Loss of life from HIV and AIDS among children in sub-Saharan Africa has set back death rates to the higher numbers of the 1980s. And the pandemic is creating a spiral of death and poverty that is ever more difficult to combat.
One and a half million pregnant women in sub-Saharan Africa are HIV-positive. Most of their children either will be born HIV-positive or will be infected as babies through breastfeeding.
About 200 in every 1,000 babies will die before their fifth birthday - wiping out 20 years of gradual reduction in child mortality in sub-Saharan Africa. In industrialized countries, only about seven babies of every 1,000 die before age five.
A chief reason for that death rate among children: the southern and east African regions have the highest rate of HIV infection in sub-Saharan Africa - and the world.
The regional director of UNICEF for east and southern Africa, Urban Jonsson, said that there has never been another pandemic like it. "But the HIV/AIDS pandemic and crisis is significantly worse in east and southern Africa, and particularly in southern Africa. In southern Africa, we have prevalence rates that were unthinkable regarding any disease, any time in history. Botswana - one-third of the adult population is infected. That has never happened in any country, any time in history," he said.
Mr. Jonsson said it is not only AIDS itself that is killing children under five. He said even more children die because of the impact of the disease on families and communities.
"But that is a smaller contribution. The bigger contribution is of course those who are affected by HIV and AIDS. These are living in families which are getting very much poorer during an HIV/AIDS crisis in the family, whether it is the father or mother or both or relatives. So the overall impact is significant. We can say that in many countries now, infant and young child mortality rate is back to the values we had 20 years ago," Mr. Jonsson said.
He said that very few studies are being done into the reasons the infection rate of HIV/AIDS has exploded in east and southern African countries. He says one reason is the depth of poverty in the region, which creates the conditions in which the virus can flourish.
"So, poverty is not just a cause, poverty is HIV/AIDS. Poverty is space in which HIV/AIDS thrives. And of course HIV/AIDS, when it develops into AIDS, the disease, contributes to poverty in many different ways, not only that adult people, who are the right age cannot work any longer, they also cost a lot of money - hospital services and a long range of things. So I cannot separate the explosion of HIV/AIDS from poverty in southern Africa. They are one and the same - one cannot be understood without the other," he said.
South Africa has one of the highest rates of HIV/AIDS in the world, with as many as 20 percent of the adult population believed infected.
Eight years ago, the focus of one of the oldest children's homes in Johannesburg, Cotlands Baby Sanctuary, shifted from caring for disabled children to caring for children dying of AIDS.
Last year, nurse Stella Mahlanga took over as director of the children's AIDS hospice at Cotlands. Since then, she said, the number of children dying has increased from one or two each week to three or four. But she said it is not only at the hospice that she has seen children die.
"There are so many children that are dying out there. We have a home-based care program here at home, we deal with people from Soweto, from Tembisa, and from KwaZulu-Natal in Hlabisa. The number of children that are dying is appalling, and now recently we are faced with children that are dying and parents that are dying and children are left to take care of each other," Ms. Mahlanga said.
In addition to caring for the children, the staff at the hospice must also counsel and support their families - and each other. Nurse Mahlanga said they comfort each other in laughter and gain strength from knowing that they have cared as best they can for each child.
"What we usually do - we do a lot of counseling, we talk to the care-givers a lot, and our worry is always is their emotional state because with so much death around us we have to keep on talking about it. And what encourages us is we do the best we can. And when a child goes - we know they are going to die but we never just neglect them and say they are coming to die here - when the child goes, we know that we've done our best, we've offered our best," she said.
This week, the Cotlands hospice staff is faced with the looming death of a seven-year-old boy whom they have named the Prince of Cotlands.
"So he's faced with so many problems. And since he came here as a two-year-old, he's lived 'til seven and he's seen so much death he becomes anxious. He's oxygen-dependent, he lives on oxygen 24 hours a day, and once there is anything wrong with his oxygen, he becomes so anxious and we all look after him. He's very charming and he also has a big heart because even if he's sick, he always has time to talk to his friends and tell them that they'll be well," she said.
When the life slips from his small body, the Prince of Cotlands will do more than add another statistic to the child mortality rate of sub-Saharan Africa. Nurse Mahlanga said he will leave behind an example of living with a big heart in the face of pain and weakness.