The Role of Families Among Orphans and Vulnerable Children in Confronting
8.4 Impact of HIV/AIDS on Children
While awareness about the number of children affected by HIV/AIDS is growing, there is still a paucity of data focused on these vulnerable children and their fami-lies. The HIV epidemic not only affects children’s health but has had an impact on four other important domains: (1) care arrangements, (2) educational opportunities, (3) mental health, and (4) HIV risk behaviors. The macro effects on the socioeco-nomic and health of families is not addressed, but for more information on this topic, see McNally et al. ( 2006 ) . While the majority of the literature focuses on children who have been orphaned, where possible, information on vulnerable chil-dren has been included.
8.4.1 Care Arrangements
The majority of children who have been orphaned by HIV/AIDS are being cared for by a family member, such as siblings or extended family members (Ankrah 1993 ; Foster et al. 1995 ; Freeman and Nkomo 2006a, b ; Jacobs et al. 2005 ; Monasch and Boerma 2004 ) . The majority of children remain with their mother if the child’s father is deceased, while extended family members step in if the mother dies (Richter and Desmond 2008 ) . Orphans frequently live in households headed by a woman (Monasch and Boerma 2004 ; Yamano et al. 2006 ) , an elderly person (Foster et al. 1995 ; Howard et al. 2006 ) , and in households where more people are dependent on fewer income earners (Ansell and van Blerk 2004 ; Ansell and Young 2004 ; Bicego et al. 2003 ; Howard et al. 2006 ; Masmas et al.
2004 ; Monasch and Boerma 2004 ; Oleke et al. 2005 ) . Child-headed households have generated a lot of concern; while children assume adult roles when the parents are ill, the prevalence of child-headed households after the parents die is low (Boris et al. 2006 ; Donald and Clacherty 2005 ; Foster et al. 1995 ; Germann 2006 ; Howard et al. 2006 ; Jones 2006 ; Monasch and Boerma 2004 ; Thurman et al. 2006a ) .
Little is known about how the decision is made to place children in different care arrangements when they are orphaned. Cultural norms in some places dictate that
children should be placed with paternal or maternal kin; however, these norms appear to be changing in areas with high rates of orphans because extended families may not be able to absorb any more children (Oleke et al. 2005 ; Jones 2006 ) . When possible, family members are preferred over other caregivers (Rotheram-Borus et al. 2002 ; Heymann et al. 2007 ; Beard 2005 ) .
Among mothers living with HIV in South Africa, 12% could not identify a caregiver for their child and described their child’s future as bleak (Freeman and Nkomo 2006a, b ) . Factors that have been proposed as playing a role in a child’s placement include: (1) the child’s HIV status (Freeman and Nkomo 2006a, b ; Townsend and Dawes 2004, 2007 ) ; (2) age (male caregivers were less willing to accept younger children; Freeman and Nkomo 2006a, b ) ; orphan girls younger than six were more likely to be offered foster care (Townsend and Dawes 2004,
2007 ) ; (3) gender [caregivers reported more willingness to take in female orphans (Townsend and Dawes 2004, 2007 ) ]; (4) additional costs [e.g., school fees (Townsend and Dawes 2004 ; Matshalaga and Powell 2002 ) ]; and (5) poverty (Howard et al. 2006 ) . These factors may also be changing due to the increasing number of orphans and potentially limited number of family caregivers (Nyambedha et al. 2003 ).
8.4.2 Education
Children’s schooling is affected by the HIV/AIDS epidemic in a number of ways, but the data on schooling is mixed. The differing results may be partially explained by the various indicators used to assess educational outcomes. Some studies focus on enrollment in primary or secondary school and on whether the children are at the age-appropriate grade level. Even when focusing on enrollment in primary school, the results of studies examining the impact of parental illness and death on schooling are mixed. While some studies have documented lower school enroll-ment among orphans, foster children, or children of HIV-infected parents (Mishra et al. 2007 ; Urassa et al. 1997 ) , other studies have failed to fi nd signifi cant differ-ences (Ainsworth et al. 2005 ; Floyd et al. 2007 ; Timaeus and Boler 2007 ) . In a large multicountry study, orphans were approximately 13% less likely to attend school than nonorphans (Monasch and Boerma 2004 ) . Makame et al. ( 2002 ) also found higher rates of children who were out of school among those orphaned by HIV/AIDS compared to nonorphans from the same poor community. Among chil-dren in Tanzania, maternal orphans and chilchil-dren in households that had recently experienced an adult death were likely to delay beginning primary school; but there was no evidence that they were dropping out of primary school due to their orphan status or adult death (Ainsworth et al. 2005 ) . While having a parent who was HIV positive did not have an impact on primary school enrollment in Malawi, children of HIV-positive parents were less likely to attend secondary school (Floyd et al. 2007 ) .
The impact of HIV could reduce a family’s ability to pay for school fees or an orphaned child could be left with a caregiver who is less willing to support educa-tion than their parents would have been (Ainsworth et al. 2005 ) . In a sample of 200 orphaned girls, Kang et al. ( 2008 ) found that paternal orphans were more likely to be out of school than maternal orphans because of lack of funds.
Additionally, the gender of the parent or caretaker with whom the child is living may impact educational outcomes. Better educational outcomes have been found for orphans living in a female-headed household (Nyamukapa and Gregson 2005 ) , an elderly headed household (Oleke et al. 2007 ) , and in households with greater access to external resources (Nyamukapa and Gregson et al. 2005 ; Oleke et al.
2007 ) . While school enrollment data are mixed, school attendance frequently drops immediately prior to and following a parent’s death (Ainsworth et al. 2005 ; Evans and Miguel 2007 ) . These results are particularly true for children who lost a mother and those with low baseline academic performance (Evans and Miguel 2007 ) . Girls sharply reduced their school hours immediately following the death of a parent due to the increased household responsibility (Ainsworth et al. 2005 ) . Maternal orphans and young women with an infected parent appear to be at increased risk for poor educational outcomes when compared to paternal orphans, double orphans, or no norphans (Beegle et al. 2006, 2009 ; Case and Ardington 2006 ; Nyamukapa and Gregson 2005 ) . Maternal orphans had 1 year less of school-ing (Beegle et al. 2009 ) , were less likely to be enrolled in school, had completed signifi cantly fewer years of schooling (Case and Ardington 2006 ) , and had lower primary school completion rates (Nyamukapa et al. 2003 ; Nyamukapa and Gregson 2005 ) .
There appear to be several reasons for low levels of primary school completion among maternal orphans. If the father is alive, others view him as being responsible for his children’s needs but surviving fathers are less committed than surviving mothers to securing their children’s education and are more committed to the needs of children from subsequent marriages. Means testing procedures applied by gov-ernment, donor agencies, and NGOs disproportionately exclude children from receiving resources if their fathers are still alive (Nyamukapa and Gregson 2005 ;Rosenberg et al. 2008 ) .
Given the mixed fi ndings on educational outcomes and the fact that the differ-ences in enrollment rates are small, researchers have begun to explore other factors that may be driving differences in school enrollment. Ainsworth and Filmer ( 2006 ) presented data indicating that the gap between the enrollment rate of poor and rich is greater than the gap between orphans and nonorphans. Lloyd and Blanc ( 1996 ) found that the household resources available to children were associated with school enrollment while children with living parents had slightly higher rates of school enrollment. Although there are some exceptions, Ainsworth and Filmer ( 2006 , p. 1114) conclude that “orphan status in most countries may not be a good targeting criterion for ‘traditional’ programs aimed at raising enrollment rates.” However, there is consensus that keeping orphans in school is a part of HIV control (Gregson et al. 2001 ) .
8.4.3 Mental Health and Well-Being
There has been increasing focus and concern regarding the psychological well-being of children who are affected by HIV/AIDS (Foster 2002a ; Omigbodun 2008 ) . Children living in areas where there is a high prevalence of HIV/AIDS are likely to have experienced multiple stressors and losses as a result of the disease.
When a child’s parent is ill, a child frequently watches as their parent’s health deteriorates. During this time, children can experience a range of emotions, including heightened levels of anxiety and depression (Bauman et al. 2006 ; Sengendo and Nambi 1997 ) . A staggering two-thirds of children with an ill mother had depression scores in the clinically signifi cant range (Bauman et al.
2006 ) . Anxiety is expressed by children who are concerned about the family’s source of income and concerns about being separated from siblings (Sengendo and Nambi 1997 ) . The loss of a parent is typically the focus in research; however, losses of other family members, teachers, and other adults in their community can have an adverse mental health effect on children.
8.4.3.1 Internalizing Disorders
Following the death of a parent, children have higher rates of internalizing behavior problems, such as depression and anxiety (Atwine et al. 2005 ; Cluver et al. 2007 ; Makame et al. 2002 ; Sengendo and Nambi 1997 ) . In a large study of 1,200 youth, Cluver and colleagues assessed three groups: (1) children orphaned by HIV/AIDS, (2) children orphaned by other causes, and (3) and children who are not orphans in South Africa (Cluver et al. 2007, 2008 ; Cluver and Gardner 2006 ) . They found high levels of psychopathology across all three groups, with the highest rates for posttrau-matic stress disorder (PTSD) (50%) and depression (17%), but these rates could not be explained by differences in exposure to community and household violence (Cluver et al. 2007 ) . Social support, however, was found to moderate this relationship, whereby children orphaned by HIV/AIDS with higher levels of social support reported lower levels of PTSD symptoms compared to those that perceived their social support as low (Cluver et al. 2009 ) . They also compared rates of depression among these three groups and found that children who were orphaned due to HIV/AIDS reported the highest rates of depression and peer problems when compared to both nonorphaned children and children orphaned as a result of other causes. While poverty, stigma, and caregiver’s illness are risk factors, receipt of social support and school attendance were protective factors (Cluver et al. 2007, 2009 ; Hamra et al. 2006 ) .
Makaya et al. ( 2002 ) conducted clinical interviews with 354 Congolese orphans and found that 20% were experiencing psychological diffi culties, including depres-sion, anxiety, irritability (34%), and PTSD (39%). Suicide is a major concern because 12% of orphans that were interviewed reported wishing they were dead compared to 3% of the nonorphan children (Atwine et al. 2005 ) ; while in another
study, 34% of children had contemplated suicide compared to 12% of nonorphans (Makame et al. 2002 ) .
Stigma and discrimination may compound the emotional distress that many chil-dren experience (Foster et al. 1997 ). Stigma can contribute to social isolation, bul-lying, shame, and a lack of opportunity to discuss their loss and access social support (Cluver and Gardner 2007 ; Cluver et al. 2009 ) . These fi ndings across multiple stud-ies on psychological distress refl ect a signifi cant cause for concern when addressing the needs of orphans affected by HIV/AIDS.
8.4.3.2 Externalizing Disorders
Externalizing reactions have also been documented among orphans, such as stealing, truancy, aggression, and running away, but these are not as common as internalizing behavior problems (Forsyth et al. 1996 ) . Rates of conduct problems and delinquency were higher among the children orphaned due to HIV/AIDS when compared to those orphaned for other reasons and a group of nonorphans (Cluver et al. 2008 ) .
8.4.4 HIV Risk Behaviors
Despite increasing access to HIV prevention education and programs in the region, levels of HIV knowledge remain low. Only 28% of 10–14 year olds were able to identify how to prevent the transmission of HIV (Arnab and Serumanga-Zake 2006 ) . Similar to fi ndings from developed countries, parental presence is associated with sexual health among adolescents in sub-Saharan Africa. When adolescents are living with both parents, they are less likely to have had sex (Ngom et al. 2003 ; Magnani et al. 2002 ; Karim et al. 2003 ) , but some studies have found that parental presence has a stronger effect on adolescent females (Karim et al. 2003 ) . For this population, HIV disease is inextricably associated with having discussions of risky sexual behav-ior with adults. When adolescent orphans were asked about their preference for com-munication within the family about HIV, youth reported wanting to have candid discussions with adults about parental illness and death. Adults, however, reported not feeling prepared to be able to have these discussions (Wood et al. 2006 ) .
Orphans have therefore been identifi ed as a population at high risk for HIV infec-tion (Birdthistle et al. 2008 ; Kang et al. 2008 ; Thurman et al. 2006b ) . Orphans are more likely to report sexual debut at a younger age (Thurman et al. 2006b ) , to be sexually active (Kang et al. 2008 ) , and to have had multiple partners. Higher rates of HIV and other STIs as well as pregnancies are also higher among orphans (Birdthistle et al. 2008 ; Kang et al. 2008 ; Operario et al. 2007 ) .
When the results have been evaluated by orphan type, maternal and double orphans appear to be at highest risk for HIV infection (Gregson et al. 2005 ) . Maternal orphans have been found to have the highest rates of HIV when compared to other adolescent girls (Kang et al. 2008 ) as they are more likely to initiate sex early and
to have had multiple partners. Paternal loss has not been found to be related to HIV infection or behavioral risk factors (Gregson et al. 2005 ) .
Marital status has also been shown to modify the relationship between orphan status and HIV risk. Girls who were or had been married were more likely to test positive for HIV and HSV-2, but married orphans were not at higher risk for HIV or HSV-2 than married nonorphans (Birdthistle et al. 2008 ) . Heightened risk is related to reduced educational opportunities and living with an HIV seropositive parent that is associated with poorer household circumstances which could result in earlier ini-tiation of sex and marriage to a man who is much older (Gregson et al. 2005 ) .