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” (Irwin et al., 2009: 21). 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.

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” (Kimou et al., 2008: 9). 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.

Among 3,646 mother-infant pairs in Ukraine followed between 2005 and 2009, receipt of antenatal antiretroviral prophylaxis was strongly associated with reduced risk of infant abandonment.

A three-year longitudinal randomized control study was conducted in Zimbabwe in 2007 to determine if providing educational support to girls was effective to combat factors associated with increased HIV risk. In the intervention school, students received educational support in the form of fees, books, uniforms and other school supplies and additionally female teachers were selected to act as helpers in monitoring school absences. Retention rates were significantly higher in the intervention cohort; the control group was 6 mores more likely to drop out of school and 3 times more likely to get married. Additionally, the intervention group participants were significantly less likely to be absent from school and to report that they delayed sexual debut. Girls in the intervention group were also more likely to endorse gender equality. In this study 10 high schools were selected and all orphan girls were invited to participate in the study, a total of 326 agreed to participate and were included in final analysis, with each primary school randomized to the intervention or control group. There were 184 girls in the intervention group with a mean age of 12.2 and 145 in the control group with a mean age of 12.3. Self-administered questionnaires were given to participants in order to collect demographic data and outcomes variables; the survey was conducted annually for three years. In addition, data regarding drop-out rate, absences, and enrollment rates were collected from the schools. Of all participants in the intervention group 8 students dropped out of school during the course of the study (4.5%) and 6 of them were married. Only two girls were known to be pregnant during the course of the study and both of them were in the control group. School support decreased HIV risk; in addition it provided numerous educational benefits to orphan girls. Although students were entitled to schooling regardless of ability to pay, fees were requested and children were chased away if they didn’t pay.

A randomized trial with 105 orphans ages 12 to 14 years in Kenya found that provision of school fees, uniforms and a community visitor who monitored school attendance resulted in decreased school dropout and delayed sexual debut. All participating households received mosquito nets and blankets, and food supplements (maize, oil, sugar) every two weeks for a cost of $100 per year per child; 53 orphans received the intervention and 52 remained in the control group. The community visitor had 10 children in the experimental group on a monthly basis and also visited schools on a weekly basis to monitor attendance. The community visitor could buy sanitary napkins for girls during menses or arrange clinic visits for malaria or parasites. The budgeted cost to the intervention group was $200 per year per child. After one year, those in the control group were significantly more likely to drop out of school (14% compared to 4%) and begin sexual intercourse (33% compared to 19%). Those in the experimental group were less likely to express acceptance of a beating if a wife refused sex and less acceptance of violence against women for any reason and increased acceptance of gender equity.

A project that provides services through home based caregivers and a community center in Zambia resulted in a positive and statistically significant effect on school enrollment. In addition, participation in the program was associated with a 15.7 increased in appropriate age-for-grade for intervention children relative to control children. The study included two rounds of post-intervention data collection in 2003 and 2006 with 2,306 children aged 6 to 19 years interviewed in 2003 and 3,105 children aged 8 to 22 years of age interviewed in 2006. The OVC subsample included 2,922 children, with 1,242 of these exposed to the intervention. Children in the intervention group received services related to education, health, HIV prevention, psychosocial support and nutrition. The community school for the intervention group had meals, clinic services, HIV prevention education and psychological counseling. Also provided were school supplies, payment of government school feeds and food rations. “While this study suggests that [the intervention] Bwafwano is effective in improving schooling outcomes, it says nothing about whether it provides the best ‘bang for the buck’ relative to the alternatives” (Chatterji et al., 2010: 139).

A study of 176 double AIDS orphans from 2006 to 2007 aged 8 to 18, from four AIDS orphanages in rural China found that children who had received family-based care reported the best scores on all psychological measures. Prior to being placed in AIDS orphanages, children has received family-based care by caregivers, including the surviving parent (38%), grandparents (22%) other relatives (19%) and non-relatives (22%). The children in the care of grandparents had the best scores on psychological measures. Depression was measured using the Center for Epidemiological Studies Depression Scale for Children; loneliness was measured using the Chinese version of the Children’s Loneliness Scale; and trauma symptoms were measured using a Chinese version of the Trauma Symptom Checklist for Children. There were 64.1% boys and 38.6% girls who had lived in the orphanage for an average of 21.17 months.

A study in Kenya with 766 caregivers and 1028 children found that support groups for caregivers was associated with better family functioning, and more positive feelings by caregivers toward children. For children whose caregivers were in support groups, these children exhibited fewer behavioral problems and reported lower incidence of abuse from adults in their household. Support for caregivers translated into positive effects both for caregivers and the children under their care, with outcomes holding after controlling for illness status and caregiver and child demographics.

A study in South Africa measuring the effectiveness of a health education intervention designed to improve the skills and knowledge of elderly caregivers of orphaned and sick children as a result of HIV/AIDS, found that 141 participants who completed all sessions of the intervention, versus the 61 participants with incomplete or no participation at all, reported a more positive attitude towards people living with HIV/AIDS. Participants who were present at all sessions also reported an increase in their perceived ability to provide care for their dependents. The intervention consisted of four sessions, implemented over the course of four weeks. The sessions covered HIV/AIDS knowledge, effective intergenerational communication, home-based basic nursing care, accessing social services and grants, and relaxation techniques. A majority of the participants were female (81.7%) and participants were divided into groups of 10 to 12 each. Overall comparative effectiveness of the sessions between those who fully participated and those who partially or did not participate at all was measured at baseline, immediately following completion of all sessions, and three months after completion of all sessions. While the findings indicate a positive effect on assisting older caregivers in their care-giving responsibilities, no changes were found for caregiver’s perceived ability to communicate with children and grandchildren.

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 (Irwin et al., 2009: 47). “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.

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 savings and loan program instituted for adolescent girl orphans in Zimbabwe found that adolescent girls were less likely to engage in transactional sex. One adolescent girl stated: “There was a temptation before to have sex for food, but now if I’m approached, I say I don’t need it. Now I can pay for my own lunch” (Miller et al., 2011a: 37).

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 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 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” (Ssewamala et al., 2009: 193). 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.

A 2005-2008 study in Uganda assessing the effect of economic assets on sexual risk-taking intentions among school going AIDS-orphaned adolescents, observed a significant reduction in sexual-risk taking intentions among 127 adolescents when enrolled in the SUUBI program – a combined microfinance youth empowerment and health-promotion approach targeting families raising AIDS-orphaned adolescents in Uganda. The study involved 260 AIDS-orphaned adolescents from 15 comparable schools, with 127 adolescents in the intervention group and 133 adolescents receiving standard of care. In addition to traditional care and support services, adolescents in the intervention group received 12 workshops on economic security and empowerment over the course of 10 months, with sessions on asset-building strategies and financial planning, a monthly mentorship program with peer mentors, and a child savings account. The child savings account served as an incentive to save, with a match rate of two to one, with a limit on the maximum savings that could be matched (US$10 a month). Each child, with his or her primary caregiver as the cosigner, had access to the money in their own account, but not the matching funds. Participants could only access funds to purchase an asset after completing the 12 workshop sessions and all participants chose education as their saving goal. The children’s caregivers also valued education and most considered investment in small business development as a risk. Specific measures adapted from previously tested scales in the US, South Africa, and Uganda, assessed intentions to engage in sexual behaviors, individual socioeconomic characteristics, peer pressure, and parental or caregiver communication.

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 (Irwin et al., 2009: 40). 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” (Irwin et al., 2009: 58). 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.

A community-based cash transfer program in Kenya that provided funds dispersed to local village development committing to strengthen their capacity to provide care and support to orphans found that communities implemented collectively diverse food- and income generating activities which benefited orphans. The program was implemented in 39 rural and subsistence farming communities and communities identified between 65 to 100 of the neediest orphans and their caregivers in each community. Each community received a cash transfer of 4000 Euros and project management committees, village development committees and the local district officer for social services prioritized activities. A total of 272 orphaned children, 30 caregivers and 80 village and project manager committee members were interviewed. Caregivers reported that the project had created unity and support among caregivers. One orphan girl stated: “This programme looks at the welfare of orphans by consulting the caregivers and orphans themselves about the problems affecting the community and supports them accordingly” (Skovdal et al., 2010: 237). A caregiver stated: “It has helped me to find hope of a brighter future for my grandchildren to become victorious and successful” (Skovdal et al., 2010: 239).

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 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 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” (Nyangara et al., 2009b: 31). 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” (Nyangara et al., 2009b: 31).

A 2010 case study in Tanzania found that community-based initiatives to meet the needs of OVC are effective in improving their quality of life. Five months after opening, Goddfrey’s Children’s Centre housed 58 orphans, about one-third of all orphaned children in the community. Orphans were selected based on the severity of their need, with emphasis placed on accommodating double orphans (with neither mother nor father alive). Orphans received three meals a day and 90% attended the public school. The Centre provided after-school help with homework. It cost approximately US $1700 per month to operate the Centre, or a daily cost per child of approximately US $1. In 2005, Tanzanian and US researchers conducted an 18-month evaluation, examining the wellbeing of its children compared with other groups of children in the community. Centre orphans reported significantly fewer symptoms of depression than orphans living in the village with extended family members, and were significantly less depressed than children living with both parents. Centre orphans reported as many social supports as other groups of children in the community and did not report feelings of stigmatization or social isolation. School attendance, optimism towards shaping their future and overall health among Centre orphans was comparable to other children in the community. However, the Centre closed due to lack of sustainable options once US funding ended.