all without taking into account orphans who are HIV positive. Many find themselves abandoned, malnourished, and deteriorating in health at a rapid rate. Tragically many young children face death having never known what it was to experience love, intimacy or dignity.

So what can be done to help? Obviously prevention is always the best place to start. Many groups are operating very effective HIV/Aids awareness and education programmes, providing information regarding sexual and reproductive health issues which are seeing demonstrable reductions in teenage pregnancies as well as increases in Voluntary Counselling and Testing - indeed many communities will not condone a marriage unless both partners have had negative tests. Condom use is also on the increase. Catholic and other Christian agencies are moderating previous hard line positions in this area and there is evidence of changed sexual behaviour patterns in many regions. On the negative side, the availability of anti-retroviral drugs is still extremely limited and even when accessible, poor diet and nutrition counteracts its impact. Measures to supplement the nutritional input of HIV positive women's diets would prolong their lives and mitigate the increase in orphans.

Residential care has been a traditional response to orphanhood but the sheer numbers and expense involved make this unsustainable for all but a few. It can only be a safety net of last resort at best. Far better is to try to assimilate orphans into their communities and enhance the capacity of guardians, siblings and volunteers to provide adequate home based care and nurture. Income generation schemes offering both microcredit and training are a critical dimension of strengthening families' economic capacity to provide for the orphan's material needs.

Access to all levels of education, vocational training and income earning activity is obviously another crucial issue and advocacy for the abolition of school fees for low income families is urgently required. Poor health services also mitigate against orphans, with chronic underinvestment and staff shortages rife, particularly in rural areas, urban slums and Internal Displacement Camps. I was only last week at an IDPC near Kitgum in northern Uganda, currently inhabited by around 12,000 people, literally hundreds of whom are orphans, patently undernourished and vulnerable to disease, living in conditions of extreme heat and severe overcrowding. Shamefully it is serviced by a solitary and very poorly resourced medical clinic, staffed only by a clinical officer and nursing assistant. No drugs have been delivered for three weeks and neither a doctor or nurse has visited the camp for six months.

Also frequently ignored is the whole dimension of trauma and unresolved grief. HopeHIV is funding the development of a range of psycho-social support programmes for orphans utilising outward bound/camping style interventions as well as art, music and drama-based therapy in group settings. Community counselling techniques help transfer concepts such as these throughout regions, building capacity to cope and giving people crumbs of hope in the face of extreme hardship.

Much is already being done but the available resources are currently far exceeded by the needs. There are however some strategic measures which would have an immediate impact. A dramatic increase in the availability of anti-retroviral drugs with accompanying nutritional supports is an obvious starting point. Secondly a focus on the provision of drastically enhanced levels of child-focused medical provision in rural areas, urban slums and IDPC's may begin to scratch the surface in mitigating flagrant violations of children's UN endorsed rights to basic health services. Thirdly a continuing concentration of resources into prevention, education and HIV/Aids awareness programmes is critical.