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Keywords:

  • antiretroviral therapy;
  • HIV care;
  • incidence;
  • orphanhood;
  • population attribution fraction;
  • Uganda

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Objective  To compare the incidence of orphanhood among children <15 years of age before and after implementing HIV care in Rakai, Uganda.

Methods  Annual household censuses and surveys were conducted on January 2001 to September 2009 in a community cohort, where HIV care including antiretroviral therapy (ART) started in June 2004. Data included parental survival of children aged 0–14 years and HIV status from consenting adults aged 15–49 years. The incidence of orphanhood was estimated as the number of new orphans divided by person-years, determined during three time periods: Pre-HIV care roll-out (January 2001–June 2003) 1–3 years before the advent of HIV care in Rakai programme, HIV care transition from September 2003–May 2006, and the expanded HIV care period from August 2006–September 2009. Poisson regression was used to estimate incidence rate ratios (IRR) of orphanhood and 95% confidence intervals, and the Population attributable fraction (PAF) of incident orphanhood due to HIV+ parental status was estimated as pd*(RR-1)/RR.

Results  A total of 20 823, 21 770 and 23 700 children aged 0–14 years were censused at the three periods, respectively. The prevalence of orphanhood significantly declined; 17.2% during Pre-HIV care roll-out, 16.0% at HIV care transition and 12.6% at expanded HIV care period (inline image, P < 0.0001). The incidence of orphanhood also declined significantly with increasing HIV care from 2.10/100 person-years (py), 1.57/100 py and 1.07/100 py (inline image, P < 0.0001). The largest declines were observed among children with HIV+ parent(s), 8.2/100 pyr, 5.2/100 pys and 3.4/100 pyr. PAF also declined from 35.3% in the pre-HIV care to 27.6% in the expanded HIV care periods.

Conclusion  After the availability of ART, there was a decline in PAF of incident orphanhood due to parental HIV+ status, and in the incidence of orphanhood especially among children with HIV-infected parents.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Sub-Saharan Africa (SSA) remains heavily affected by HIV/AIDS contributing at least two thirds (67.6%) of the global 33.3 million infections, about three quarters of AIDS deaths, and 69.2% of the global new infections (UNAIDS/WHO 2010). HIV/AIDS-related adult mortality has resulted in a large number of orphaned children (Sewankambo et al. 1994, 2000; Makumbi et al. 2005). In Uganda, 23.3% of children aged 0–14 years have lost one or both parents, and 30% are either orphans or vulnerable children (UDHS 2006). Studies conducted in Zimbabwe, Uganda, Tanzania, Malawi and South Africa indicate a high incidence of orphanhood ranging from 1.5 to 2.7 per 100 person-years (py) (Makumbi et al. 2005; Watts et al. 2005; Hosegood et al. 2007), with about 37.3% risk of incident orphanhood attributable to parental HIV infection (Makumbi et al. 2005). However, since the advent of HIV care services such as cotrimoxazole prophylaxis and antiretroviral therapy (ART), HIV-infected adults survive longer and orphanhood incidence among children under 18 years with HIV-infected parents has dropped (Jonathan et al. 2004, 2008; Nunn et al. 2008. A study conducted in Tororo, Uganda, showed that provision of ART to a cohort of HIV-infected adults was associated with a 93% reduction in orphanhood, and a reduction in mortality among both uninfected children and their infected parents (Jonathan et al. 2004, 2008). In Botswana, model-based estimates also suggest reductions in the number of new orphans by 40% as result of ART programmes, which cover about 80% of those in need (John et al. 2008), and a preventive impact on children welfare and health if Highly Active Anti-Retroviral Therapy (HAART) access is universal (Anema et al. 2011). Although the scale up of HIV care programmes in SSA has resulted in improved adult survival of the HIV-infected individuals, the effect of these programmes on the incidence of orphanhood has not been fully explored at a population level. We therefore compared the incidence of orphanhood among children aged <15 years of age before and after the implementation of an HIV care programme in a rural resource limited setting of Rakai district, southwestern Uganda, with a mature generalized HIV/AIDS epidemic.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Study setting and population

The Rakai Health Sciences Program (RHSP) is a collaboration between researchers working at the Johns Hopkins University, Baltimore, MD, USA, and Makerere University, Kampala Uganda, and the Ministry of Health through the Uganda Virus Research Institute, Uganda. RHSP has followed a population-based cohort in 50 rural villages in Rakai district since 1994 through the Rakai Community Cohort Study (RCCS), with annual follow-up of all persons aged 15–49 years. The community cohort annually collects census data including marital status, sex, age of each resident and each individual household member’s relationship to the household head, their survival status and out- or in-migration into the household. During census data collection, questions about survival of biological parents for each household member are asked to determine whether one or both parents are alive or dead, and if still alive, then co-residence is determined. Data on household possessions (radio, TV, automobile, and bicycle), structure (type of roofing material, floor, walls and number of rooms), type of water sources (collected after 1998) and possession of domestic animals and poultry are also obtained. Study participants are recruited through household surveys, where individual interviews are conducted with consenting participants, using a quantitative data collection tool, and blood for HIV testing is obtained. Annually a total of about 14 000 participants aged 15–49 years are interviewed through same sex interviewer-administered questionnaires. For this analysis, the HIV care period was categorized into three intervals, Pre-HIV care roll-out (January 2001–July 2003) 1–3 years before the advent of HIV care in the Rakai programme, HIV care transition from September 2003–June 2006 that includes the year of initiation of the HIV care programme, and the expanded HIV care period from August 2006–November 2009, which is 2–5 years after the HIV care programme was established. The proportion of adult (15–49 years) HIV-positive study participants receiving ART in Rakai at the two HIV care periods when HAART was available in the communities: in the HIV care transition (approximately 10% females, 7% males) and in the expanded HIV care (approximately 20% female, 18% males). However, during the expanded HIV care period, about 48% females and 37% males who were HIV+ were enrolled into HIV care including pre-ART services. Each adult with available HIV results was linked to their HIV-test results at the start of each of the three HIV care inter-survey analysis periods. Then, every child with a co-resident biological parent was linked to the parent’s HIV status. Parental HIV status was categorized as HIV-negative (HIV-negative) if both parents were HIV uninfected, or one parent uninfected and the other with unknown status; HIV-positive (HIV+) if at least one parent was known to be HIV infected; Unknown status if both parents’ HIV status was unknown at the start of each inter-survey HIV care period. The children’s age was categorized as <5 years (0–4), 5–9 years or 10–14 years.

All consenting participants provided venous blood for HIV-1 testing using two different enzyme immunoassays (Vironostika HIV-1; Organon Teknika, Charlotte, NC, USA, and Cambridge Biotech, Worcester, MA, USA), with Western blot confirmation of all discordant tests and of all HIV seroconverters (HIV-1 WB; Bio-Merieux–Vitek, St Louis, MO, USA).

Household social economic status (SES) was based on the structure of the dwelling. Modern construction materials such as cement, iron sheets or roofing tiles are expensive, and their use in this rural setting is a potential indicator of wealth. Therefore, the dwelling structure was categorized as high SES if its roofing material was iron/tiles and both the walls and floor were cement, while it was categorized as low SES if dwelling structure had only one or none of the modern materials (for the roof, walls and floor) used in construction of the high SES. The middle SES category had at most two of the dwelling structure parts (roof, walls and floor) constructed using modern materials. Materials most commonly used by low SES households were grass thatch for the roof, and mud and wattle for the walls or floor. All annual census and survey data were collected by well-trained and experienced research assistants (RA) who visit all households in the communities at every study round. The RCCS where these data are drawn received ethical clearance from the Uganda Virus Research Institute Science and ethics Committee, and the Uganda national council of Science and Technology.

HIV care programme

Since June 2004, with funding from the President’s Emergency Plan For AIDS Relief (PEPFAR), the RHSP has cumulatively provided HIV care to about 5000 individuals, including ART to approximately 2300 HIV-infected persons, with a CD4 ≤ 250 cells/mm3 or WHO Stage IV disease. HIV care was provided via 17 mobile community-based outpatient clinics, called suubi or ‘Hope’ clinics, operated on a bi-weekly basis. All patients received a health status evaluation, health and HIV prevention education, treatment for opportunistic infections and a basic HIV care package consisting of cotrimoxazole for opportunistic infection prophylaxis, a clean water vessel and hypochlorite solution for water disinfection, two insecticide treated bed nets for malaria prevention and were offered free condoms. Among the Rakai cohort participants interviewed between February 2005 and August 2006, 11.9% (1451/12216) were HIV+. However, only 68.5% (784/1145) of the HIV+ individuals enrolled into HIV care within 6 months post-receipt of Voluntary Counseling and Testing (VCT); enrolment into HIV care was greater among females (71%) than males (62.3%) (Nakigozi et al. 2011).

Statistical analysis

The prevalence of orphanhood was estimated as the proportion of children aged <15 years, with one or both parents deceased identified at household censuses at the baseline survey of each of the HIV care analysis period, that is, January 2001/April 2002 (pre-HIV care roll-out), September 2003/October 2004 (HIV care transition) and August 2006/March 2008 (expanded HIV care) periods. All orphans were children aged <15 years and resident in the household at the baseline survey of each HIV care period; a maternal orphan was defined as a child with a dead biological mother but with a biological father still alive irrespective of his co-residence status; a paternal orphan was a child with a dead biological father but with a biological mother still alive irrespective of her co-residence status, while a double orphan was a child who had both biological parents dead. For all children with any of the surviving biological parent, we assessed parental co-residence by orphanhood status and type.

For the incidence of orphanhood, children who were non-orphans at the baseline survey of each of the HIV care analysis period and were still residents in those households at the inter-survey follow-up visit were included in this analysis. The incidence was estimated as the number of children who lost at least one parent during the inter-survey HIV care follow-up periods, divided by the total person-years of exposure for non-orphaned children eligible for the incidence analysis at each HIV care period baseline survey. It was assumed that on average, incident orphanhood occurred in the mid-point of each follow-up interval (because dates of parent’s death were not known), on the assumption that these events were evenly distributed over time. Children in households who out-migrated between each HIV care period baseline and follow-up censuses were removed from the analysis within that interval. Children’s age was collected as of last birthday because many of the adult respondents could not tell the exact dates of birth. Thus, for this analysis, eligibility was being <15 years at the start of each HIV care interval, whose median follow-up time was 1.3 person-years. We estimated the incidence of orphanhood per 100 py as the number of new orphans divided by person-time of follow-up, overall and stratified by the child’s reported ages categorized as 0–4, 5–9 and 10–14 years and parental HIV status. We used Poisson regression to estimate the incidence rate ratios (IRR) of orphanhood and their 95% confidence intervals comparing the three HIV care periods: pre-HIV care roll-out, HIV care transition and expanded HIV care period.

We estimated the population attribution fraction [PAF (%)] of incident orphanhood due to HIV+ parental status using the formula, PAF = pd*[(IRR-1)/IRR]; where pd = proportion of cases (incident orphans) exposed to the risk factor (HIV+ parent); IRR = the incidence rate ratio (the relative risk) adjusted for potential confounders (Rockhill et al. 1998). We also conducted a test for trend for the prevalence and incidence of orphanhood. Statistical analyses used Stata software package version 9.2 (College Station, Texas, USA).

Sub-analysis for the competing risk.  To address the competing risk of child death and becoming orphaned, we conducted a competing risk analysis in a sub-analysis. In this analysis, we constructed a composite orphanhood/mortality outcome measure, which combined both the incidence orphanhood and death of children aged less than 15 years during the inter-survey visits considered for this analysis.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

Table 1 shows the distribution of children and household characteristics. We observed a higher proportion of females and the under-five (U5) children across all HIV care periods. About 9% of the children had at least one parent known to be HIV+. The majority (approximately 57%) of the children are still co-resident with their biological parents. Children’s co-residence was higher with the mother compared to the father, irrespective of whether the child was an orphan or a non-orphan, across all HIV care periods. The proportion of children in households with a ‘high’ dwelling structure ranking, as a measure of SES has been significantly increasing over the HIV care periods, 31.9%, 35.4, 41.4% (inline image = 192.75, P < 0.0001).

Table 1.  Distribution of children (<15 years) and household characteristics by HIV care period
 Pre-HIV care roll-out (January 2001/April 2002)HIV care transition (September 2003/October 2004)Expanded HIV care (August 2006/March 2008)
N (%) N (%) N (%)
  1. SES, social economic status. High if iron/tiles (roof), cement (walls and floor); Low if no modern materials but mainly grass thatch roof and, mud and wattle for walls and/or floor; Middle SES if at most two parts of structure used modern materials; about seven observation are missing data on SES.

Total20 823 (100)21 770 (100)23 700 (100)
Gender
 Female10 633 (51.1)11 145 (51.2)12 211 (51.5)
 Male10 190 (48.9)10 625 (48.8)11 489 (48.5)
Age-group
 0–48090 (38.9)8115 (37.3)8686 (36.6)
 5–96773 (32.5)7225 (33.2)7869 (33.2)
 10–145960 (28.6)6430 (29.5)7145 (30.1)
Parental HIV status
 Both HIV−/One known HIV− and one Unknown11 303 (54.3)11 389 (52.3)13 765 (58.1)
 Both unknown7639 (36.7)8535 (39.2)7888 (33.3)
 At least one known HIV+1881 (9.0)1846 (8.5)2047 (8.6)
Parental co-residence
 Non-orphans
  Both co-resident11 949 (57.4)12 332 (56.6)13 634 (57.5)
  Both not co-resident2192 (10.5)2486 (11.4)3001 (12.7)
  Mother not co-resident776 (3.7)895 (4.1)1009 (4.3)
  Father not co-resident2323 (11.2)2567 (11.8)3071 (13.0)
 Orphans
  Paternal but mother not co-resident692 (3.3)635 (2.9)567 (2.4)
  Maternal but father not co-resident405 (1.9)424 (1.9)396 (1.7)
  Paternal with co-resident mother1214 (5.8)1184 (5.4)1046 (4.4)
  Maternal with co-resident father351 (1.7)321 (1.5)280 (1.2)
  Double orphans921 (4.4)926 (4.3)696 (2.9)
Household’s SES*
 Dwelling structure Ranking
  High6636 (31.9)7714 (35.4)9802 (41.4)
  Middle5622 (27.0)6428 (29.5)7366 (31.1)
  Low8556 (41.1)7622 (35.0)6511 (27.5)
 Toilet/latrine
  None928 (4.5)463 (2.1)701 (3.0)
  Yes19 895 (95.5)21 306 (97.9)22 971 (97.0)
 Source of water
  Lake/river559 (2.7)2038 (9.4)1819 (7.7)
  Tap/protected20 264 (97.3)19 732 (90.6)21 874 (92.3)

Table 2 shows the prevalence of orphanhood by the children’s age and parental HIV-infection status at the three time periods. A total of 20 823, 21 700 and 23 700 children aged 0–14 years were available in the censused households at the baseline visit of each HIV care periods, making them eligible for this analysis. On average, 9.0% of the eligible children had at least one known HIV+ parent at the baseline survey of each HIV care period. Overall, the prevalence of orphanhood was highest in the earliest Pre-HIV care roll-out period 17.2%, which declined to 16.0% at HIV care transition and 12.6% at expanded HIV care (inline image, P < 0.001). Paternal orphanhood was the most prevalent form of parental loss in all age groups and time periods. Loss of both parents (double orphanhood) was higher than loss of a mother alone during the first two periods, but very similar during the expanded HIV care period (2006–2009). The prevalence of orphanhood declined markedly between the pre-HIV care roll-out and HIV care periods among children born to HIV+ parents and those with unknown parental HIV status. The prevalence of orphanhood was significantly lower among children in middle SES households relative to those in high/low SES, irrespective of the HIV care period.

Table 2.  Trends in the prevalence of orphanhood by child age, parental HIV status and HIV care period
AllPre-HIV care roll-out (January 2001/April 2002)HIV care transition (September 2003/Oct 2004)Expanded HIV care (August 2006/March 2008) P-value for inline image over time
N (%) N (%) N (%) 
  1. SES, social economic status.

  2. Orphanhood prevalence was calculated based on reported loss of one or both parents at start of each analysis interval (period).

  3. *HIV negative: Both parents are HIV− or one is HIV negative and the other has unknown status; HIV+: at least one parent HIV+; Unknown: Both parents’ status unknown.

  4. †High if iron/tiles (roof), cement (walls and floor); Low if no modern materials but mainly grass thatch roof and, mud and wattle for walls and/or floor; Middle SES if at most two parts of structure used modern materials; about seven observation are missing data on SES.

Type of orphanhood20 823 (100)21 770 (100)23 700 (100) 
Overall orphans3583 (17.2)3490 (16.0)2985 (12.6)<0.001
 Double921 (4.4)926 (4.3)696 (2.9) 
 Maternal alone756 (3.6)745 (3.4)676 (2.8) 
 Paternal alone1906 (9.2)1819 (8.4)1613 (6.8) 
Parental HIV status*
 HIV+463/1881 (24.6)439/1846 (23.7)377/2047 (18.4)<0.0001
 HIV negative641/11303 (5.7)587/11389 (5.2)638/13 765 (4.6)0.0002
 Unknown2479/7639 (32.5)2464/8535 (28.9)1969/7888 (25.0)<0.0001
Children with HIV+ parents
 0–4 HIV+68/790 (8.6)61/729 (8.4)33/767 (4.3)0.001
 5–9 HIV+187/633 (29.5)148/634 (23.3)123/681 (18.1)<0.0001
 10–14 HIV+208/458 (45.4)230/483 (47.6)221/599 (36.8)<0.0001
Children with unknown parent HIV status
 0–4168/1809 (9.3)169/2192 (7.7)139/2018 (6.9)0.0063
 5–9793/2717 (29.2)739/2864 (25.8)585/2676 (21.7)<0.0001
 10–141518/3113 (48.8)1556/3479 (44.7)1245/3194 (39.0)<0.0001
Household’s SES†
 Rank of dwelling structure
  High150/1464 (10.2)138/1689 (8.2)194/2529 (7.7) 
  Middle38/446 (8.5)18/354 (8.1)33/873 (3.8) 
  Low3395/18913 (18.0)3334/19726 (17.0)2758/20292 (13.6) 

The incidence of orphanhood by child’s age and parental HIV status is shown in Table 3. A total of 13 689, 14 258 and 15 472 were non-orphans at the baseline visit of each of the three time periods, respectively, and were still available in their households at the follow-up visit making them eligible for this analysis. The median (IQR) follow-up time in years in the inter-survey periods was 1.23 (1.19, 1.26) for Pre-HIV care roll-out, 1.43 (1.40, 1.45) for HIV care transition and 1.72 (1.69, 1.77) for HIV care periods. A total of 943 incident orphans were observed with 346 in pre-HIVcare roll-out, 314 in HIV care transition and 281 in the expanded HIV care period. In all the three periods, paternal orphanhood contributed the highest proportion of new orphans: 66.5%, 74.7% and 73.0% in the three consecutive periods, respectively. Comparing the pre-HIV care and HIV care periods, among the incident orphans, the proportion of paternal orphans significantly increased 66.5–73.0% (results not shown in Table 3).

Table 3.  Incidence of orphanhood by child’s age parental HIV status by HIV care periods
 Pre-HIV care roll-out (January 2001–July 2003)HIV care transition (September 2003–June 2006)Expanded HIV care (August 2006–September 2009)
Total non-orphansIncident orphan/person-yearsIncidence rate/100 person-yearsTotal non-orphansIncident orphan/person-yearsIncidence rate/100 person-yearsTotal non-orphansIncident orphan/person-yearsIncidence rate/100 person-years
  1. *HIV-negative: Both HIV− or HIV− and other unknown; HIV+: At least one parent HIV+; Unknown: Both parents’ status unknown.

Overall13 689346/16483.92.1014 258316/20222.21.5615 472281/26299.31.07
Parental HIV status
 HIV-negative8833140/10702.31.39082102/129420.810 538123/180040.7
 Unknown3790105/4543.42.34117138/5808.72.43750 92/6328.91.5
 HIV+1066101/1238.38.21059 76/1471.65.21184 66/1966.23.4
Child age (years)
 0–46198101/7511.21.346260 85/8909.00.956475 83/11038.50.75
  Parental HIV status
   HIV-negative4457 29/5433.00.534357 36/62130.584780 47/8181.30.57
   Unknown1207 24/1455.71.651417 25/2012.21.241184 17/2001.60.85
   HIV+534 48/622.37.71486 24/682.73.52511 19/855.52.22
 5–94738137/56882.415199137/73621.865734123/97361.26
  Parental HIV status
   HIV-negative2825 61/3408.21.793191 37/4549.20.813793 53/6472.80.82
   Unknown1547 40/1856.12.151605 67/2255.72.971499 43/2529.81.70
   HIV+366 36/424.08.49403 33/556.75.93442 27/732.83.68
 10–142753108/32843.292799 94/39512.383263 75/55251.36
  Parental HIV status
   HIV-negative1551 50/1861.02.691534 29/2178.71.331965 23/3350.00.69
   Unknown1036 41/1231.33.331095 46/1540.62.991067 32/1797.41.78
   HIV+166 17/191.98.86170 19/231.98.19231 20/377.85.29

The incidence of orphanhood declined significantly from 2.10/100 py during the pre-HIV care roll-out to 1.57/100 py at HIV care transition and to 1.07/100 py during the expanded HIV care period (P < 0.001). Although there was a general decline in the incidence of orphanhood even among children of HIV-uninfected parents, the largest declines in incident orphanhood were more evident among children with HIV+ parent(s), 8.1/100 pyr in the pre-HIV care roll-out, 5.2/100 pys in the HIV care transition and 3.4/100 pyr in the expanded HIV care period. Among children aged 0–4 years with HIV-infected parents, the incidence of orphanhood prior to HIV care roll-out was high at 7.71/100 py, but significantly declined during HIV care transition (3.52/100 py) and expanded HIV care periods (2.22/100 py). Similar trends were observed for the 5–9 and 10–14 year olds.

Table 4 shows the PAF of incident orphanhood due to parental HIV status by HIV care periods. The PAF of incident orphanhood declined from 35.3% in the pre-HIV care to 27.6% in the expanded HIV care-initiation periods. Although the incidence of orphanhood significantly declined between the pre-HIV care roll-out and the HIV care-transition periods, irrespective of parental HIV status, the proportion of incident orphans with an HIV+ and PAF was similar across these two time periods.

Table 4.  PAF of incidence of orphanhood due to parental HIV by HIV care periods
 Pre-HIV care roll-out (January 2001–July 2003)HIV care transition (September 2003–June 2006)Expanded HIV care (August 2006/November 2009)
Parental HIV status
HIV−HIV+HIV−HIV+HIV−HIV+
  1. IRR, incidence rate ratios; PAF, population attributable fraction.

  2. *Adjusted for child age, household social economic status as measured by dwelling structure ranking and source of water.

Total non-orphans8833106690821059105381184
Person-years10702.31238.312942.01471.618004.31966.2
Incident orphans1401011027612366
Incidence/100 person-years1.38.20.85.20.73.4
Adjust IRR (95% CI)*1.06.25 (4.82, 8.11)1.06.65 (4.94, 8.96)1.04.73 (3.94, 6.40)
Proportion of incident orphans with HIV+ parent0.42 0.43 0.35 
PAF (%) = pd*[(IRR-1)/IRR]35.3 36.5 27.6 

In the sub-analysis for the competing risk analysis, there was a significant decline in the composite outcome over the three HIV care periods. The overall incidence in the composite orphanhood/mortality outcome was 3.1/100 py (517/16636.24) in pre-HIV care roll-out periods, 2.5/100 py (507/20356.96) in HIV care transition and 1.5/100 py (405/26430.96) in expanded HIV care period (inline image, P < 0.0001). The greatest declines in composite orphanhood/mortality outcome were observed among children with HIV+ parents: 10.3/100 py (129/1256.7), 7.5/100 pys (112/1498.8) and 4.6/100 pys (92/1993.4) (inline image, P = 0.001), in the three increasing HIV care time periods, respectively. The declining trends are similar to what we observed when incidence of orphanhood was the only event of interest.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The scale up of HIV care programmes has resulted into significant reductions in the rates of prevalent and incident orphanhood among children born to HIV-infected parents. The incidence of orphanhood among children of HIV-infected parents prior to availability of HIV care was high but declined substantially during the HIV care transition and expanded HIV care implementation periods. These findings are consistent with model estimates from Botswana that indicated a 40% decline in new orphanhood rates when ART uptake was 80% for those in need (John et al. 2008) and a study in Tororo, Uganda, that showed a 93% reduction in orphanhood among children of HIV+ patients started on Antiretroviral drugs (ARVs) Jonathan et al. (2008).

In this study, we have also provided information on the increasing uptake of HIV care services in this cohort. A previous study in the same cohort showed that 68.5% of HIV+ patients who received VCT and were in need of care were able to enrol into a community HIV care programme offered by the RHSP (Nakigozi et al. 2011). Unpublished observations in this cohort indicate an increase in the proportion of all HIV+s receiving ART among females from 10% to 20% and among males from 7% to 18% during the HIV care transition and expanded HIV care periods, respectively. Therefore, the observed declines in incident orphanhood may be linked to the increasing coverage of HIV care including receipt of ART in this population.

The observed declines in incident orphanhood can be attributed to the improvement in survival of HIV-infected adults as shown in previous studies elsewhere (Jahn et al. 2008; Jonathan et al. 2008; Herbst et al. 2009; Reniers et al. 2009). About 37% of incident orphanhood in this cohort has previously been shown to be attributable to parental HIV infection (Makumbi et al. 2005) and that most adult deaths in Rakai (Sewankambo et al. 1994, 2000) or in other SSA settings were attributable to HIV infection (Mulder et al. 1994; Todd et al. 1997; Boerma et al. 1998). This current analysis also showed a decline in the PAF of incident orphanhood due to parental HIV+ status, further suggesting that the availability of HIV care is improving the survival of HIV-infected adults, thus reducing incident orphanhood.

We also observed a significant decline in the rate of orphanhood among children with HIV-uninfected parents. This observed incidence of orphanhood among children with uninfected parents was similar to a study conducted in Zimbabwe (Watts et al. 2005). Also, this finding is consistent with global trends of declining adult non-HIV mortality (Rajaratnam et al. 2010), probably due to general improvement in health services. However, our estimated incidence of orphanhood among children with uninfected parents could be an overestimate of the actual incidence because children with HIV-discordant parents may have been included in the HIV-uninfected category. All children with only one known HIV-negative parent and the other with unknown status were categorized as HIV negative.

In this study, we addressed the competing risks of incident orphanhood and infant and child mortality. Availability of HAART may have improved child survival or resulted in more HIV-uninfected children whose parents were HIV+ and at the same time increasing adult survival, thus reducing incident orphanhood. However, the similar declining trends were observed when incident orphanhood alone and composite orphanhood/mortality outcome were analysed. This result further showed that HAART and HIV care are impacting on incident orphanhood.

This observed decline in the rate of orphanhood associated with provision of HIV care will result in fewer children in need of caregivers, thus lowering the overall risk of poor health among these children. (Bishai et al. 2003; Sarkar et al. 2003). Previous studies have showed that orphans were at increased risk of severe malnutrition (Nyandiko et al. 2009), school dropout, teenage pregnancies (Palermo & Peterman 2009), sexually transmitted infections (Gregson et al. 2005; Birdthistle et al. 2008), poor mental health (Ruiz-Casares et al. 2009) and deficits in height (Beegle et al. 2009).

Our study strongly suggests that the HIV care programmes in SSA should continue to roll out because of the already known benefits of HIV care to the individuals infected including improved survival and better health, and the resulting decline in the incidence of orphanhood, as evidenced from this analysis.

Overall, about 35% of the observations had missing data on parental HIV status, which may have led to an underestimate of the contribution of the parental HIV status to incidence orphanhood. Indeed, the out-migration of HIV/AIDS parents who seek care elsewhere may lead to underestimate the HIV+ associated incidence orphanhood.

Declining infant and child mortality as a result of improving ART provision especially among the children of HIV-/AIDS-infected parents may lead to competing risk of the orphanhood event, resulting in underestimation. However, we have conducted competing risk analysis to account for this potential competing risk. The trends are similar to when no competing risk assessment is taken into account.

These are the first empirical data on the impact of HAART on the incidence of orphanhood. Most of the previous findings have been based on models. Therefore, these findings will contribute to the much needed inputs for those using modelling approaches to assess the benefits of HIV care on incident orphanhood.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

There was a significant decline in the prevalence and incidence of orphanhood especially among children with HIV-infected parents, and a decline in PAF of incident orphanhood because of parental HIV+ status, after the availability of HIV care programmes. These findings suggest that the anticipated numbers of orphaned children because of HIV/AIDS and the consequences of orphanhood may be substantially reduced, especially if a high access to ART is achieved.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References

The Censuses and Surveys in the Rakai Cohort communities were conducted with funding from National Institutes of Allergy and Infectious Diseases (NIAID), National Institute of Child Health and Human Development (NICHD) and The Walter Reed Army Institute of Research. Laboratory support was, in part, provided by the International Centers of Excellency of the National Institutes of Health under the stewardship of Dr. Steven J. Reynolds. We acknowledge the contribution of all Rakai Health sciences Program Staff and Rakai Communities. The study was presented in part at IN-DEPTH AGM 2009.

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  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. References
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