SECTION VI: DISCUSSION AND CONCLUSIONS Chapter 12: Discussion of Results
2.2. Epidemiological factors impacting on the psychosocial well-being of children
2.2.1. The changing face of society
The HIV/AIDS pandemic has significant implications for population demographics, suggesting that children will be raised in a society that will be different from the one in which their parents were raised. The changing demography indicates the nature and scale of the problem and suggests important shifts in attitudes that are likely to be held by parents, educators and society at large (Giese, Meintjes, Croke, & Chamberlain, 2003; Kolisang & Lourens, 2002; Cook, 1998).
• Total population loss: Within sub-Saharan Africa, death rates may double or even triple (UNAIDS, 2001). In a world that can barely sustain its' current population, one needs to acknowledge that death is nearly always emotionally distressing, most especially, if the death results in orphanhood. The social costs of the increased number of deaths are enormous and include disintegration of the family and extended family systems, disruption to all social structures and the pervasive effects of anxiety, grief and fear. As an elderly community stalwart, Mrs Ngubu6 said "we are so tired of deaths, we can't even find the energy to cry, to sing, to do all the things that we are supposed to do... there are just too many deaths every month. Every weekend we spend our time going from funeral to funeral. We are tired"
(Personal communication with members of the partnering communities, 2002).
Pseudonyms will be used throughout this dissertation to protect the identity of community members
Life expectancy patterns: There is an anticipated drop in life expectancy from 60 - 70 years to 40 years or less in nine sub-Saharan countries by the year 2010 (USAID, 1997). Lowered life expectancy detrimentally impacts on one's life plans and the value that one places on the future. Approximately 50% of HIV+ people are infected before their 25* birthday and most will die before their 35* birthday, leaving behind a generation of children raised by grandparents and extended family members (UNAIDS, 2001).
Infant and child mortality rates: HIV/AIDS has a profound effect on the mortality of infants (under 1 year of age) and children less than 5 years of age as a result of MTCT through intrauterine and perinatal infection. AIDS-related mortality will eliminate the gains made in child survival over the past 20 years. Child mortality rates are expected to triple in Zambia and Zimbabwe and double in Kenya and Uganda (South Africa was not included in this study) (ibid.). This could adversely impact on the attachment relationship formed between an infant and the primary caregiver, who will be fearful of the child's chances of survival. One South African report has indicated that HIV/AIDS orphans are 2,5 to 3,5 times more likely to die than non-orphans (HIV Infant Care Programme, 2000, in Giese, 2002).
One of the debates pertaining to treatment and prevention programmes revolves around the issue of providing anti-retroviral treatment (ART) to HIV+ pregnant women. Long-course ART programmes offered during pregnancy in combination with caesarean section deliveries can reduce MTCT to very low rates (Gow et al., 2002). In resource-limited environments, a brief course of ART given to the mother prior to giving birth by caesarean, followed by a short course to the babies after birth, can reduce MTCT by 35 - 50% (Gow et al., 2002). A ten year longitudinal study on 3,004 children showed unequivocally that maternal HIV status and survival are strong predictors of child survival (Nakiyingi, Whitworth, Ruberantwari, Busingye, Mbulaiteye & Zaba, 2002). The risk of child mortality was three times as high for children of HIV+ mothers, with 14% of child mortality being directly attributable to maternal HIV+ status (ibid.). Children whose HIV+ mothers had already died were five times more likely to die before age 5 years, than the children of surviving HIV+ mothers (ibid.). Analysis of these figures can leave no doubt that children are better off physically (and emotionally) if their mothers are able to be the primary caregivers. Withholding ART regimens seems short-sighted and unethical.
Age demographics: In sub-Saharan Africa, there will be 12 times as many children under age 15 as adults over age 64 (McDevit, 1996), leaving a predominantly child population with relatively scarce numbers of adults and elderly people. This will inevitably change concepts of childhood and the needs, responsibilities and rights of children, as well as attitudes towards the elderly. At present, 60% of all people living in South Africa who are classified as poor are either over the age of 60 years or younger then 18 years of age (Woolard &
Barberton, in Richter, 2003).
Gender ratios: In South Africa, women have a higher rate of HIV infection (12,8%) than men (9,5%), Within the 15 - 24 age range, double the number of women (12%) were infected than men (6%) (Shisana & Simbayi, 2002). It is probable that there could be 1.5 men for
every woman in some sub-Saharan African countries within the next 20 years (Hunter &
Williamson, 2000). It also seems that physiologically immature and post-menopausal women are at increased risk of infection (Adar & Stevens, 2000; Rooth & Dryer, 2002). Within cultural groups who retain division of labour along gender lines, especially in terms of child care being perceived as a gender-specific task, these demographics will significantly impact on general well being of families and communities (Baylies & Bujira, 2002; de la Harpe, de la Harpe, Leitch, & Derwent, 1998; Foster & Williamson, 2000; Marcus, 2002). In addition, this will create a situation in which there are fewer economically active females, even though women will continue to be the backbone and strength behind most community based and public health initiatives (Baylies & Bujira, 2002).
Degenerating circumstances of the elderly: In general older people will suffer more economic setbacks due to the loss of support from their children who die from HIV/AIDS, combined with the perceived obligation that they have to care for orphaned grandchildren.
The responsibility of caring for children and the sick will probably fall largely on elderly women, who will also experience a drastic deterioration in their social and material resources for coping (Ayieko, 2003; Hunter & Williamson, 2000).
Household composition and co-residence: The highest prevalence rate (28%) of HIV infection in South Africa occurs in the 25 - 29 age group, followed by the 30 - 34 age group where 24% of HIV+ individuals occur (Shisana & Simbayi, 2002). Thus 52% of HIV+
individuals are within the childbearing, economically-active segment of the population. The consequences are that, firstly, the proportion of households with three resident generations will decrease, as young and middle-aged parents die and grandparents are left with young children in their care (Hunter & Williamson, 1999). The number of households in sub- Saharan Africa that currently have orphans in their care (usually in informal foster placements) is already a substantial proportion of the total. This pattern will increase exponentially in all high prevalence communities, impacting on most families whether they have an HIV+ member or not. Secondly, 16 % of all households may be headed by single parents (Hunter & Williamson, 2000). Even though there is a higher rate of HIV infection amongst women, it is likely that the majority of single parents will be widows (Ibid.).
Widows are more likely to be migratory as they seek employment or remarry, while continuing to care for their children (Foster & Williamson, 2000). Furthermore, the extended family, the foundation stone of much of traditional black culture, will be burdened and may collapse under the strain (Foster, 1998; Giese et al., 2003; Marcus, 2002).
Geographic Profiles: Despite concern for the deep rural areas of Africa, people living in the urban informal settlements appear to be at greatest risk of HrV infection, followed by those resident in urban areas (Shisana & Simbayi, 2002). The drift towards urbanisation for economic survival has given rise to many informal settlements that lack basic facilities and present their own risk of opportunistic infections. In the main, informal settlements are poverty stricken ghettos. Nevertheless, trends towards urbanisation continue to increase in most developing countries. There is however a tendency for urban dwellers to return to rural areas when they become ill and unemployable in the towns and cities (Foster & Williamson,
2000; UNICEF, 1999). In addition, the townships of South Africa carry a legacy from the apartheid era and may lack infrastructure, similar in many respects to the informal settlements found elsewhere in the world.