Strategies for providing care and support to children orphaned by AIDS

Feasibility of Developing Audiovisual Material for Training Needs in a Vietnam Orphanage: A Mixed-Method Design

Disabled children living in orphanages in low-income countries may not have access to the therapy they need. The COVID-19 pandemic has complicated the situation dramatically, making online training activities a possible innovative option to meet the real needs of local staff. This study aimed to detect the training needs of the local staff of an orphanage in Vietnam, as well as develop an audiovisual training material and measure its feasibility. Training needs were identified through a focus group carried out by the volunteers of Fisios Mundi, a nongovernmental organization. The audiovisual training material was developed to meet these specific needs. Lastly, its feasibility was evaluated, in terms of both content and format, through an ad hoc questionnaire. Nine volunteers participated in the project. Twenty-four videos were created and structured around five themes. This study expands the body of knowledge on how an international cooperation project can be developed in a pandemic situation. The audiovisual training material content and format created in this project was considered by the volunteers as very feasible and useful for training the staff of a Vietnamese orphanage.

A physical symptom-based measure of quality of care for children affected by HIV/AIDS

Based on cross-sectional data of 1,625 children aged 6-18 years who were affected by parental HIV/AIDS in central rural China, we evaluated a physical symptom based measure of quality of care (QOC_PS) for these children. The QOC_PS has acceptable reliability estimates for children of both genders, at different age, and by orphanhood status. Known-group validation and construct validity analysis demonstrated a good validity of QOC_PS indicator. The QOC_PS score was significantly associated with psychosocial well-being measures among children. The physical symptom based measure provides a psychometrically appropriate indicator of quality of care for children affected by HIV/AIDS in China. It could be used as an alternative measure to assess quality of care in resource-poor settings where other objective measurements are not available or feasible. Future research is needed to further validate the scale among children in different living environments across various cultural settings.

Reconsidering the orphan problem: the emergence of male caregivers in Lesotho

Care for AIDS orphans in southern Africa is frequently characterized as a "crisis", where kin-based networks of care are thought to be on the edge of collapse. Yet these care networks, though strained by AIDS, are still the primary mechanisms for orphan care, in large part because of the essential role grandmothers play in responding to the needs of orphans. Ongoing demographic shifts as a result of HIV/AIDS and an increasingly feminized labor market continue to disrupt and alter networks of care for orphans and vulnerable children. This paper examines the emergence of a small but growing number of male caregivers who are responding to the needs of the extended family. While these men are still few in number, the strength of gendered ideologies of female care means that this group of men is socially, if not statistically significant. Men continue to be considered caregivers of last resort, but their care will close a small but growing gap that threatens to undermine kin-based networks of care in Lesotho and across the region. The adaptation of gender roles reinforces the strength and resilience of kinship networks even when working against deeply entrenched ideas about gendered division of domestic labor.

Health Outcomes of International HIV-infected Adoptees in the US

BACKGROUND

International adoption of HIV-infected children is becoming increasingly common. Their health has not yet been described.

METHODS

HIV-infected international adoptees or refugees in foster care aged 0-20 years followed at Seattle Children's Hospital or Children's Hospital Colorado between January 1, 2004 and May 31, 2013 were included. Parameters were collected through retrospective chart review of baseline (first 6 months at study site) and annual follow-up visits.

RESULTS

Africa (90%) was the primary region of origin for the 79 children who met inclusion criteria. Median follow-up was 3 years (range: 0-7). At baseline, acute malnutrition was uncommon (8%); however, stunting occurred in 32%. Most stunting resolved during the study period. The most common medical issues at baseline were dermatologic (Tinea and Molluscum contagiosum) and gastrointestinal (parasites and diarrhea). Almost half (48%) had either mental health issues or behavioral problems. Educational delays (50%) were also common. Upon adoption, only 1% was severely (CD4% < 15%) immunosuppressed. Fifty-nine (75%) were on antiretroviral therapy (ART); 45 of these (76%) had suppressed viral load (VL). Of 14 children on ART with detectable VL, 11 (79%) demonstrated non-nucleoside reverse transcriptase inhibitor resistance and 1 (7%) protease inhibitor resistance.

CONCLUSIONS

In this cohort of HIV-infected international adoptees, severe immunosuppression was uncommon. Most medical issues were mild. Stunting was common at baseline but largely resolved. Mental health issues, behavioral problems, and educational delays were common. Most children were on ART at adoption and most of these showed suppressed VL. Non-nucleoside reverse transcriptase inhibitor mutations were present in most viremic children.

Models of care for orphaned and separated children and upholding children's rights: cross-sectional evidence from western Kenya

BACKGROUND

Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children's basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya.

METHODS

The Orphaned and Separated Children's Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher's exact test was also used if some cells had expected value of less than 5.

RESULTS

Included in this analysis are data from 300 households, 19 Charitable Children's Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI's and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as 'Pure CCI' for those only providing residential care, 'CCI-Plus' for those providing both residential care and community-based supports to orphaned children , and 'CCI-Shelter' which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living.

CONCLUSIONS

Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children.

Sexual partnerships and considerations for HIV antiretroviral pre-exposure prophylaxis utilization among high-risk substance using men who have sex with men

Men who have sex with men (MSM) remain at great risk of HIV in the United States, representing 65 % of incident HIV infections. One factor contributing to the high rate of HIV infection among MSM is use of "recreational" drugs that are highly associated with unprotected anal sex. Pre-exposure chemoprophylaxis (PrEP) is a novel biomedical HIV prevention strategy that has the potential to reduce HIV transmission in MSM. Main and casual sex partners play a role in HIV prevention efforts for MSM. The study aimed to qualitatively explore the perceived influences of sexual relationships on promoting and inhibiting PrEP use among high-risk MSM who report regular drug use. Semi-structured qualitative interviews were conducted with 40 participants recruited in Boston, Massachusetts. Data were analyzed using descriptive qualitative analysis. Casual partners presented a distinct set of concerns from primary partnerships. MSM generally viewed main partners as a potential source of support for taking PrEP. Given their informal and often temporary nature, PrEP disclosure to casual partners was considered unnecessary. HIV-related stigma and substance use were also perceived as barriers to discussing PrEP use with casual partners. MSM articulated a high degree of personal agency regarding their ability to take PrEP. Findings suggest that behavioral interventions to improve PrEP utilization and adherence for high-risk MSM should be tailored to sex partner type and the parameters established between sex partners. Approaches to PrEP disclosure and partner engagement should be informed by the relative benefits and limitations characterized by these different types of relationships.

Migration, Household Configurations, and the Well-Being of Adolescent Orphans in Rwanda

This study uses data from the 2002 Rwandan census to situate the discourse on migration and orphan well-being within the context of the household. According to its findings, migrant orphans are less likely than non-migrant orphans to live in households with less favorable structural characteristics such as single-parent households. Significant differences are also found in the implied gains to living standards and schooling associated with migration among paternal, maternal, and double-orphans. However, the higher living standards and schooling attainment of orphan migrants relative to their non-migrant counterparts disappear within child-headed household contexts. More generally, the results indicate that the higher living standards of migrant orphans are in part driven by the fact that they mostly live in households with migrant household-heads or migrant spouses. Yet the analysis also suggests that orphans living within these contexts experience higher levels of intra-household discrimination in investments in their schooling, relative to their orphan counterparts who live in non-migrant households.

Extended families and perceived caregiver support to AIDS orphans in Rakai district of Uganda

PURPOSE: To understand the role of extended family in responding to problems of AID-orphaned children and adolescents in Uganda, the study examines who are the primary caregivers of AIDS-orphaned children and adolescents, what are the types of caregiving provided to orphans and whether the quality of caregiving varies by the primary caregiver's gender and type. METHODS: The study uses bivariate analyses and mixed effects models utilizing baseline data from a cluster randomized experimental design including 283 orphaned adolescents in Uganda. RESULTS: The analysis revealed a generally dominating role of female caregivers for both single and double orphans. In the absence of biological parents - as in the case of double orphans - grandparents' role as caregivers prevail. On average, the study participants indicated receiving the high level of perceived caregiver support: the average score of 3.56 out of 4 (95% CI=3.5, 3.65). Results of mixed effect models (adjusting for school effects) revealed significant differences in perceived caregiver support by caregiver's gender. Compared to their male counterparts, female participants with whom the child/adolescent lives (B=0.22, 95% CI=0.11, 0.34) and women who are currently taking care of a child/adolescent (B=0.15, 95% CI=0.05, 0.26) provide greater caregiver support as perceived and reported by a child/adolescent. Similarly, female financiers - compared to male source of financial support - provide greater caregiver support as perceived and reported by a child/adolescent (B=0.16, 95% CI=0.04, 0.3). CONCLUSIONS: Our findings demonstrate that extended families are still holding up as an important source of care and support for AIDS orphaned children and adolescents in Uganda. The findings support the argument about importance of matrilineal and grandparental care for AIDS orphans.

The impact of the HIV/AIDS epidemic on kinship resources for orphans in Zimbabwe

The extended family has been recognized as a major safety net for orphans in sub-Saharan Africa. However, the mortality crisis associated with HIV/AIDS may drastically reduce the availability of relatives and thus undermine traditional forms of mutual support. In this article, the microsimulator SOCSIM is used to estimate and project quantities such as the number of living uncles, aunts, siblings, and grandparents available to orphans. The model is calibrated to the setting of Zimbabwe, using data from demographic and Health Surveys and estimates and projections of demographic rates from the United Nations. The article shows that there is a lag of more than ten years between the peak in orphanhood prevalence and the peak in scarcity of grandparents for orphans. The results indicate that a generalized HIV/AIDS epidemic has a prolonged impact on children and orphans that extends well beyond the peak in mortality. A rapid increase in the number of orphans is followed by a steady reduction in the number of living grandparents for orphans. Consequently, the burden of double orphans (both of whose parents have died) is likely to shift to uncles and aunts. In Zimbabwe, the number of living uncles and aunts per double orphan decreased between 1980 and 2010, but it is expected to increase progressively during the next few decades. Changes in kinship structure have important social consequences that should be taken into account when seeking to address the lack of care for orphans.

Power and empowerment: fostering effective collaboration in meeting the needs of orphans and vulnerable children

In sub-Saharan Africa, HIV/AIDS has resulted in a rapidly growing population of orphans and vulnerable children (OVC). These OVC have strained the traditional safety net provided by extended families to its breaking point. Increasingly, community-based initiatives are emerging to fill the gap. However, relatively little is known about these efforts and their effectiveness. This article looks at one such initiative in rural Tanzania, and explores the relationship between local communities that seek to empower themselves to address the needs of their OVC and external organisations that have the resources and power to help them. This case study describes the successful effort of a community to build a Centre housing its orphans, and the subsequent closure of that Centre despite its evident success, because of a conflict between internal and external interests. This case study is used as the basis of a broader discussion on how those with power, and communities seeking empowerment, are complexly intertwined.

Children affected by HIV/AIDS: SAFE, a model for promoting their security, health, and development

A human security framework posits that individuals are the focus of strategies that protect the safety and integrity of people by proactively promoting children's well being, placing particular emphasis on prevention efforts and health promotion. This article applies this framework to a rights-based approach in order to examine the health and human rights of children affected by HIV/AIDS. The SAFE model describes sources of insecurity faced by children across four fundamental dimensions of child well-being and the survival strategies that children and families may employ in response. The SAFE model includes: Safety/protection; Access to health care and basic physiological needs; Family/connection to others; and Education/livelihoods. We argue that it is critical to examine the situation of children through an integrated lens that effectively looks at human security and children's rights through a holistic approach to treatment and care rather than artificially limiting our scope of work to survival-oriented interventions for children affected by HIV/AIDS. Interventions targeted narrowly at children, in isolation of their social and communal environment as outlined in the SAFE model, may in fact undermine protective resources in operation in families and communities and present additional threats to children's basic security. An integrated approach to the basic security and care of children has implications for the prospects of millions of children directly infected or indirectly affected by HIV/AIDS around the world. The survival strategies that young people and their families engage in must be recognized as a roadmap for improving their protection and promoting healthy development. Although applied to children affected by HIV/AIDS in the present analysis, the SAFE model has implications for guiding the care and protection of children and families facing adversity due to an array of circumstances from armed conflict and displacement to situations of extreme poverty.

Care arrangements of AIDS orphans and their relationship with children's psychosocial well-being in rural China

There is an estimated 100,000 children orphaned by AIDS in China, but data on the care arrangement of these orphans are limited. In this study, we examine the relationship between AIDS orphans' care arrangement and their psychosocial well-being among a sample of AIDS orphans in rural China. A total of 296 children who lost both parents to AIDS participated in the study, including 176 in orphanages, 90 in kinship care and 30 in community-based group homes. All participants completed a cross-sectional survey assessing their traumatic symptoms, physical health and schooling. Data reveal that the AIDS orphans in group homes reported the best outcomes in three domains of psychosocial well-being, followed by those in the orphanages and then the kinship care. The differences in psychosocial well-being among the three groups of children persist after controlling for key demographic characteristics. The findings suggest that the appropriate care arrangement for AIDS orphans should be evaluated within the specific social and cultural context where the orphans live. In resource-poor regions or areas stricken hardest by the AIDS epidemic, kinship care may not sufficiently serve the needs of AIDS orphans. Community-based care models, with appropriate government and community support preserving the family style and low child-to-caregiver ratio may constitute an effective and sustainable care model for the best interest of the AIDS orphans in developing countries.

Diversity and mobility in households with children orphaned by AIDS in Couffo, Benin

This paper characterises children orphaned by AIDS in the Couffo region of Benin. A 2006 census conducted for the research revealed a total of 315 such orphans, aged 0 to 14 years, within 88 households. Seventy-one percent of these children were under the care of their mothers or grandmothers, 68% were fatherless, 58% were between the ages of 7 and 12, and 68% were in primary school. An in-depth study of the orphans' lives, undertaken to complement the census, revealed that these orphans were highly mobile between households, with almost 50% of them moving homes within a six-month period. An analysis of this phenomenon found that orphan mobility was a deliberate household strategy to manage orphanhood. Tensions arising out of care arrangements and resource allocation were among the main reasons for the high degree of orphan mobility. The context of orphan mobility also highlighted the practical role the orphans were able to fulfil within the affected households. The findings show that orphan mobility is a social phenomenon with two functions: on one hand, it may help HIV/AIDS-affected households to manage the increase in the number of orphans; on the other, it can provide an opportunity for orphans to move to a 'safer' environment anytime they do not feel secure. The implications for institutions providing care to orphans were also identified. Among other things, we recommend that a distinction be made between the main caregiver and the 'endorser' of an orphan as this was found to be an important difference. We also recommended that a distinction be made between orphans under and over the age of 10. For instance, children in the age group 10-14 years should be defined as 'pre-adults,' as their position within the household and their needs for services are different from those of orphans under age 10.

Life improvement, life satisfaction, and care arrangement among AIDS orphans in rural Henan, China

The Chinese government's response to the increasing number of children orphaned in the HIV epidemic included setting up AIDS orphanages and supporting community-based group homes for double orphans (children who lost both parents to HIV). The impact of these strategies, compared to traditional kinship care, on children's outcomes has not been studied in China. The purpose of this study was to compare perceived life improvement and life satisfaction among double orphans in three main care arrangements (group home, AIDS orphanage, kinship care) in two rural Chinese counties. Participants included 176 children from four orphanages, 30 from eight group homes, and 90 from kinship households. Results indicated that children living in government-supported group homes were more likely to report greater life improvement and positive attitudes toward their current lives than children in orphanages and kinship care. Results suggested that perceived life improvements may have resulted from access to basic needs in extremely poor communities.

Asset ownership and health and mental health functioning among AIDS-orphaned adolescents: findings from a randomized clinical trial in rural Uganda

This study evaluated an economic empowerment intervention designed to promote life options, health and mental health functioning among AIDS-orphaned adolescents in rural Uganda. The study used an experimental design in which adolescents (N=267) were randomly assigned to receive an economic empowerment intervention or usual care for orphaned children. The study measured mental health functioning using 20 items of the Tennessee Self-Concept Scale (TSCS: 2)--a standardized measure for self-esteem-and measured overall health using a self-rated health measure. Data obtained at 10-month follow-up revealed significant positive effects of the economic empowerment intervention on adolescents' self-rated health and mental health functioning. Additionally, health and mental health functioning were found to be positively associated with each other. The findings have implications for public policy and health programming for AIDS-orphaned adolescents.

Interventions for improving the psychosocial well-being of children affected by HIV and AIDS

BACKGROUND

As a result of HIV-related mortalities more than 13 million children under the age of 15 have lost a parent due to HIV and AIDS. There are also many children who have HIV-positive parents or primary caregivers; these children are affected by HIV and AIDS and are potentially vulnerable to HIV transmission. Children affected by HIV and AIDS are more vulnerable and face greater challenges to their psychosocial well-being compared to other children of the same age. Interventions have been adopted with the aim of improving the psychosocial well-being of children affected by HIV and AIDS.

OBJECTIVES

The primary objective of this review was to assess the effectiveness of interventions that aim to improve the psychosocial well-being of children directly affected by HIV and AIDS.

SEARCH STRATEGY

Electronic databases were systematically searched using pre-defined search terms. Internet searches of relevant organizations involved in HIV and AIDS work were conducted and experts in the field and were contacted directly. Searches were conducted between January and September 2008.

SELECTION CRITERIA

Randomised controlled trials, crossover trials, cluster-randomised trials and factorial trials were eligible for inclusion. If no controlled trials were found, data from well-designed non-randomised intervention studies (such as before and after studies), cohort, and case-control observational studies were considered for inclusion. Studies which included male and female children under the age of 18 years of age, either orphaned due to AIDS (one or more parents died of HIV related-illness or AIDS), or vulnerable children (one or more parents living with HIV or AIDS) were eligible for review.Interventions that aim to improve the psychosocial well-being of children affected by HIV and AIDS were included in the review. This included psychological therapy, psychosocial support and/or care, medical interventions and social interventions. Psychosocial outcomes were defined as any intervention that measures psychological and/or social factors.

DATA COLLECTION AND ANALYSIS

Two of the authors independently screened the results of the search. The full text of all potentially relevant studies were obtained and were independently assessed by the two reviewers using pre-determined criteria.

MAIN RESULTS

No studies of interventions for improving the psychosocial well-being of children affected by HIV and AIDS were identified.

AUTHORS' CONCLUSIONS

Current practice is based on anecdotal knowledge, descriptive studies and situational analyses. Such studies do not provide a strong evidence base for the effectiveness of these interventions.

IMPLICATIONS FOR RESEARCH

This systematic review has identified the need for high quality intervention studies. In order to increase the quality and quantity of such studies there is a need for greater partnerships between program implementers and researchers.

IMPLICATIONS FOR PRACTICE

In the absence of rigorous intervention studies, the body of knowledge available consists of "lessons learned," child psychological theory and other related research in the adult population. However, such knowledge should not replace the urgent need for rigorous monitoring and evaluation of existing programs and intervention studies to ensure evidence-based practice and policy, and prevent subjecting children to interventions which show no benefit or interventions that could unintentionally lead to harm.

Peer-group support intervention improves the psychosocial well-being of AIDS orphans: cluster randomized trial

Accumulating evidence suggests that AIDS orphanhood status is accompanied by increased levels of psychological distress such as anxiety, depression, intense guilt, shame, and anger. However, few studies have examined the possible reduction of psychological distress in AIDS orphans through the help of interventions that promote well-being. The objective of the study was to evaluate the effects of a school-based peer-group support intervention combined with periodic somatic health assessments and treatment on the psychosocial well-being of AIDS orphans in the Mbarara District of southwestern Uganda. In a cluster randomized controlled design, 326 AIDS orphans aged 10-15 years were assigned to either peer-group support intervention combined with monthly somatic healthcare (n=159) or control group (n=167) for follow-up assessment. Baseline and 10 week follow-up psychological assessments were conducted in both groups using self-administered Beck Youth Inventories. Complete data were available for 298 orphans. After adjusting for baseline scores, follow-up scores for the intervention group in comparison with controls showed significant improvement in depression, anger, and anxiety but not for self-concept. This study demonstrated that peer-group support intervention decreased psychological distress, particularly symptoms of depression, anxiety and anger. Thus, the use of peer-group support interventions should be incorporated into existing school health programs.

A systematic review on the meaning of the concept 'AIDS Orphan': confusion over definitions and implications for care

Global publications on the international AIDS epidemic report on the existence of an ever-increasing number of orphans and vulnerable children. It has been suggested that by the end of this decade there will be in excess of 25 million AIDS orphans globally, an issue which will require understanding and organisation of long-term medical, psychological and social support. This study provides a systematic review to examine the use, overuse and misuse of the term orphan and explores the benefits and limitations of this approach. It then summarises the knowledge on orphans to date. Using a search strategy of published studies and recent conference abstracts, 383 papers were identified where the concept of AIDS and Orphan was raised. The papers were systematically coded and reviewed to understand when and how a child is labelled an orphan, and to summarise the effect of orphanhood on outcome measures, most notably psychologically and physically. All controlled studies published prior to 2006 were reviewed. A consistent picture of negative effects of parental death (however defined) on a wide range of physical, socioeconomic and psychological outcomes were recorded. Seventeen studies met criteria for in-depth review (empirical, fully published, control group). The majority of studies are cross-sectional (two are longitudinal) and employ a very wide array of measures - both standardised and study specific. This detailed analysis shows a mixed picture on outcome. Although most studies report some negative effects, there are often no differences and some evidence of protective effects from quality of subsequent care and economic assistance. The lack of consistent measures and the blurring of definitions are stumbling blocks in this area.

Factors associated with religious congregation members' support to people living with HIV/AIDS in Kumasi, Ghana

Physical, social and economic constraints often limit the ability of people living with HIV/AIDS to meet their basic needs. Community members are a valuable source of support for people living with HIV/AIDS, although little is known about the types of support they provide or how to mobilize this support. To examine this issue, a survey of 1200 members of 6 religious congregations was conducted in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV/AIDS in the last 6 months, mostly through prayer, financial support, and counseling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV/AIDS, collective efficacy related to HIV/AIDS, and perceived risk of becoming infected with HIV. To enhance support to people with HIV/AIDS, programs should involve community leaders and encourage dialogue on ways to address the epidemic.

Barriers and incentives to orphan care in a time of AIDS and economic crisis: a cross-sectional survey of caregivers in rural Zimbabwe

Background

Africa is in an orphan-care crisis. In Zimbabwe, where one-fourth of adults are HIV-positive and one-fifth of children are orphans, AIDS and economic decline are straining society's ability to care for orphans within their extended families. Lack of stable care is putting thousands of children at heightened risk of malnourishment, emotional underdevelopment, illiteracy, poverty, sexual exploitation, and HIV infection, endangering the future health of the society they are expected to sustain.

Methods

To explore barriers and possible incentives to orphan care, a quantitative cross-sectional survey in rural eastern Zimbabwe asked 371 adults caring for children, including 212 caring for double orphans, about their well-being, needs, resources, and perceptions and experiences of orphan care.

Results

Survey responses indicate that: 1) foster caregivers are disproportionately female, older, poor, and without a spouse; 2) 98% of non-foster caregivers are willing to foster orphans, many from outside their kinship network; 3) poverty is the primary barrier to fostering; 4) financial, physical, and emotional stress levels are high among current and potential fosterers; 5) financial need may be greatest in single-orphan AIDS-impoverished households; and 6) struggling families lack external support.

Conclusion

Incentives for sustainable orphan care should focus on financial assistance, starting with free schooling, and development of community mechanisms to identify and support children in need, to evaluate and strengthen families' capacity to provide orphan care, and to initiate and support placement outside the family when necessary.

Challenges of a pandemic: HIV/AIDS-related problems affecting Kenyan widows

The paper reports the findings of a qualitative study using focus group discussions and in-depth interviews about the challenges faced by widows as they confront the direct and indirect impacts of HIV/AIDS in Nyanza, Kenya. Two focus groups were conducted with widows from two community-based organizations. This was followed by in-depth interviews with four members and two leaders from each of the community-based organizations. The contents were analysed using grounded theory. The findings reveal several challenges encountered by widows in their struggles with the direct and indirect impacts of HIV/AIDS. Widows who know or do not know their HIV status are conscious about the possibility of contracting or transmitting the virus. Wife inheritance (a Luo custom), emerged as an outstanding issue for the widows in the context of HIV/AIDS transmission. The widows employ various strategies to resist being inherited. Widows in the current epidemic navigate issues of sexuality in various ways, such as insisting their partners use condoms or permanently abstaining from sexual intercourse.

"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.

The social situation of motherless children in rural and urban areas of Guinea-Bissau

With the increasing prevalence of HIV infection and the high maternal mortality, orphans are a rapidly growing problem in Africa. However, few studies describe the social conditions of these children. Our study focuses on motherless children in urban and rural areas of Guinea-Bissau. A rural and an urban cohort of children (128 and 192, respectively) that had been followed by demographic surveillance since 1990 were identified and the relatives of these children interviewed. A control cohort of 808 individuals was also identified. Although orphan children remained disadvantaged, there were few differences between surviving motherless and control children in nutritional status, use of health care services, school attendance, quality of housing, and clothing. Motherless children moved more frequently and were more likely to live in small families, often with an older grandmother. The traditional extended family system appears to be capable of handling motherless children in a non-discriminatory fashion. However, the AIDS epidemic will continue to stress the extended family system and social services to the limit.

Fosterage patterns in the age of AIDS: continuity and change

An estimated 4 million children, or about 10% of the entire South African population, will be orphaned by the year 2015. There is growing consensus that the extended family system is no longer capable of providing for orphans given severe economic constraints. There is, therefore, an urgency to develop appropriate interventions to support families and take care of these children. This article examines some of the existing literature on child fosterage and uses it to highlight understudied aspects of the current situation of children orphaned through AIDS in South Africa. Of particular concern are the points of continuity and change in fosterage patterns before and after the onset of the epidemic in South Africa. I suggest that an understanding of the short- and long-term consequences for children orphaned by AIDS in South Africa calls for historical contextualisation given that child fostering, both voluntarily and involuntarily, has been a feature of black family life since well before the onset of HIV/AIDS. In addition, I demonstrate the value of examining kinship, family, and networks in order to fully understand the circumstances of fostering these children. The paper concludes with a call for more research on children orphaned by AIDS in South Africa that will provide not only more data, but also enrich theoretical approaches to studying patterns of child fosterage in Africa and elsewhere.

Children orphaned by AIDS: a global perspective

Internationally, the orphan crisis caused by the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pandemic remains a serious issue with long-term social consequences. At the end of 2001, an estimated 14 million children worldwide had lost their mother or both parents to AIDS or related causes. Sub-Saharan Africa is the most severely affected, accounting for more than 80 percent of those orphaned as a result of AIDS. Without the care of parents or an appointed caregiver, children are likely to face extraordinary risks of malnutrition, poor health, inadequate schooling, migration, homelessness, and abuse. Strengthening existing family and community capacity to assist orphans in Africa should be the first priority. Community support must be coupled with support for education for orphans. Combining local and international responses to deliver protection and services to all orphans and vulnerable children is critical. In addition, saving the lives of parents through access to antiretroviral therapies in resource-poor countries in conjunction with bold support for alleviation of poverty and education must be an integral part of the global response to the orphan crisis in sub-Saharan Africa.

AIDS policy modeling for the 21st century: an overview of key issues

Decisions about HIV prevention and treatment programs are based on factors such as program costs and health benefits, social and ethical issues, and political considerations. AIDS policy models--that is, models that evaluate the monetary and non-monetary consequences of decisions about HIV/AIDS interventions--can play a role in helping policy makers make better decisions. This paper provides an overview of the key issues related to developing useful AIDS policy models. We highlight issues of importance for researchers in the field of AIDS policy modeling as well as for policy makers. These include geographic area, setting, target groups, interventions, affordability and effectiveness of interventions, type and time horizon of policy model, and type of economic analysis. This paper is not intended to be an exhaustive review of the AIDS policy modeling literature, although many papers from the literature are discussed as examples; rather, we aim to convey the composition, achievements, and challenges of AIDS policy modeling.