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

I can teach what's in the book": Understanding the why and how behind teachers' implementation of a social-emotional learning (SEL) focused curriculum in rural

Contextualizing the role of teachers in social-emotional learning (SEL) in Malawi, we examine how teachers' comfort with, commitment to, and perceived school culture toward SEL relate to their actual teaching of it. Using surveys from 432 primary school teachers (20-60 years old), we found teacher comfort and supportive school culture were positively related to integration of SEL into classroom instruction, while commitment had no statistically significant relationship with implementation. We explore plausible explanations for these findings by interviewing 42 teachers. Together, our findings highlight the importance of teacher support systems and cultural compatibility of the curriculum for successful SEL implementation.

A cluster randomized controlled trial to evaluate a resilience-based intervention for caregivers of HIV-affected children in China

OBJECTIVES

The Child-Caregiver-Advocacy Resilience (ChildCARE) intervention aims to enhance the psychosocial wellbeing of children affected by parental HIV by providing programing at three levels: child, caregiver, and community. The objective of the current study was to evaluate the intervention's efficacy in improving mental health and parenting outcomes for participating caregivers.

DESIGN

A cluster randomized controlled trial was used to evaluate initial efficacy of the intervention.

METHODS

A total of 790 caregivers of children affected by parental HIV were recruited from Henan, China. Caregivers and their children were randomly assigned to one-of-four intervention arms (control, child-only, child + caregiver, child + caregiver + community) to evaluate the multiple components of ChildCARE. Those assigned to receive the caregiver intervention participated in five 2-h intervention sessions designed to improve their parenting skills and enhance their ability to cope with daily stressors. Caregivers reported on their mental health and parenting behaviors at baseline, 12, 24, and 36 months, with mixed effect modeling used to examine intervention effects.

RESULTS

Caregivers who participated in the intervention reported decreased anxiety and parental stress at 12 months (P < 0.05). Participants also reported increased use of structured parenting skills (i.e., parental demandingness) at 12 and 24 months (P < 0.05). However, by 36 months, they reported significantly lower levels of parental competence (P < 0.01) than those assigned to the control condition.

CONCLUSION

Preliminary findings suggest that the caregiving component of ChildCARE yields initial improvements in some key parenting and mental health outcomes. However, the challenges of caring for children affected by HIV are complex and may require more intensive intervention to yield marked, positive changes across key caregiver outcomes.

The History of the HIV/AIDS Epidemic in Africa

HIV testing of African immigrants in Belgium showed that HIV existed among Africans by 1983. However, the epidemic was recognized much later in most parts of sub-Saharan Africa (SSA) due to stigma and perceived fear of possible negative consequences to the countries' economies. This delay had devastating mortality, morbidity, and social consequences. In countries where earlier recognition occurred, political leadership was vital in mounting a response. The response involved establishment of AIDS control programs and research on the HIV epidemiology and candidate preventive interventions. Over time, the number of effective interventions has grown; the game changer being triple antiretroviral therapy (ART). ART has led to a rapid decline in HIV-related morbidity and mortality in addition to prevention of onward HIV transmission. Other effective interventions include safe male circumcision, pre-exposure prophylaxis, and post-exposure prophylaxis. However, since none of these is sufficient by itself, delivering a combination package of these interventions is important for ending the HIV epidemic as a public health threat.

What do we know about children living with HIV-infected or AIDS-ill adults in Sub-Saharan Africa? A systematic review of the literature

Millions of children in Sub-Saharan Africa live with adults, often parents, who are HIV-infected or ill due to AIDS. These children experience social, emotional, and health vulnerabilities that overlap with, but are not necessarily the same as, those of orphans or other vulnerable children. Despite their distinctive vulnerabilities, research aimed at understanding the situation of these children has been limited until very recently. This review summarizes the state of knowledge based on a systematic search of PubMed and Web of Science that identified 47 empirical research articles that examined either the population prevalence of children living with HIV-infected or AIDS-sick adults, or the consequences of adult HIV infection or AIDS illness for child well-being. This review confirms that this population of children is substantial in size, and that the vulnerabilities they experience are multi-faceted, spanning physical and emotional health and schooling. Mechanisms were examined empirically in only a small number of studies, but encompass poverty, transmission of opportunistic infections, care for unwell adults, adult distress, AIDS stigma, lack of social support, maternal breastfeeding issues, and vertical HIV transmission. Some evidence is provided that infants, adolescents, children with infected or ill mothers, and children living with severely ill adults are particularly vulnerable. Future research would benefit from more attention to causal inference and further characterization of processes and circumstances related to vulnerability and resilience. It would also benefit from further study of variation in observed associations between adult HIV/AIDS and child well-being based on characteristics such as age, sex, kinship, severity of illness, TB co-infection, disclosure, and serostatus awareness. Almost one-quarter of the studies reviewed did not investigate variation based on any of these factors. More nuanced understanding of the short- and long-term effects of adult HIV on children's needs and circumstances will be important to ongoing discussions about equity in policies and interventions.

Working Memory Profiles in HIV-Exposed, Uninfected and HIV-Infected Children: A Comparison with Neurotypical Controls

This study compared the working memory profiles of three groups of children, namely HIV-infected (HIV-I; n = 95), HIV-exposed, uninfected (HIV-EU; n = 86) and an HIV-unexposed, uninfected, (HIV-UU; n = 92) neurotypical control group. Working memory, an executive function, plays an important role in frontal lobe-controlled behaviors, such as motivation, planning, decision making, and social interaction, and is a strong predictor of academic success in school children. Memory impairments have been identified in HIV-I children, particularly in visuospatial processing. Verbal working memory has not been commonly investigated in this population, while it is unknown how the working memory profiles of HIV-EU children compare to their HIV-I and HIV-UU peers. Of interest was whether the working memory profiles of the HIV-EU children would be more similar to the HIV-I group or to the uninfected control group. The results revealed no significant differences in working memory performance between the HIV-I and HIV-EU groups. However, this does not mean that the etiology of the working memory deficits is the same in the two groups, as these groups showed important differences when compared to the control group. In comparison to the controls, the HIV-I group experienced difficulties with processing tasks irrespective of whether they drew on a verbal or visuospatial modality. This appears to stem from a generalized executive function deficit that also interferes with working memory. In the HIV-EU group, difficulties occurred with verbally based tasks, irrespective of whether they required storage or processing. For this group, the dual demands of complex processing and using a second language seem to result in demand exceeding capacity on verbal tasks. Both groups experienced the greatest difficulties with verbal processing tasks for these different reasons. Thus, disruption of different cognitive abilities could result in similar working memory profiles, as evidenced in this study. This has implications for the underlying developmental neurobiology of HIV-I and HIV-EU children, as well the choice of appropriate measures to assist affected children.

Children Living with HIV-Infected Adults: Estimates for 23 Countries in sub-Saharan Africa

Background

In sub-Saharan Africa many children live in extreme poverty and experience a burden of illness and disease that is disproportionately high. The emergence of HIV and AIDS has only exacerbated long-standing challenges to improving children’s health in the region, with recent cohorts experiencing pediatric AIDS and high levels of orphan status, situations which are monitored globally and receive much policy and research attention. Children’s health, however, can be affected also by living with HIV-infected adults, through associated exposure to infectious diseases and the diversion of household resources away from them. While long recognized, far less research has focused on characterizing this distinct and vulnerable population of HIV-affected children.

Methods

Using Demographic and Health Survey data from 23 countries collected between 2003 and 2011, we estimate the percentage of children living in a household with at least one HIV-infected adult. We assess overlaps with orphan status and investigate the relationship between children and the adults who are infected in their households.

Results

The population of children living in a household with at least one HIV-infected adult is substantial where HIV prevalence is high; in Southern Africa, the percentage exceeded 10% in all countries and reached as high as 36%. This population is largely distinct from the orphan population. Among children living in households with tested, HIV-infected adults, most live with parents, often mothers, who are infected; nonetheless, in most countries over 20% live in households with at least one infected adult who is not a parent.

Conclusion

Until new infections contract significantly, improvements in HIV/AIDS treatment suggest that the population of children living with HIV-infected adults will remain substantial. It is vital to on-going efforts to reduce childhood morbidity and mortality to consider whether current care and outreach sufficiently address the distinct vulnerabilities of these children.

A qualitative exploration of the impact of HIV and ART on social disruption and household continuity in Uganda

With increased uptake of antiretroviral therapy (ART) throughout sub-Saharan Africa, it is critical to have a better understanding of the impact of ART on all health dimensions since the treatment can have the expected benefits as well as unintended negative consequences. We conducted semi-structured interviews with 24 adult HIV clients (19 women and 5 men) in Uganda who had been on ART for at least six months. A grounded approach and content analysis were used to explore the effects of having HIV and undergoing ART on household continuity, social engagement, experience of support and stigma, and children's school attendance. Most of the participants reported loss of a spouse/partner and household discontinuity (e.g. having to move in with extended family) because of HIV, and this was largely unchanged after being on ART. While experiences of HIV stigma and social disengagement were common after an HIV diagnosis, most participants reported improved social interaction after having commenced ART, which for some was tied to economic productivity. Many of the participants' children who had stopped going to school were able to return after the parent was on ART. HIV care and ART, with related improvements in clients' physical and work-related functioning, together with family support, helped to reverse some of the deleterious effects of having HIV. Nonetheless, support that augments healthcare is needed to help individuals provide for themselves and their families, both socially and economically.

Intergenerational transfers in the era of HIV/AIDS: Evidence from rural Malawi

BACKGROUND

Intergenerational transfer patterns in sub-Saharan Africa are poorly understood, despite the alleged importance of support networks to ameliorate the complex implications of the HIV/AIDS epidemic for families.

OBJECTIVE

There is a considerable need for research on intergenerational support networks and transfers to better understand the mechanisms through which extended families cope with the HIV/AIDS epidemic and potentially alleviate some of its consequences in sub-Saharan Africa, and to comprehend how transfers respond-or not-to perceptions about own and other family members' health.

METHODS

Using the 2008 round of the Malawi Longitudinal Study of Families and Health (MLSFH), we estimate the age patterns and the multiple directions of financial and non-financial transfer flows in rural Malawi-from prime-aged respondents to their elderly parents and adult children age 15 and up. We also estimate the social, demographic and economic correlates of financial and non-financial transfers of financial intergenerational transfers in this context.

RESULTS AND CONCLUSIONS

Our findings are that: (1) intergenerational financial and non-financial transfers are widespread and a key characteristic of family relationships in rural Malawi; (2) downward and upward transfers are importantly constrained and determined by the availability of transfer partners (parents or adult children); (3) financial net transfers are strongly age-patterned and the middle generations are net-providers of transfers; (4) non-financial transfers are based on mutual assistance rather than reallocation of resources; and (5) intergenerational transfers are generally not related to health status, including HIV positive status.

Inequality in early childhood: risk and protective factors for early child development

Inequality between and within populations has origins in adverse early experiences. Developmental neuroscience shows how early biological and psychosocial experiences affect brain development. We previously identified inadequate cognitive stimulation, stunting, iodine deficiency, and iron-deficiency anaemia as key risks that prevent millions of young children from attaining their developmental potential. Recent research emphasises the importance of these risks, strengthens the evidence for other risk factors including intrauterine growth restriction, malaria, lead exposure, HIV infection, maternal depression, institutionalisation, and exposure to societal violence, and identifies protective factors such as breastfeeding and maternal education. Evidence on risks resulting from prenatal maternal nutrition, maternal stress, and families affected with HIV is emerging. Interventions are urgently needed to reduce children's risk exposure and to promote development in affected children. Our goal is to provide information to help the setting of priorities for early child development programmes and policies to benefit the world's poorest children and reduce persistent inequalities.

HIV infection and sexual risk behaviour among youth who have experienced orphanhood: systematic review and meta-analysis

BACKGROUND

Previous research has suggested that orphaned children and adolescents might have elevated risk for HIV infection. We examined the state of evidence regarding the association between orphan status and HIV risk in studies of youth aged 24 years and younger.

METHODS

Using systematic review methodology, we identified 10 studies reporting data from 12 countries comparing orphaned and non-orphaned youth on HIV-related risk indicators, including HIV serostatus, other sexually transmitted infections, pregnancy and sexual behaviours. We meta-analyzed data from six studies reporting prevalence data on the association between orphan status and HIV serostatus, and we qualitatively summarized data from all studies on behavioural risk factors for HIV among orphaned youth.

RESULTS

Meta-analysis of HIV testing data from 19,140 participants indicated significantly greater HIV seroprevalence among orphaned (10.8%) compared with non-orphaned youth (5.9%) (odds ratio = 1.97; 95% confidence interval = 1.41-2.75). Trends across studies showed evidence for greater sexual risk behaviour in orphaned youth.

CONCLUSIONS

Studies on HIV risk in orphaned populations, which mostly include samples from sub-Saharan Africa, show nearly two-fold greater odds of HIV infection among orphaned youth and higher levels of sexual risk behaviour than among their non-orphaned peers. Interventions to reduce risk for HIV transmission in orphaned youth are needed to address the sequelae of parental illness and death that might contribute to sexual risk and HIV infection.

Increased risk of HIV-infection among school-attending orphans in rural Zimbabwe

In Zimbabwe around 1.1 million children have been orphaned due to AIDS. We conducted a survey among school-attending youth in rural south-eastern Zimbabwe in 2003, and examined the association between orphaning and risk of HIV. We enrolled 30 communities in three provinces. All students attending Year 2 of secondary school were eligible. Each completed a questionnaire and provided a finger-prick blood specimen for testing for HIV-1 and HSV-2 antibodies. Female participants were tested for pregnancy. Six thousand seven hundred and ninety-one participants were recruited (87% of eligible); 35% had lost one or both parents (20% of participants had lost their father; 6% their mother; and 9% both parents). Orphans were not poorer than non-orphans based on reported access to income, household structure and ownership of assets. There was strong evidence that orphans, and particularly those who had lost both parents, were at increased sexual risk, being more likely to have experienced early sexual debut; to have been forced to have sex; and less likely to have used condoms. Fifty-one students were HIV positive (0.75%). Orphans were three times more likely to be HIV infected than non-orphans (adjusted odds ratio = 3.4; 95% confidence interval: 1.8-6.6). Over 60% of those HIV positive were orphaned. Among school-going youth, the rates of orphaning were very high; there was a strong association between orphaning and increased risk of HIV, and evidence of greater sexual risk taking among orphans. It is essential that we understand the mechanisms by which orphaned children are at increased risk of HIV in order to target prevention and support appropriately.

Sibling caregiving among children orphaned by AIDS: synthesis of recent studies for policy implications

OBJECTIVE

The HIV/AIDS epidemic has increased the number of orphans who have to care for their younger siblings. However, their caregiving practices are poorly reported. This review aimed to explore and accumulate available evidences on sibling caregiving among children orphaned by AIDS.

METHODS

We conducted a systematic review of sibling caregiving among AIDS orphans in developing countries and identified 25 relevant articles. We analysed the compiled literature and extracted information on the prevalence of sibling caregiving, the framework of sibling caregiving, factors influencing caregiving, and the impact of sibling caregiving on caregivers and those cared for.

RESULTS

Sibling caregiving, which includes economic, physical, psychological, and educational care, was influenced by children's, familial, community, and policy factors. Unlike sibling caregiving that occurs under adequate adult supervision, sibling caregiving among AIDS orphans negatively impacts both the sibling caregivers and the cared for. However, the lack of studies about such sibling caregiving had prevented measurement of the level of burden and impact of sibling caregiving on orphans.

CONCLUSIONS

Policy makers need to be aware that older children caring for younger siblings risk physical and psychological ill health and information must be collected so that measures can be developed to mitigate this burden on orphans.

The orphaning experience: descriptions from Ugandan youth who have lost parents to HIV/AIDS

The HIV/AIDS epidemic has continued to pose significant challenges to countries in Sub-Saharan Africa. Millions of African children and youth have lost parents to HIV/AIDS leaving a generation of orphans to be cared for within extended family systems and communities. The experiences of youth who have lost parents to the HIV/AIDS epidemic provide an important ingress into this complex, evolving, multi-dimensional phenomenon. A fundamental qualitative descriptive study was conducted to develop a culturally relevant and comprehensive description of the experiences of orphanhood from the perspectives of Ugandan youth. A purposeful sample of 13 youth who had lost one or both parents to HIV/AIDS and who were affiliated with a non-governmental organization providing support to orphans were interviewed. Youth orphaned by HIV/AIDS described the experience of orphanhood beginning with parental illness, not death. Several losses were associated with the death of a parent including lost social capitol, educational opportunities and monetary assets. Unique findings revealed that youth experienced culturally specific stigma and conflict which was distinctly related to their HIV/AIDS orphan status. Exploitation within extended cultural family systems was also reported. Results from this study suggest that there is a pressing need to identify and provide culturally appropriate services for these Ugandan youth prior to and after the loss of a parent(s).

Contrasting causal pathways contribute to poorer health and nutrition outcomes in orphans in Zimbabwe

Orphaned children have been found to be at greater risk of poor health and malnutrition compared to non-orphans in sub-Saharan African countries. However, levels of disadvantage vary by location and little is known about the causal pathways that lead from orphanhood to poorer health and malnutrition. Aggregate data from recent Demographic and Health Surveys in 22 countries were used to compare overall levels of ill-health and malnutrition by orphan status. Data from the Manicaland Child Cohort Study in Zimbabwe - a closed cohort study with detailed longitudinal information on orphan's experience - were used to describe how patterns of ill-health and malnutrition alter over the child's life-course and to test causal pathways between orphanhood and ill-health and malnutrition, hypothesized in a previously published theoretical frame-work. Modest increases in ill-health and malnutrition were found in orphans in the Demographic and Health Surveys data, with maternal and double orphans being worst affected. Non-significant associations were found between orphanhood and ill-health in the Manicaland Child Cohort Study data, but no associations with malnutrition were found. None the less, smaller increases in body mass index with age were seen among orphans (ologit test for difference: adjusted odds ratio = 0.68; p = 0.07) and maternal orphans (ologit test for difference: adjusted odds ratio = 0.67; p = 0.03) than among non-orphans. Stigma and discrimination contributed to poor diet, malnutrition and ill-health in children whose mothers had died, while heightened poverty was a more important factor for paternal orphans. These results suggest social and psychological support for orphans and their families could be as important as material support in preventing malnutrition and ill-health.

The long-term social and economic impact of HIV on the spouses of infected individuals in northern Malawi

OBJECTIVE

To assess the social and economic impact of HIV-related illness and death on the spouses of HIV-infected individuals.

METHODS

From population-based surveys in the 1980s in Karonga district, northern Malawi, 197 'index individuals' were identified as HIV-positive. A total of 396 HIV-negative 'index individuals' were selected as a comparison group. These individuals, and their spouses and children, were followed up in 1998-2000, in a retrospective cohort study. All analyses compared spouses of HIV-positive indexes with those of HIV-negative indexes.

RESULTS

By 1998-2000, most marriages involving an HIV-positive index individual had ended in widowhood. Twenty-Six percent of the wives of HIV-positive index men experienced household dissolution precipitated by widowhood, compared with 5% of the wives of HIV-negative index men. Corresponding percentages for husbands of index women were 14% and 1%. Widow inheritance was uncommon. The remarriage rate among separated or widowed wives of HIV-positive index men was half that of such wives of HIV-negative index men. About 30% of surviving wives of HIV-positive index men were household heads at the time of follow-up, compared with 5% of such wives of HIV-negative index men. Almost all these women were widows who lost their husband when >35 years old, and they had relatively few household assets.

CONCLUSIONS

The social and economic impact of HIV on the spouses of HIV-infected individuals in rural northern Malawi is substantial. Interventions that strengthen society's ability to absorb and support widows and widowers, and their dependents, without necessarily involving the traditional coping mechanism of remarriage, are essential.