Supporting children in need through a community-based orphan visiting programme

Rethinking the family in the context of care for adolescents living with HIV in Swaziland

Drawing from 18 months of ethnographic fieldwork in one urban and one rural setting in Swaziland, involving 13 case studies of adolescents living with HIV, in this article we explore the meaning of the family as it applies to Swazi adolescents' everyday life. Our findings suggest that the meaning of the family is constantly evolving and transforming based on changing needs of, and expectations by, adolescents in different contexts and moments of the care continuum. Central to the meaning of the family is a strong desire for belonging - that is, being accepted, welcomed and appreciated. Traditional institutions that used to regulate where children belong still shape adolescents' perceptions, hopes and desires, but may also prevent their realisation. Support groups are important but do not substitute for the familial belongings adolescents living with HIV have lost, and long for. Policymakers, programme managers and health providers working with adolescents living with HIV need to embrace the complexity and dynamism of the meaning of family and base their policies, programmes, standards and guidelines not only on the factual care arrangements that adolescents find themselves in, nor on legal definitions of rights and responsibilities, but also on what adolescents want.

Household dynamics and socioeconomic conditions in the context of incident adolescent orphaning in KwaZulu-Natal, South Africa

We compared demographics, socioeconomic status, and food insecurity between households with and without recent orphans in a region of high HIV/AIDS mortality in South Africa. We recruited a cohort of 197 recent orphans and 528 non-orphans ages 9-15 and their households using stratified cluster sampling. Households were classified into three groups: orphan-only (N=50); non-orphan-only (N=377); and mixed (N=210). Between September 2004 and May 2007, households were interviewed three times regarding demographics, income and assets, and food insecurity. Baseline bivariate associations were assessed using chi-square- and t-tests. Longitudinal bivariate associations and multivariate models were tested using generalized estimating equations. At baseline, mixed households generally exhibited greater characteristics of vulnerability than orphan and non-orphan households. They were larger, had older, less educated household heads, and reported a much smaller annual per capita income. Orphan households were more likely to report a death in the previous year, and less likely to have an adult employed. These differences persisted over the study. Even non-orphan households exhibited characteristics of vulnerability, with 14% reporting a death one year before baseline, 45% of whom were prime-age adults. At baseline, a much smaller proportion of orphan households reported receiving the child support grant than the other household types, but notably, there were no differences among households in receipt of the grant by Round 3. Household food insecurity was highly prevalent: more than one in five orphan-only and mixed households reported being food insecure in the previous month. These findings suggest that the effects of HIV/AIDS only exacerbate existing high levels of poverty in the district, as virtually all households are vulnerable regardless of orphan status. Community-level programs must help families address a spectrum of needs, including food security, caregiving, and financial support, as well as better target social welfare grants and make them more accessible to vulnerable households.

Does the Orphan Disadvantage "Spill Over?" An analysis of whether living in an area with a higher concentration of orphans is associated with children's school enrollment in sub-Saharan Africa

BACKGROUND

Despite considerable concern regarding the social consequences of sub-Saharan Africa's high orphan prevalence, no research investigates how living in a community densely populated with orphans is more broadly associated with children's-including nonorphans'-acquisition of human capital.

OBJECTIVE

We provide a new look at the implications of widespread orphanhood in sub-Saharan Africa by examining whether living in an area with a high concentration of orphans is associated with children's likelihood of school enrollment.

METHODS

We use data from the Demographic and Health Survey (DHS) and the Multiple Indicators Cluster Survey (MICS) to estimate multilevel logistic regression models to assess whether living in a setting with a higher concentration of orphans is associated with school enrollment among 383,010 children in 336 provinces in 34 sub-Saharan African countries.

RESULTS

Orphan concentration has a curvilinear association with children's school enrollment in western and eastern Africa: the initially positive association becomes negative at higher levels. In central and southern Africa, orphan concentration has a positive linear association with children's school enrollment.

CONCLUSION

In western and eastern Africa, the negative association between living in a setting more densely populated with orphans and children's school enrollment provides suggestive evidence that the orphan disadvantage "spills over" in the communities most heavily affected. Conversely, in central and southern Africa, the positive association between living in a setting more densely populated with orphans and children's school enrollment highlights the resiliency of these relatively wealthier communities with high levels of orphans. Although longitudinal research is needed to confirm these findings and clarify the underlying mechanisms, this study lays the groundwork for a new body of research aimed at understanding the broader social implications of widespread orphanhood in sub-Saharan Africa.

Evaluation of the community response to HIV and AIDS: learning from a portfolio approach

While communities have played a large role in the HIV/AIDS response, their contributions and innovative approaches to HIV prevention, treatment, care and support have not always been the focus of systematic and rigorous evaluations. To address this gap, the World Bank led an evaluation of the impact of the community response to HIV, including country studies in Burkina Faso, India, Kenya, Lesotho, Nigeria, Senegal, South Africa and Zimbabwe over a three-year period. Due to the complexity and varied nature of community responses, the evaluation attempted to determine the results that investments have produced at the community level by applying a mixed method approach: Randomized Controlled Trials, quasi-experimental studies, qualitative studies and analytical studies including financial data. Specifically, the studies examined a typology of community response and the flow of funds to community-based organizations, while investigating the impact of the community responses on (1) knowledge and behavior, (2) use of services, (3) social transformation, and (4) HIV incidence. This editorial summarizes the results of this evaluation portfolio, finding that investments in communities have produced significant results, including, improved knowledge and behavior, and increased use of health services, and even decreased HIV incidence. Evidence on social transformation was more mixed, with community groups found to be effective only in some settings. Each study in the evaluation provides a partial view of how communities shape the local response; however, taken together they corroborate the common wisdom that communities can be a vital part of the global HIV/AIDS response.

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.

Building orphan competent communities: experiences from a community-based capital cash transfer initiative in Kenya

As a result of the increasing number of orphans in sub-Saharan Africa, numerous programmes have been initiated to facilitate the care and support of orphaned and vulnerable children. This paper reports on a community-based capital cash transfer initiative in Kenya and explores its role in building orphan competent and supportive communities through its participatory project cycle. Using a mixture of individual and group interviews, 300 orphaned children and 110 adults involved in this initiative were interviewed using open-ended questions. A thematic analysis of the data revealed that many of the communities participating in this programme had become more united and active in the support of orphaned children following the mobilization of much needed economic, political and social support resources. Despite many difficulties, largely due to the complexity of communities, we conclude that community-based capital cash transfer initiatives can facilitate the building of orphan competent communities.

The quality of material care provided by grandparents for their orphaned grandchildren in the context of HIV/AIDS and poverty: a study of Kopanong municipality, Free State

A pervasive argument in the literature on AIDS orphans in South Africa is that grandparents, who often care for their orphaned grandchildren, lack the material means to provide adequate care. This study investigated that claim in an area of ubiquitous poverty and very high unemployment. It is based on the analysis of data obtained from two surveys carried out by the HSRC in the semi-rural municipality of Kopanong in the Free State. The first study was a census which targeted the whole population. The second, smaller survey sampled households which accommodated orphaned and vulnerable children. Based on four proxy indicators for material care: possession of birth certificates, uptake of welfare grants, levels of school attendance, and the number of meals consumed daily, the study revealed that there was very little difference in the quality of care provided by grandparents and other carers, including biological parents. Indeed, since the old age pension is much higher than the child support grant and the foster care grant it may be that grandparents who are pensioners generally have higher incomes than most other adults. In line with the findings of other research, the study found that poverty is a major problem confronting all carers in the area. It concludes that interventions that primarily target orphans overlook the material needs of all poor children. It therefore joins the calls of other researchers for greater state support for all poor children, irrespective of whether they are orphans and who their carers are.

Does being an orphan decrease the nutritional status of Luo children?

The HIV/AIDS pandemic is creating a generation of orphaned children in Africa. The number of orphans will continue to increase long after the HIV/AIDS crisis has peaked; therefore, it is important to determine how best to assist these children. Current studies investigating the impact of orphanhood have conflicting results and conclusions. Several studies report that orphans are at a disadvantage and are more likely to suffer from malnutrition, whereas other studies report no difference between the nutritional status of orphans and nonorphans. Four hundred eleven Luo children (mean age 9 +/- 1 years) were recruited to participate in a study investigating the impact of orphanhood on nutritional status. Participants underwent an interview, anthropometric measurements, testing for anemia, a clinical history, and a physical exam. Anthropometric variables and hemoglobin level were compared across groups using a t-test. The reference population used for comparison of anthropometric variables is the 2000 CDC growth reference data. All analyses were gender specific, and the effect of length of orphanhood was also investigated. The data presented here suggest that there is no significant difference between the nutritional status of orphaned and nonorphaned Luo children. This study supports research indicating there is little, if any, difference in nutritional indicators between orphans and nonorphans. Orphans may live in households with higher socioeconomic statuses than nonorphans. Luo orphans may not be at higher risk for poor nutritional status than nonorphans; therefore, interventions targeted at this age group should include both orphaned and nonorphaned children.

Correlates of grief among older adults caring for children and grandchildren as a consequence of HIV and AIDS in South Africa

OBJECTIVE

Over the past few years, older people have become the main caregivers for their sick adult children and orphaned grandchildren due to HIV/AIDS in South Africa. This article aims to investigate the scope of care provided by older people, with a specific focus on the experience of grief due to multiple losses and its correlates.

METHODS

Quantitative interviews were conducted among 820 isiXhosa speaking caregivers of 60 years and older in the Eastern Cape of South Africa.

RESULTS

Older persons are involved in a wide range of care activities with several dependents to care for. Grief among older adults is most strongly predicted by perceived stigma around HIV and AIDS and worries about providing the care.

DISCUSSION

This study provides insight into correlates of grief among older caregivers and results in useful information to inform the development of interventions to assist older persons in coping with their responsibilities as caregivers.

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.

'I felt I have grown up as an adult': caregiving experience of children affected by HIV/AIDS in China

BACKGROUND

The growing global epidemic of HIV/AIDS has a significant impact on the lives of both people living with HIV/AIDS and their family members including children. Children of parents with HIV/AIDS may experience an increased responsibility of caregiving in family. However, limited data are available regarding the caregiving experience and its impact on psychosocial well-being among these children. This study was designed to address these issues by using qualitative data collected from children affected by HIV/AIDS in China.

METHODS

The qualitative data were collected in 2006 in rural central China, where many residents were infected with HIV/AIDS through unhygienic blood collection procedures. In-depth individual interviews were conducted by trained interviewers with 47 children between 8 and 17 years of age who had lost one or both parents to AIDS.

RESULTS

Findings of this study suggest that many children affected by AIDS had experienced increased responsibilities in housework and caregiving for family members. Such caregiving included caring for self and younger siblings, caring for parents with illness and caring for elderly grandparents. Positive impacts from children's participation in family caregiving included personal growth and emotional maturity. Negative consequences included physical fatigue, psychological fear and anxiety and suboptimal schooling (dropping out from school, repeated absence from school and unable to concentrate in class).

CONCLUSION

While the increased caregiving responsibilities among children reflected some cultural beliefs and had some positive effect on personal growth, the caregiving experience generally negatively effected the children's physical and mental health and schooling. The findings in the current study suggest that community-based caregiving support is necessary in areas with high prevalence of HIV and limited resources, especially for the families lacking adult caregivers. In addition, social and psychological support should be made available for children participating in family caregiving.

Grandmother Co-Residence and School Enrollment in sub-Saharan Africa

The HIV/AIDS pandemic in sub-Saharan Africa has brought renewed attention to the role of grandmothers as caregivers of children. Using 2004 DHS data, we examine the relationship between co-residence with a grandmother and child schooling in Lesotho, a country with one of the highest rates of HIV infection. Results confirm the critical role grandmothers play in the event of maternal death. Maternal orphans who live with a grandmother are just as likely to be in school as children living with a mother. The protective effect of living with a grandmother is also important for children whose mothers are alive but not affiliated with their households. The results of the analysis underscore the importance of attending to the simultaneous presence of mothers and grandmothers, as well as the circumstances associated with mother absence, when assessing the relationship between grandmother co-residence and child outcomes.

Caregivers' and non-caregivers' knowledge regarding HIV/AIDS and attitude towards HIV/AIDS and orphans in Nigeria

Nigeria has an estimated 930,000 AIDS orphans, which has a marked impact on family and community. This study was performed to characterise caregivers' knowledge regarding HIV/AIDS and their attitude towards HIV/AIDS, orphans in general and AIDS orphans in particular. Caregivers and non-caregivers aged 25-70 years in Nigeria were interviewed from January and March 2003, and logistic regression analysis was used to determine associations between caregivers' knowledge regarding HIV/AIDS and attitudes towards HIV/AIDS, orphans and AIDS orphans, and demographic characteristics and background status regarding HIV/AIDS and orphans. A total of 824 interviewees participated in the survey (82.4% response rate), of whom 290 (35.2%) were current caregivers of orphans. The mean number of orphans per current caregiver was 1.8 (standard deviation 1.4). Factors related to higher knowledge level regarding HIV/AIDS were female gender [odds ratio (OR) = 3.49; 95% confidence interval (CI): 2.33, 5.22] and belief that AIDS is a common disease (OR = 3.39; 95% CI: 2.19, 5.26). Factors associated with positive attitudes towards HIV/AIDS, orphans in general and AIDS orphans in particular were age 35-44 years (OR = 1.73; 95% CI: 1.11, 2.69), Koranic schooling (OR = 8.69; 95% CI: 2.42, 31.19), polygamy (OR = 1.76; 95% CI: 1.17, 2.62), belief that there are increasing numbers of orphans in the community (OR = 2.59; 95% CI: 1.32, 5.08) and having relatives or friends with HIV/AIDS (OR = 2.88; 95% CI: 1.61, 1.58). There was a slight correlation (r = 0.17, P < 0.001) between caregivers' knowledge regarding HIV/AIDS and positive attitudes towards HIV/AIDS, orphans and AIDS orphans. Demographic characteristics and personal experience should be taken into consideration to improve attitudes and behaviour related to HIV/AIDS and caring for orphans and AIDS orphans.

'We are no longer called club members but caregivers': Involving youth in HIV and AIDS caregiving in rural Zambia

This study assessed the strategy of building young people's capacity to provide care and support to people living with HIV and AIDS in rural Zambia. Members of youth anti-AIDS clubs in schools and communities were trained as adjunct caregivers using a locally developed curriculum that allowed them to explore and challenge gendered notions of caregiving and emphasized networking with existing resources. Results show that caregiving increased among males (47% to 82%) and females (41% to 78%). Both sexes provided similar caregiving services, including help with household chores and personal care tasks. Youth also undertook activities with children to decrease their isolation, help them stay in school, and reach additional services. While clients and caregivers reported positive aspects of the programme, both reported frustration with the youths' inability to meet material needs. This study demonstrates that trained youth already involved in anti-AIDS efforts can meet a range of care needs and be valuable assets to their community. It also highlights the importance of communicating clearly what youth can and cannot do, ongoing monitoring and support of youth caregivers, and involving community leaders to give youth credibility and access to local resources.

Guardianship of orphans and vulnerable children. A survey of current and prospective South African caregivers

Increasing numbers of orphaned and vulnerable children resulting from AIDS deaths requires practical placement strategies. While the extended family is regarded as both the most likely and the preferred option by most key planners and organizations, warnings of the limitations of this alternative have been increasing. This study assessed the views of 1400 adults (both current and prospective caregivers) regarding the placement of children. Most current caregivers believed that either their partner (30%), a grandparent (25%) or another family member (33%) would look after the child/children if they were no longer able to. However, 12% of parents could not identify a carer or predicted only a bleak future for their children. There was strong willingness amongst adults of various relational proximity to take in children if required to -71% of both fathers and grandparents, 63% of siblings and 23% of best friends said they would take in children. Nonetheless this research suggests that the willingness may not necessarily be translated into reality. Most prospective caregivers identified significant additional stressors (most importantly financial) and expressed a strong need for assistance if they were to take in additional children. The HIV status of the child is also likely to sway placement decisions for some people. Nonetheless opportunities to keep children in families are clearly high, but people will need considerable help to realize this potential. For some children alternatives other than the extended family will be required.

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.

The incidence and prevalence of orphanhood associated with parental HIV infection: a population-based study in Rakai, Uganda

BACKGROUND

There are limited empirical data on the prevalence and incidence of orphanhood due to parental HIV infection.

OBJECTIVE

To assess the prevalence and incidence of orphanhood, and the population attributable fraction (PAF) of incident orphanhood associated with parental HIV infection, in a rural population with a 14.8% adult HIV prevalence.

METHODS

The data are derived from a community cohort in Rakai District, Uganda. Census data were collected on all resident members in 10,657 households, including survival of parents of resident children in 1996/1997. Consenting adults were interviewed, provided blood for HIV testing, and were followed up 10 months later to determine parental death and incident orphanhood. The incidence rate ratio (IRR) of orphanhood associated with parental HIV-infection was estimated by Poisson multivariate regression.

RESULTS

A total of 22,712 children aged 0-14 years were enumerated in 1996/1997. The overall prevalence of orphanhood was higher among children of HIV-infected parents (22.7%) compared with children of uninfected parents, 7.9%. The annual incidence of orphanhood was 8.2% if at least one parent was HIV positive, and 0.5% if both parents were HIV negative (adjusted IRR = 18.93). Older age of children, and older maternal age were significantly associated with an increased risk of orphanhood. The PAF of incident orphanhood due to parental HIV infection was 37.3%, and was highest among younger children (adjusted PAF = 50.6% for 0-4 year olds), and children with younger mothers aged < 25 years (adjusted PAF = 75.7%).

CONCLUSIONS

Parental HIV infection markedly increased the incidence of orphanhood, especially among younger children and the children of younger mothers.

Lay health workers in primary and community health care

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained.

MAIN RESULTS

Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions.

AUTHORS' CONCLUSIONS

LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

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.

The methodology of HIV/AIDS impact studies: a review of current practices

This review of studies on the socio-economic impact of HIV/AIDS shows that diversity in methodological design, which often is a result of practical considerations and resource constraints rather than of poor design, is the norm. This limits the comparability of research findings. More detailed reporting on method, which is not the norm, can go some way towards facilitating such comparison. Furthermore, the review underlines the importance of exploring intervention issues in more detail. Researchers need to employ results in answering specific policy questions. Scope remains for more impact studies to be conducted in developing countries in general and in certain high prevalence countries in specific, i.e. Southern Africa. Studies that explore the urban/rural dynamics of and clients' perceptions and behavior in seeking care and support are necessary to better understand the epidemic. The role of community-based organizations, non-governmental organizations and other stakeholders in studies of this nature can be expanded. Larger studies generally have more statistical power, but smaller, in-depth studies can be equally valuable. A careful stratification of sample populations can enhance the quality of cross-sectional studies. Qualitative methods should be used to complement the current reliance on survey-based methods of data collection. More longitudinal studies are required to explore the long-term impacts of HIV/AIDS. HIV/AIDS training for fieldworkers should be standard in studies of this nature, while cognizance should be taken of the dangers of employing local people as fieldworkers in studies of such sensitive nature. Scope remains for the further empirical analysis of data from impact studies, which requires these data sets being made accessible to more researchers. In the longer term, an attempt at standardizing core modules in impact studies can help to improve our understanding of the impact of HIV/AIDS in different settings.

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.

Recent upturn in mortality in rural Zimbabwe: evidence for an early demographic impact of HIV-1 infection?

OBJECTIVES

To describe recent mortality trends in rural Zimbabwe and to assess the impact of HIV-1 infection.

METHOD

Comparative, cross-sectional, retrospective, demographic survey with 1-year follow-up. Parallel HIV-1 surveillance. Comparison of results with 1992 national census and vital registration data and results from mathematical model-based population projections.

SETTING AND PARTICIPANTS

Residents of 929 (745 revisited in 1995) households in two rural areas of Manicaland Province, Zimbabwe, with contrasting HIV-1 prevalence: Honde and Rusitu valleys. Subjects gave information on parental survival for 2320 resident children. Female residents aged 13-49 years (n = 1237) provided information on birth histories and child survival. Consenting women attending local antenatal clinics (n = 487) provided blood samples for HIV-1 screening and demographic information.

MAIN OUTCOME MEASURES

HIV-1 prevalence in pregnant women; per capita death registration rates; incidence of parental death for children aged under 8 years; infant mortality and age-specific death probabilities.

RESULTS

HIV-1 prevalence was high in each study area. Death registration and age-specific mortality have begun to rise. The largest increases were seen in the area of higher HIV-1 prevalence (Honde) and among younger adults, particularly men. Incidence of parental death was observed to be rising. Increases in registered deaths were concentrated among HIV-1-associated causes.

CONCLUSIONS

The observed increases in mortality by age, sex and cause of death were consistent with those expected early in a severe HIV-1 epidemic, on the basis of mathematical model projections and observations elsewhere in Africa. Further rises in mortality, particularly among women and young children, and consequent increases in orphanhood, are to be expected in rural areas of Zimbabwe.