Orphans and Vulnerable Children

A prospective cohort study with 1,373 HIV-positive and 4,601 HIV-negative household members (over 70% respondents were women) conducted from 2001-2005 in Uganda showed that access to antiretroviral therapy (ART) and co- trimoxazole prophylaxis treatment program led to large reduction in mortality among HIV-positive adults living in resource-poor settings and in the rate of orphanhood. Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-positive adult participants, an 81% reduction in mortality in their uninfected children younger than 10 years and a 93% estimated reduction in orphanhood. During the study periods households were visited every week by lay trained paid providers who resupplied medicine and monitored drug adherence, hospital admissions, potential symptoms of drug toxicity, death of a household member in the preceding 7 days, and orphanhood. No routine clinic visits were scheduled after enrollment and home-based care and services were provided, which greatly helped in overcoming the problem of inability of ART-eligible people to access routine health services due to poverty or poor transportation.

The Joint Learning Initiative on Children and HIV/AIDS compiled over 50 systematic reviews by working groups of world OVC experts and found that “family-centred treatment programmes may accelerate the expansion of paediatric treatment, improve children’s adherence to therapy, and secure better outcomes for children living with HIV,” . JLICA cited a 2007 cohort study of 151 children in South Africa who were started on HAART, which determined that 89% of children had an adherence to treatment of greater than 95%, leading to 84% virologic suppression after 6 months and 80.3% suppression after a year. The study found that having at least one HIV- positive parent decreased the children’s chances of death, leading to the conclusion that treating parents and keeping families infected with HIV together can improve HIV outcomes (Reddi et al., 2008).

A Joint Learning Initiative on Children and HIV/AIDS executed a systematic review of the impact of adult use of antiretroviral treatment on family well- being. The study evaluated primary research and modeling studies and found that “having parents on ART reduces the likelihood of children’s labour supply; increases children’s school attendance and improves their nutritional intake,” . Among 41 other studies, JLICA cited a 2004-2005 longitudinal household survey of 775 randomly chosen households, households with at least one known HIV-positive adult on ARV, and households with a known HIV-positive adult not receiving ARV in 100 villages in rural Western Kenya. The study evaluated 482 children living in these households and determined that after treating adults with antiretroviral therapy for six months, the number of hours that the children in the household attend school increased by 20 percent overall, and 30 percent for boys. After six months of adult ART, the average hours a week worked by boys in the labor supply decreased by 7.46 hours. Lastly, ARV treatment of parents was found to improve the nourishment of young children (Zivin et al., 2006).

A study done in India (year not given) with 312 HIV-positive children (including those on HAART) and 2,278 HIV-affected children (including those not on ART) showed that after providing free clinical care (including ART), nutritional supplements and community-based support to HIV-positive children for 12 months, pediatric quality of life score among HIV-positive and affected children improved significantly in all domains – physical, social, emotional and educational, with no differences by sex. The program also resulted in a significant increase in the proportion of HIV-affected children aware of their parent’s status (from 16% to 25%) as well as an increase in the proportion of HIV-positive children aware of their parent’s status (from 12% to 19%) and their own HIV status (from 10% to 20%). Among HIV-positive children who were enrolled in school at baseline, 95% continued going to school at 12 months. The proportion of affected children (one or both parents HIV-positive) who missed more than five school days per month significantly decreased.

Services that are “provided through integrated, family-centered delivery models” work best for children, according to the Joint Learning Initiative on Children and HIV/AIDS final report on children, AIDS and poverty . “Programmes obtain the best results for children when they adopt integrated intervention strategies providing a range of services to the whole family. The most effective delivery systems integrate HIV and AIDS services with family-centered primary health care and social services provided through community-based models,” (Irwin et al., 2009: 48). JLICA highlights Rwanda’s National Policy and Strategic Plan for Orphans and Vulnerable Children, which looks beyond AIDS to provide a “minimum package of services” of healthcare, nutrition, formal education, livelihood training, protection, and psychological and socioeconomic support. The decentralized, rights-based system “can connect families to such opportunities through referral systems and linkages to public support or NGO programmes,” (Irwin et al., 2009: 49 citing Binagwaho et al., 2008).

An orphan day care center in Botswana provides centralized care to over 355 orphans ages 2 to 18 with pre-school aged children cared for in a safe, supervised environment during the workday, relieving the caregiving burden for guardians and facilitating their ability to work or care for relatives with HIV. Older children come to the center after school to receive meals, participate in activities and receive counseling. The family outreach program delivers counseling to children’s guardians during home visits. The center in Botswana has quality control measures in place to ensure that orphans benefit, but the labor-intensive efforts are more challenging to scale up.

A study with 103 (61 male, 42 female, age range: 3-127 months) institutionalized HIV-infected orphaned children in Tanzania showed that after one year of being on HAART, children with severe malnutrition and declined CD4 values had significant increases in their CD4 counts. Their CD4 cell percentages increased from 10.3 to 25.3 percent and absolute count, from 310 to 660/mm3. Their nutritional status improved significantly. Two out of 27 untreated children became eligible for antiretroviral treatment. The study also showed that institutionalized children who do not meet the criteria for treatment can be safely monitored for immunological status with no mortality and no difference in clinical events compared to treated children in the short-term. HAART can be effectively used for HIV-positive children in resource poor settings along with good nutritional intake and regular medical care.

A retrospective review in Kenya with 279 children (49% girls and 54% orphans) enrolled at nine HIV clinics between 2002 and 2005 and on antiretroviral therapy (ART) showed that ART for HIV-positive children produced significant and sustainable CD4 improvement and weight gains during the initial 30 weeks. The study found no effect of orphan status on ART adherence or rise in CD4 counts, at least in the short-term. The mean peak for CD4 percent increase at 30 weeks for orphans was 23% and that for non-orphans was 24%. The study indicates the feasibility of providing ART to children in resource poor settings.

A cluster randomized control trial of a school-based peer-group support intervention with 326 AIDS orphans (aged 10-15) in Mbarara District, Uganda found that peer-group interventions when led by teachers and complemented by healthcare check-ups significantly decreased anxiety, depression and anger among the intervention group. Of the children, 42.6% were double orphans. The intervention provided twice-weekly peer-group support meetings conducted by a trained teacher over the course of ten weeks and supplemented these sessions with monthly healthcare examinations and treatment. The support meetings presented topics of concern to orphans through plays, poems, stories and games, asked the orphans to identify the problems embedded in the activities, inquired whether they had experienced similar issues, explored the causes of the problems and their effects on families, and brainstormed solutions. Although the children in the intervention group had started out having lower self-concept scores and higher indications of depression than the control group, the intervention group had lower scores of anxiety, depression, and anger at baseline..

A study done in Mexico from 2005-2008 with 135 HIV-positive children and adolescents (77 girls) between age 6 and 17 years found that ten sessions of Cognitive Conductual Therapy (CCT) reduced the initial depression level and maintained it for at least 6 months after the therapy. Of the 135 HIV-positive children and adolescents, 131 were infected by perinatal transmission and 54 were diagnosed with depression.

A 2006 follow up survey of an 18-month intervention with 593 youth household heads (equal number of males and females) aged 27 years and under, in Rwanda reported that a mentorship program may mitigate grief among youth. Youth with a mentor showed a decrease in marginalization, increase in perceptions of adult support and stability in grief levels. They also reported a slight though significant decrease in depressive symptoms. The mentoring program appears to have enhanced available support and overall community connectedness.

A 2006-2007 post-test study of 6,127 children ages 8-14 in four OVC programs in Kenya and Tanzania found that kids’ clubs had mixed results in improving children’s psycho-social outcomes. One successful kids’ club, which met once a month and had a standardized curriculum and an OVC supervisor on staff, was associated with higher perceptions of having adult support, improved pro-social behavior and fewer emotional problems.

A study in Benin from 2005-2007 with 91 children, 51% female, aged 5 months to 15 years, found that psychological disorders disappear after two months of continued psychological care given to them as well as to their parents, caregivers or other relatives involved in childcare. In this intervention, follow up for those with psychological problems was done twice a week for a month, and twice a month until the patient was stable. Psychological care was integrated into the care package for HIV-exposed or infected children and comprised of clinical, social and nutritional, therapeutic education and pediatric community-based care . (Abstract)

A randomized clinic trial studied 268 adolescent orphans in their final year of primary school from fifteen comparable primary schools in Rakai District, Uganda and found that at ten months post-intervention, adolescents who had participated in an economic empowerment intervention had significantly better self-esteem and self-rated health measures than the control group. Girls reported greater increases in self-esteem than boys. Self-esteem was positively correlated with self-rated health functioning, and adolescents with increased self-esteem were found less likely to intend to engage in risky sexual behaviors. The SUUBI economic intervention focused on increasing assets for families and provided workshops on asset-building and planning, monthly meetings with mentors on life planning, and a Child Development Account (CDA) for each adolescent with a 2:1 match of contributions that could be used for “secondary education, vocational training and/or for a small family business” . The average monthly net deposit was $6.33, which accumulated to $228 per year, enough to cover almost two years of secondary education. The study participants had an average age of 13.7 years. The proportion of study participants who were paternal, maternal and double orphans was 41%, 19% and 40%, respectively (Ssewamala et al., 2009).

A study done in Kenya (year not given) with 228 OVC showed that OVC with a head of household involved in saving and loans associations (SLAs) had more diverse diets, ate more frequently and had better nutritional status than those from a household with a head not involved in SLA. Households involved in SLAs had significantly higher agricultural productivity and income generating activities after a two-year intervention by a community-based care program for OVC. The program organized OVC household heads (of whom 95% were women) into SLAs to pool money and borrow sums that they paid back with interest. OVC household heads were trained in cash management and were given agricultural support. The study further indicated that 78% of OVC households involved in SLAs had either three or more feedings as compared to 64% of OVC households not involved in SLA.

A study in Haiti, Kenya, Tanzania, Rwanda and Zambia (year not given) with 2,205 OVC ages 7–17 years found OVC with agricultural training, farming inputs and home/community gardens to be more likely to report greater frequencies of having enough food to eat (54% compared to 35%). The study found that dual orphans were most vulnerable to food insecurity.

Old age pensions bring specific benefits to vulnerable children. The Joint Learning Initiative on Children and HIV/AIDS final report, which compiled over 50 systematic reviews by working groups of world OVC experts, found “that old age pensions help children … households that include pension recipients increase spending related to children’s welfare,” particularly in the African policy context. JLICA cited a 2004 study that evaluated the impact of South Africa’s Old Age Pensions on children’s school attendance. When a household member received a pension, the children in the household attended school 20 to 25% more often. In the poorest quartile, old age pensions increased the chance that girls would attend school fulltime by 7% and for boys by 5%. .”

A final report of a study on children, AIDS, and poverty, which compiled over 50 systematic reviews by working groups of world OVC experts, suggested “income transfers as ‘a leading edge’ intervention to rapidly improve outcomes for extremely vulnerable children and families,” . JLICA suggests unconditional income transfers and child poverty support grants for the African policy contexts. In particular, income transfers to women in the households improve children’s outcomes. The JLICA review of cash transfer programs cited a pilot income transfer study in Malawi and Zambia which found that in high HIV prevalence areas where families were targeted for the income transfer based on poverty, 70% of the participating families were affected by HIV (Adato and Bassett, 2008 citing Schubert et al., 2007).

A study with 1,400 adults in South Africa found that assistance to families as well as additional funds to support OVCs increased the likelihood of adults supporting orphans. When non-direct financial assistance such as paying for the child’s education and providing for a trained person to assist in care, were included, adults were more willing to care for orphans. However, 28% of best friends, 29% of strangers and 15% of fathers and 17% of grandparents said they would decline to take in a child or children if they were HIV-positive.

A cross-sectional survey (year not given) in rural China with 124 double AIDS orphans (42% were female) with an average age of 12.4 years and with at least one sibling (69 separated from siblings and 55 living with a sibling) concluded that separation from siblings is associated with trauma symptoms of AIDS orphans who had lost both parents and were placed in group care settings. The study found that the orphans separated from their siblings had significantly higher scores on anxiety, anger, dissociation and sexual distress as compared to than those living with their siblings.

A 2006-2007 study of 6,127 children ages 8-14 and 4,591 caregivers in four OVC programs in Kenya and Tanzania found that services targeting OVC or families affected by HIV/AIDS may also add to stigma. “A noticeable fraction of the sample across each study setting reported that there was community jealousy of services provided to OVC and their families.” Between 22 and 57 percent of the children across all study sites perceived jealousy for the services they received, while among caregivers these perceptions were higher – from 27 to 67 percent. “These results bear credence to both the importance of engaging the community in decisions regarding who will receive services, as well as programmatic efforts to sensitize the community on the needs of OVC and those of HIV-affected families,”

A community development project that incorporated income-generating activities for women’s cooperatives in Côte d’Ivoire identified 409 OVC, all of whom were provided school kits and fees, medical care, psychosocial support and monthly food supplements for families in need, along with increased HIV testing of those in the community. Because the community perceives the program as a community development program rather than a narrowly defined HIV/AIDS program, this may have reduced the stigma attached to OVCs. Linking HIV prevention, testing and care with income generation for women may increase care and support for OVC . (Abstract)

A post-test cross sectional study conducted in Kenya (year not mentioned) with 2,472 OVC adult guardians (92% female) showed that guardians exposed to curriculum-based anti-stigma community meetings had more positive attitudes towards OVC and PLHA than guardians not exposed to community meetings. OVC guardians who attended meetings were twice as likely (51%) as non-attendees (27%) to have ever been tested for HIV . (Abstract)