The overwhelming majority of children orphaned or affected by HIV/AIDS in sub-Saharan Africa are currently being cared for within their immediate and extended families. For most of these children, no option is as good as living with healthy parents; where this is not possible (given the realities of the HIV/AIDS epidemic), family- and community-based sources of care are the most child-centered – and the only practical – means of responding to the scale of the problem. Considerations of both child rights and child development unequivocally support family-based care, with the responsibility for it located firmly in local communities.

Achieving a strong and reliable system of family-based care, however, requires a systematic approach to strengthening family and community capacities by mobilizing communities. Mobilizing communities in turn requires the support of national and local policy. Steps also need to be taken to provide appropriate care for those children who have slipped through family and community safety nets. This care is likely to consist of various forms of fostering (by which we mean the care of children by unrelated adults, whether informally or with agency involvement) or adoption. Both approaches need to be adapted according to cultural considerations.

This chapter has three main sections. The first section critiques the practice of offering institutional forms of care as a benevolent and efficient response.