Children orphaned by AIDS: a global perspective

COVID-19 orphans-Global patterns associated with the hidden pandemic

Whilst the COVID-19 pandemic has caused significant mortality across the globe, many children have been orphaned due to the loss of their parents. Using the framework of an ecological analysis, we used estimates of total maternal/paternal orphans using an online COVID-19 orphanhood calculator to estimate the total orphans per COVID-19 death for 139 countries. Descriptive statistics were used to determine global patterns behind this risk of children being orphaned. Linear regression models were fitted to determine factors associated with this risk, and the association with vaccination coverage was calculated. We found that there is tremendous global variation in the risk that COVID-19 deaths will lead to orphaned children, and that this risk is higher in countries below median GDP per capita (1·56 orphans per deaths) compared to countries above (0·09 orphans per death). Poverty prevalence (B = 2·32, p<0·01), GDP per capita (B = -0·23, p<0·05), and a greater proportion of people with NCDs being reproductive aged (B = 1·46, p<0·0001) were associated with this risk. There was a negative correlation between 2nd dose vaccination coverage and orphans per death (p<0·05). The risk of children being orphaned per COVID-19 death, alongside fertility rate, is due to there being a greater share of COVID-19 deaths among younger persons. This is more likely in poorer countries and those where the age distribution for non-communicable diseases that elevate COVID-19 mortality risk are more uniform. Due to vaccine coverage inequity, more children will suffer the loss of their parents in poorer countries.

A pilot project: handwashing educational intervention decreases incidence of respiratory and diarrheal illnesses in a rural Malawi orphanage

Children who live in orphanages represent a population particularly vulnerable to transmissible diseases. Handwashing interventions have proven efficacy for reducing the rate of transmission of common infectious diseases. Few studies have analyzed the delivery of health interventions for children in orphanages in sub-Saharan Africa. To address this gap, we conducted an ecological assessment and piloted a handwashing intervention in an orphanage in rural Malawi, focusing on caregiver knowledge and behaviors, child handwashing behaviors, and disease incidence. A secondary study aim was to demonstrate program feasibility for a future randomized controlled trial. Orphanage caregivers participated in a three-module educational intervention on handwashing based on WHO recommendations and workshops on how to teach the curriculum to children. Seventeen orphanage caregivers and 65 children were monitored for handwashing behavior and child disease incidence. Friedman's tests were conducted to compare changes in caregiver knowledge and behaviors. Child handwashing behaviors and surveillance of child disease incidence were measured pre- and post-intervention. There were significant increases in caregiver hand hygiene knowledge. At six months post-intervention, handwashing with soap increased significantly among caregivers (p < 0.001) and was observed in children. The incidence of acute respiratory infections decreased from 30% to 6% post-intervention, resulting in an 80% decrease. The incidence of diarrhea decreased from 9.2% to 6.2% post-intervention, resulting in a 33% decrease. A brief educational intervention may improve handwashing knowledge and behaviors and help to decrease the incidence of common infectious diseases in an orphanage in rural Malawi. In addition, the caregiver uptake of the intervention demonstrated feasibility for future studies.

Toward an enhanced understanding of psychological resilience for HIV youth populations

Though mother-to-child HIV transmission has been dramatically reduced in the past decade, there are currently an estimated 1.8 million children living with HIV across the globe, and over 30% of all new HIV infections occur among youth ages 15-25. While all youth experience developmental challenges, children and adolescents who are living with HIV must navigate these challenges within the context of high HIV stigma and must cope with a host of psychosocial and health-related challenges. In addition, because HIV disproportionately impacts individuals from minority statuses (e.g., race, ethnicity, gender, sexuality) and people living in poverty, vulnerabilities are often compounded. Resilience frameworks emphasize the capacity for positive adaptation to adversity, and thus provide a useful lens to identify and build upon individual and community strengths. This article introduces a special issue of AIDS Care that examines factors associated with resilience among children and adolescents affected by or living with HIV, as well as innovative interventions designed to build resilience among HIV youth populations. The articles highlighted within this issue examine the possibility of building resilience across diverse settings (e.g., schools, communities, healthcare clinics) and with varied populations (e.g., youth living with HIV, AIDS orphans, young men who have sex with men). We also highlight innovative approaches to resilience-building, including a new mobile Health (mHealth) smartphone game that aims to improve adherence among youth living with HIV in the United States.

Strategies to bring about change: a longitudinal study on challenges and coping strategies of orphans and vulnerable children and adolescents in Namibia

Longitudinal research provides insight about the life trajectories of children, the challenges that children experience in different phases of their lives, and the way children cope with these challenges. The article examines the perspectives of 14 orphaned or vulnerable children, initially aged 9 to 12 years (in grades 3 and 4), concerning changes in their difficulties and coping strategies. The children participated in the research in 2003 and again in a follow-up study in 2010 to 2012. Focus group discussions with the children/adolescents were used, as well as child-orientated methods such as drawings, and in-depth interviews with the adolescents and caregivers. Most of the participants described their life situation as better at the time of the 2010/12 study than it had been in 2003. In general, they were receiving more financial support than before from their immediate and extended family or were supporting themselves. One important change since 2003 was that nine of the 14 had since received a state-provided child welfare grant for at least some years. Also, those who said they had previously experienced mistreatment had since left these home situations. The children's agency in making positive changes to their life situations is described by the participants. As adolescents, they tried to access family support by actively asking for financial assistance, and in return they generally felt obligated to support the family once they began earning an income. The strategies they most used to get away from abusive home situations were to inform a relative about the mistreatment or to run away. Children's and adolescents' limitations concerning strategies for improving their adverse living situations are also discussed.

Posttraumatic stress symptoms and structure among orphan and vulnerable children and adolescents in Zambia

BACKGROUND

Scant information exists on posttraumatic stress disorder (PTSD) symptoms and structure in youth from developing countries.

METHODS

We describe the symptom profile and exposure to trauma experiences among 343 orphan and vulnerable children and adolescents from Zambia. We distinguished profiles of posttraumatic stress symptoms using latent class analysis.

RESULTS

Average number of trauma-related symptoms (21.6; range 0-38) was similar across sex and age. Latent class model suggested three classes varying by level of severity: low (31% of the sample), medium (45% of the sample), and high (24% of the sample) symptomatology.

CONCLUSIONS

Results suggest that PTSD is a continuously distributed latent trait.

High risk of ART non-adherence and delay of ART initiation among HIV positive double orphans in Kigali, Rwanda

Background

To reduce HIV/AIDS related mortality of children, adherence to antiretroviral treatment (ART) is critical in the treatment of HIV positive children. However, little is known about the association between ART adherence and different orphan status. The aims of this study were to assess the ART adherence and identify whether different orphan status was associated with the child’s adherence.

Methods

A total of 717 HIV positive children and the same number of caregivers participated in this cross-sectional study. Children’s adherence rate was measured using a pill count method and those who took 85% or more of the prescribed doses were defined as adherent. To collect data about adherence related factors, we also interviewed caregivers using a structured questionnaire.

Results

Of all children (N = 717), participants from each orphan category (double orphan, maternal orphan, paternal orphan, non-orphan) were 346, 89, 169, and 113, respectively. ART non-adherence rate of each orphan category was 59.3%, 44.9%, 46.7%, and 49.7%, respectively. The multivariate analysis indicated that maternal orphans (AOR 0.31, 95% CI 0.12–0.80), paternal orphans (AOR 0.35, 95% CI 0.14–0.89), and non-orphans (AOR 0.45, 95% CI 0.21–0.99) were less likely to be non-adherent compared to double orphans. Double orphans who had a sibling as a caregiver were more likely to be non-adherent. The first mean CD4 count prior to initiating treatment was 520, 601, 599, and 844 (cells/ml), respectively (p<0.001). Their mean age at sero-status detection was 5.9, 5.3, 4.8, and 3.9 (year old), respectively (p<0.001).

Conclusions

Double orphans were at highest risk of ART non-adherence and especially those who had a sibling as a caregiver had high risk. They were also in danger of initiating ART at an older age and at a later stage of HIV/AIDS compared with other orphan categories. Double orphans need more attention to the promote child’s adherence to ART.

Positive future orientation as a mediator between traumatic events and mental health among children affected by HIV/AIDS in rural China

OBJECTIVE

The current study was designed to explore the effect of future orientation in mediating the relationship between traumatic events and mental health in children affected by HIV/AIDS in rural China.

METHODS

Cross-sectional data were collected from 1221 children affected by HIV/AIDS (755 AIDS orphans and 466 vulnerable children). Future orientation among children was measured using three indicators (future expectation, hopefulness toward the future, and perceived control over the future). Measures of mental health consisted of depression, loneliness, and self-esteem. Children's experience of any traumatic events was measured using a modified version of the Life Incidence of Traumatic Events-Student Form. Mediation analysis was conducted using structural equation modeling (SEM) methods.

RESULTS

Among the children surveyed, most of the traumatic indicators were negatively associated with future expectation, hopefulness, perceived control, and self-esteem, and positively associated with depression and loneliness. The SEM of mediation analysis demonstrated an adequate fit. Future orientation fully mediated the relationship between traumatic events and mental health and accounted for 67.9% of the total effect of traumatic events on mental health.

CONCLUSIONS

Results of this study support the positive effect of future expectation in mediating the relationship between traumatic events and mental health among children affected by HIV/AIDS in China. Future mental health promotion and intervention efforts targeting children affected by HIV/AIDS should include components that can mitigate the negative impact of traumatic events on their lives. These components may aim to develop children's positive future expectations, increase their hopefulness toward the future, and improve their perceived control over the future.

Effect of economic assets on sexual risk-taking intentions among orphaned adolescents in Uganda

OBJECTIVES

We examined the effect of economic assets on sexual risk-taking intentions among school-going AIDS-orphaned adolescents in rural Uganda.

METHODS

AIDS-orphaned adolescents from 15 comparable schools were randomly assigned to control (n = 133) or treatment (n = 127) conditions. Treatment participants received child savings accounts, workshops, and mentorship. This economic intervention was in addition to the traditional care and support services for school-going orphaned adolescents (counseling and school supplies) provided to both treatment and control groups. Adolescents in the treatment condition were compared with adolescents in the control condition at baseline and at 10 months after the intervention.

RESULTS

After control for sociodemographic factors, child-caregiver/parental communication, and peer pressure, adolescents in the economic intervention group reported a significant reduction in sexual risk-taking intentions compared with adolescents in the control condition.

CONCLUSIONS

The findings indicate that in Uganda, a country devastated by poverty and disease (including HIV/AIDS), having access to economic assets plays an important role in influencing adolescents' sexual risk-taking intentions. These findings have implications for the care and support of orphaned adolescents, especially in poor African countries devastated by poverty and sexually transmitted diseases.

Psychosocial consequences for children experiencing parental loss due to HIV/AIDS in central China

Individual in-depth interviews were conducted with 47 children (ages 8-17 years) experiencing the loss of one or both parents due to HIV/AIDS in two rural counties of central China. Findings in this study reveal that the families of the children orphaned by AIDS had experienced financial burdens because of treatment costs for sick parents and loss of labor in the household. The majority of the participants reported some level of stigmatization because of their parents' HIV status. The participants described feelings of sadness, fear, anxiety, anger, loneliness, low self-esteem, social withdrawal, and sleep problems. Implications for intervention programs include the need for psychological support and special counseling services, more public education with accurate knowledge about HIV/AIDS to decrease stigma and discrimination, and financial programs to decrease economic and caregiving burdens for these children.

Emotional development and nutritional status of HIV/AIDS orphaned children aged 6-12 years old in Thailand

OBJECTIVE

To explore the emotional development and nutritional status of HIV/AIDS orphans by their infection status.

METHODS

A community-based cross-sectional survey was conducted during January and December 2005 in four provinces and Bangkok Metropolis where the prevalence of HIV/AIDS among pregnant women was high. The study population consisted of 388 HIV/AIDS orphans who were maternal or paternal or double orphans aged 6-12 years old. The orphans' main caregivers gave informed consent to the project and assessed the emotional development of their orphaned children. The children were measured for weight, height, and emotional development by standard instruments. They were divided into three groups regarding their HIV/AIDS infection status reported by their caregivers: infected, non-infected, and unknown. The chi(2) test was used to determine the association between nutritional status and infection status.

RESULTS

Regarding HIV/AIDS infected children, 19.1% were infected, 57.5% were not infected, and 23.4% were unknown. The main caregivers of all types of orphans were grandparents. Only 13.7% of infected orphans lived with their mothers. Most caregivers were females and more than 40 years old. Infected orphans had mean scores of overall emotional development and for each domain less than other groups. The mean scores of self-control and quick recovery were significantly different between infected and non-infected groups (P-value < 0.05). Nearly 50% of infected orphans were rather short and approximately 42% were under weight and light. The findings revealed a significant association between height for age, weight for age and infection status of orphans at a P-value of <0.001.

CONCLUSIONS

Orphanhood itself is a vulnerable status and HIV/AIDS infected orphans are most vulnerable. Acceptable and friendly services for orphans and their families are crucial. The services should continue and protect stigmatization.

Constraints to educational opportunities of orphans: a community-based study from northern Uganda

The objective of this article is to assess constraints on educational opportunities of orphans cared for within the extended family system in Lira district, northern Uganda. The data were collected through: review of school census records; ethnographic fieldwork; in-depth interviews with 21 community leaders, 45 heads of households caring for orphans and 35 orphans. Focus group discussions were held with men and women caring for orphans, community leaders and orphans. A household survey was conducted in 402 households caring for orphans. We found that very poor widows living on less than half a dollar per day head 48% of the households caring for orphans. The elderly heads of households were 3 times more likely to have all the children in their household in schools than the younger ones. Furthermore, the widowed and single heads of households were more likely to have all orphans in school than the married, and households that received external support offered better educational opportunities. Poverty, as indicated by lack of food while at school and heavy involvement of orphans in domestic labour, were identified as major constraints on orphans' schooling. There is an urgent need to support orphans' education in northern Uganda beyond the current Universal Primary Education efforts. The most vulnerable households need to be targeted, and the communities need to be sensitized to child labour, school meals and sex abuse.

The social and economic impact of parental HIV on children in northern Malawi: retrospective population-based cohort study

From population-based surveys in the 1980s in Karonga district, northern Malawi, 197 'index individuals' were identified as HIV-positive. 396 HIV-negative 'index individuals' were selected as a comparison group. These individuals, and their spouses and children, were followed up in 1998-2000. 582 of 593 index individuals were traced. 487 children of HIV-positive, and 1493 children of HIV-negative, parents were included in analyses. Rates of paternal, maternal, and double orphanhood among children with one or both parents HIV-positive were respectively 6, 8, and 17 times higher than for children with HIV-negative parents. Around 50% of children living apart from both parents had a grandparent as their guardian; for most of the rest the guardian was an aunt, uncle, or sibling. There were no child-headed households. Almost all children aged 6-14 were attending primary school. There was no evidence that parental HIV affected primary school attainment among children <15 years old. Children of HIV-positive parents were less likely to have attended secondary school than those of HIV-negative parents. The extended family has mitigated the impact of orphanhood on children, but interventions to reduce the incidence of orphanhood, and/or which strengthen society's ability to support orphans, are essential, especially as the HIV epidemic matures and its full impact is felt.

Living environment and schooling of children with HIV-infected parents in southwest China

A cross-sectional household survey was conducted in Longchuan County, China, to study the lives of children with HIV-infected parents. Registered HIV-infected drug users and their households were approached and information about the living environment of children < or =15 years of age was collected. Of the 266 households interviewed, there were 213 children < or =15 years old. Forty percent of the children had lost at least one parent. Most of the children resided in a household with low economic status and a high dependency ratio. One-half of the children experienced discordant family relations, family anxiety and shame. Compared to orphans, non-orphans and their families were less likely to receive social support from the community. Orphans and older children were less likely to attend school and more likely to be truant if enrolled in school. Findings in the current study suggest that many children whose parents are infected with HIV or have died from HIV are living in stressful environments with minimal support from the community. Efforts should be taken to provide support and supervision to these children.

Travel and sexually transmitted infections

Increasing population mobility and increasing frequency and variety of sexually transmitted infections (STI) are closely linked around the globe. Although all mobile populations are at increased risk for acquiring STIs, international travelers are the focus of this review. Several aspects of travel such as opportunity, isolation, and the desire for unique experiences all enhance the likelihood of casual sexual experiences while abroad. The situational loss of inhibition of travel can be markedly enhanced by alcohol and drugs. Several of the most important elements of the complex interaction between travel and STIs are discussed.

"When the obvious brother is not there": political and cultural contexts of the orphan challenge in northern Uganda

It is estimated that two million of Uganda's children today are orphaned primarily due to AIDS. While recognising the immense impact of HIV/AIDS on the present orphan problem, this article calls for a broader historic and cultural contextualisation to reach an understanding of the vastness of the orphan challenge. The study on which the article is based was carried out among the Langi in Lira District, northern Uganda, with a prime focus on the situation of orphans within the extended family system. The data were collected through ethnographic fieldwork (8 months); in-depth interviews with community leaders (21), heads of households (45) and orphans (35); through focus group discussions (5) with adult men and women caring for orphans, community leaders and with orphans; and also through documentary review. A survey was conducted in 402 households. The findings reveal a transition over the past 30 years from a situation dominated by 'purposeful' voluntary exchange of non-orphaned children to one dominated by 'crisis fostering' of orphans. Sixty-three percent of the households caring for orphans were found to be no longer headed by resourceful paternal kin in a manner deemed culturally appropriate by the patrilineal Langi society, but rather by marginalised widows, grandmothers or other single women receiving little support from the paternal clan. This transition is partly linked to an abrupt discontinuation of the Langi 'widow inheritance' (laku) practice. It is argued that the consequential transformations in fostering practices in northern Uganda must be historically situated through a focus on the effects of armed conflicts and uprooting of the local pastoral and cotton-based economy, which have occurred since the late 1970s. These processes jointly produced dramatic economic marginalisation with highly disturbing consequences for orphans and their caretakers.

Major factors affecting the emergence and re-emergence of infectious diseases

The diversity of infectious disease threats currently facing humanity is unprecedented because of the remarkable emergence and reemergence of pathogens worldwide. Because of population mobility, globalization of commerce and the food supply, and the effects of the HIV/AIDS pandemic, infections in the developing world must be addressed to prevent infections in industrialized countries. Because pathogens do not recognize national boundaries, the rapidity with which individuals can circumnavigate the globe incubating infections makes the control of communicable diseases an enormous challenge for governments as well as for the public and primary health care systems. A global strategy for dealing with infectious disease threats must be developed and implemented as soon as possible.