Orphans and Vulnerable Children
Girls who have been orphaned by HIV/AIDS face an intersection of vulnerabilities: As children, they lack the legal rights (e.g., inheritance and property), maturity, and skills to care and provide for themselves. As girl children, they most often do not have equal access to household resources for schooling, nutrition, or health care. When a catastrophic event hits the family, girls are more often the ones who must leave school and take on a greater burden within the home. A study in Tanzania found a dramatic increase in labor force participation by adolescents ages 10–14 and a decrease in school attendance, especially for girls, which correlated with the increased HIV/AIDS prevalence and incidence between 1990 and 1991 (Wobst and Arndt, 2004). A study in Rwanda found that “90 percent of the estimated 45,000 child-headed households were headed by girls” (UNHCR, 2001 cited in Lawday, 2002). Many receive little social support because of the stigma associated with HIV/AIDS. OVC, and girls in particular, are more likely to have high rates of absenteeism from school, experience behavior or performance problems in school, or leave school altogether (Cornia, 2002; Steinberg et al., 2002). In households that experience the death of a woman, girls have lower enrollment rates and are more likely to assume activities typically done by women (Desmond et al., 2000). Further, a study based in Zambia with 228 OVC found female OVC had less decision-making power, lower self-confidence, negotiation and communication skills than males (Alvarez et al., 2008).
Girls Who Have Lost Their Mothers Are at Particularly High Risk
Parental death is recognized as one of the most stressful life events a child or adolescent can endure… (Hallman et al., 2008: 38). Interviews conducted in 2005 with orphans and vulnerable children, their parents and caregivers, students and teachers in communities heavily affected by HIV/AIDS in South Africa and Swaziland found that parental death is one of the major causes of disruption of children’s lives. Interviewees reported that illness and/or death of parents leads to increased poverty, child’s engagement in risky behavior and more vulnerability to HIV infections, and a higher likelihood of dropping out of school. The interviews reported that boys are more likely to get involved in multiple concurrent relationships and drug-taking while girls are more likely to get pregnant or engage in sex work or sexual relationships with older men in exchange for money and food. Girls are also at higher risk of rape and abuse by teachers in their school (Poulsen, 2006).
A study of 200 orphaned and non-orphaned girls ages 16 to 19 in Zimbabwe highlighted that maternal care and support is important for HIV prevention. Seven percent of girls in the study had lost only their mother while 20 percent had lost both parents. Female adolescent maternal orphans were found to have more than five times the odds of engaging in sexual activity with their current partner, more than fourteen times the odds of receiving basic needs from their current sexual partner, and nearly five times the odds of acquiring HIV as compared to study participants who had not lost their mothers. The study also found that maternal orphans were less likely to have been physically forced the first time they had sex. This could be because more maternal orphans were intentionally engaging in sexual activity for material benefits and may thus be less likely to have been forced to engage in sex for the first time (Kang et al., 2008).
Data from Rwanda and Zambia show that orphanhood, especially if it occurs closer to adolescence, results in earlier sexual initiation (Murray et al., 2004). Early sexual debut places girls at risk of HIV, other STIs, and unwanted pregnancies. Further, loss of a parent increases vulnerability to trafficking, child prostitution, and hazardous labor situations (Ayieko, 1998; Human Rights Watch, 2003), in addition to forced sex (Birdthistle et al., 2008). These vulnerabilities enhance orphans’ risk for acquiring HIV. A study in Zimbabwe found a greater number of female orphans ages 15 to 18 had higher incidence of HIV infections than their non-orphan peers (Gregson et al., 2005). “…The majority of orphans and children whose parents are HIV-positive or AIDS-unwell are in fact adolescents and have a great need for information and skills on sexual and reproductive health and development. These topics are frequently omitted from OVC programmes…” (Hallman et al., 2008: 36).
Many Families Caring for Orphans Are Struggling
Evidence compiled during the Joint Learning Initiative on Children suggests that policies, programs and funding should support family-centered services that address material needs, cognitive development and psychosocial support (Richter, 2008). A study in Botswana using data from a 2002 sample of 1,033 working adults found that 37% provided orphan care. Nearly half of working households with orphan care responsibilities reported experiencing financial difficulties, lacking resources to provide basic needs such as food, shelter or transport. Only 42 social workers were responsible for the care of more than 100,000 orphans (Miller et al., 2006; Heymann et al., 2007). A baseline study conducted in 2007 in Malawi with 785 AIDS-affected households indicated that cash transfers were needed for social protection of OVC. Forty percent of households had no working age adult even though 60% of households contained 2.6 children. Seventy-three percent of households went without enough to eat for eight or more days in the past month (Huijbregts et al., 2008). A case control study done in 2007 in Uganda with 369 HIV-positive children (49% female) between ages 7 months to 15 years found that children cared for by grandparents were less likely than those cared for by biological parents to have their immunizations up to date and more likely to have poor nutritional status (Kintu et al., 2008).
More Effective Programming and Policies for OVC Are Needed
Despite the recognition of the magnitude and negative consequences of this problem, the evidence on effective programming for children affected by HIV/AIDS remains scant (Thurman et al., 2007). As of 2008, only 32 countries had a national plan of action with benefits for orphans (UNICEF, 2008). Yet a substantial epidemic of HIV/AIDS in older survivors of mother-to-child transmission is emerging in Southern Africa…[with] a failure to…adequately address the clinical needs of HIV-infected older children and adolescents” (Ferrand et al., 2009: 2039). Few countries have adopted national strategic plans to address the needs of orphans and vulnerable children. While many NGOs, faith-based groups, and community-based organizations are working at the grassroots level to meet the needs of children affected by HIV/AIDS, few specifically address the needs of female OVC. A recent review of 14,343 documents with 414 judged relevant and reviewed on OVC found that “few provided strong evidence and most moderate to strong evidence described the situation of children, with little on effective interventions,” with important gaps in evidence. Strong evidence was found that institutional care of OVCs should be the last resort (Franco et al., 2008).
Access to treatment is another programmatic gap for orphans living with HIV. A study in rural Uganda of 101 HIV-positive children (56 girls and 45 boys), of whom 47 were orphans, highlighted the need to improve access to antiretrovirals for orphans. The study found that orphans were more likely to be at WHO clinical stage 4, suggesting that orphans are at a greater risk of progressing to AIDS than non-orphans and in need of timely treatment initiation (Ntanda et al., 2009).
A number of policy gaps exist regarding OVC (Smart, 2003; Engle, 2008). A review of National Plans of Action for OVC found that “there is a wide range in the developmental appropriateness of the plans within the 17 countries. The most common interventions are health and nutrition and birth registration. Slightly less than half of the plans have components that include childcare centres (8) or community-based centre programmes (7). Some NPAs incorporated concerns for psychosocial support for younger children (4), a holistic approach to the treatment of HIV-infected children (6) and incorporating young children’s concerns into home-based care (3). Only two programmes mentioned capacity building for working with young children and three plans had age categories in their monitoring and evaluation plans. Some NPAs included programmes for young children but did not include funding” (Engle, 2008: v).
Significantly, “WHO, UNAIDS and the international data sets are not gathered or coded by gender. This serious omission leads to ignorance by neglect – despite well established gender challenges in later life” (Sherr, 2008). Evaluations of OVC programs are just beginning. Chatterji et al. (2005) have noted that educational programs should target all out-of-school children, not only orphans. Adolescents ages 13–19 in particular need encouragement and support to stay in school. Program implementers need to develop proven and sustainable interventions to help improve the individual material well-being of children—both orphans and children with chronically ill caregivers. Policies should also ensure that national maternal and child health (MCH) programs focus attention on orphans. In particular, the primary caregivers of these children, some of whom are very young (15–24) or older (50+), need to be targeted by health promotion campaigns that typically reach mothers ages 25–49.