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10/12/2009 AI DS Orphans and Vulnerable Children in South Africa: I ntergenerational Health Risks Don Operario Department of Community Health Brown University Research Collaborators Oxford University Oxford University – Lucie Cluver, Caroline Kuo, Tyler Lane University of Cape Town – Lauren Wild University of KwaZulu-Natal University of KwaZulu Natal – Alan Whiteside, Tim Quinlan University of the Witwatersrand – Mosa Moshabela 1

10/12/2009 Support From  ESRC (UK)  ESRC (UK)  NIH (USA)  John Fell Fund (UK)  Leverhulme Trust (UK)  HEARD/DfID (SA-UK) HEARD/DfID (SA UK) Estimated number of children under 18 orphaned by AIDS in sub-Saharan Africa (1990–2007) 12 12 Millions 10 8 6 4 2 0 1990 1995 2000 2002 2003 2004 2005 2006 2007 6.2 Source : UNAIDS/WHO, 2008 2

10/12/2009 Orphans in South Africa HI V+ people AI DS- AI DS- orphaned h d orphaned h d children children 2008 2008 2020 Worldwide 33 million 15 million 20 million South Africa 5.7 million 1.4 million 2.3 million UNAIDS (2008), UNAIDS (2006), UNAIDS/WHO (2007), Dorrington et al (2005). 3

10/12/2009 Debates regarding OVCs  How to define Orphans and Vulnerable  How to define Orphans and Vulnerable Children  Whether OVCs show greater risk outcomes  How to intervene at population level; How to intervene at population level; what to intervene upon  Targeting without stigmatizing Orphan Definition “An orphan is defined as a child under An orphan is defined as a child under the age of 18 who has had at least one parent die. A child whose mother has died is known as a maternal orphan; a child whose father has died i is a paternal orphan. A child who has l h hild h h lost both parents is a double orphan.” UNAIDS (2002). ‘Children on the Brink’ 4

10/12/2009 Study 1: I s orphanhood associated with HI V Risk among young people in South Africa? Study 1: SA National Study 1: SA National Household Survey (2003) Household Survey (2003)  Prevalence parental death  Prevalence parental death Prevalence parental death ( Prevalence parental death (n= 11,904 15 ( (n= 11,904 15-24 yr) 11 904 15 11 904 15 24 24 yr) 24 ) ) – Any orphanhood: 27% Any orphanhood: 27% – Maternal orphans: 8% Maternal orphans: 8% – Paternal orphans: 23% Paternal orphans: 23% – Double orphans: 3% Double orphans: 3% Operario et al. (2007). Operario et al. (2007). JAIDS JAIDS 5

10/12/2009 Orphanhood and HI V risk Weighted % g Unadj. OR j Adj OR (95% j ( (95% CI ) CI ) HIV Positive 1.49 (1.32-169) 1.09 (1.05-1.36) Orphan 12.3 Non-orphan 8.5 Ever had vaginal 1.65 (1.51-1.79) 1.21 (1.09-1.34) intercourse Orphan 72.7 Non-orphan Non orphan 61.7 61 7 Unprotected 1.22 (1.11-1.35) 1.11 (1.00-1.22) intercourse, last episode Orphan 49.3 Non-orphan 44.3 Operario et al. (2007). Operario et al. (2007). JAIDS JAIDS Orphanhood and Education Overall 39%, Did NOT complete compulsory primary Overall 39%, Did NOT complete compulsory primary education on schedule education on schedule d d ti ti h d l h d l FEMALES MALES Unadj. OR Adj OR Unadj. OR Adj OR (95% CI ) (95% CI ) (95% CI ) (95% CI ) Maternal Orphan 1.52 1.42 1.13 0.92 (1 15 2 01) (1.15-2.01) (1.03-1.97) (1 03 1 97) (0 84 1 52) (0.84-1.52) (0 67 1 27) (0.67-1.27) Paternal Orphan 1.52 1.34 1.23 1.10 (1.28-1.80) (1.11-1.61) (1.04-1.46) (0.92-1.32) Operario et al. (2008). Operario et al. (2008). JRA JRA 6

10/12/2009 Study 2: I s AI DS orphanhood I s AI DS orphanhood associated with mental health problems among young people in South Africa? Africa? Study 2: Cape Flats Study 2: Cape Flats Orphan Study (2005 Orphan Study (2005- -6) 6)  n= 1,025  n= 1 025 n= 1,025 n= 1 025  10 10 – – 19 years old 19 years old  3 groups: 3 groups: 3 groups: 3 groups: – Children orphaned by AIDS Children orphaned by AIDS – Children orphaned by non Children orphaned by non- -AIDS causes AIDS causes – Non Non- -orphaned children orphaned children 7

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10/12/2009 Determining Cause of Parental Death  AIDS death  AIDS death – “Verbal Autopsy” method: Weight loss, diarrhea, chronic fever + OI symptom – Hosegood et al., (2004). AIDS  Non-AIDS deaths – Vehicle accidents, homocide, suicide, other illness illness  Could not determine – Declined to answer, witchcraft, tuberculosis w/o other indicators (n= 81) 9

10/12/2009 AI DS Orphans Other Orphans Non Orphans n= 425 n= 241 n= 278 Age (M,SD) + 13.7 (2.5) 13.4 (2.4) 13.0 (2.0) Female (%) 50.6 43.2 46.4 Xhosa (%) Xhosa (%) 98 1 98.1 96 7 96.7 96 4 96.4 Informal dwelling 43.0 43.0 29.1 (%) + Moved bw 2+ homes 66.4 69.3 71.6 http://www.who.int/whosis/mort/verbal_autopsy_standards1.pdf (%) Loss of mother (% ) + 58.6 28.2 -- Loss of father (%) + Loss of father (%) 66 1 66.1 83 0 83.0 -- -- Loss both parents 24.9 12.4 -- (%) + Age first 10.1 (3.8) 7.8 (4.6) bereavement (M,SD) + Cluver et al. (2008). Cluver et al. (2008). JCPP JCPP Outcomes Measures  Depression (CDI-short form)  Depression (CDI-short form)  Anxiety (CMAS-R)  Peer problems (SDQ)  Post-traumatic stress (Child PTSD checklist) checklist)  Delinquency (CBCL)  Conduct Problems (SDQ) 10

10/12/2009 AIDS AIDS- -orphans have more problems orphans have more problems Multivariate associations between orphanhood by AIDS, orphanhood by other causes, and psychological outcomes, controlling for sociodemographic cofactors Peer Conduct Depression(1) Anxiety(2) Problems(3) PTSD(4) Delinquency(5) Problems(6) Unadjuste Adjuste Unadjuste Adjuste Unadjuste Adjuste Unadjuste Adjuste Unadjuste Adjuste Unadjuste Adjuste d Model d Model d Model d Model d Model d Model d Model d Model d Model d Model d Model d Model AIDS- .200** .179** .097* .069 .290** .261** .299** .267** .144** .124** .142** .130** Orphanhood Other- .035 .029 -.008 -.022 .055 .040 .087* .073 -.002 -.011 .015 .009 orphanhood R-Square .032 .052 .008 .026 .068 .090 .067 .090 .019 .048 .016 .036 R-Square .023 .022 .026 .027 .035 .023 change 7.64** 6.28** 8.22** 6.56** 6.43** 7.40** F-change Cluver et al. (2008). Cluver et al. (2008). JCPP JCPP * Denotes significance at the 0.05 level * * Denotes significance at the .001 level 1 Adjusted model controls for age, gender 2 Adjusted model controls for age, gender, informal dwelling 3 Adjusted model controls for age, household size, > 2 moves between homes 4 Adjusted model controls for age, gender, household size, > 2 moves between homes 5 Adjusted model controls for age, gender, informal dwelling, migration, > 2 moves between homes 6 Adjusted model controls for age, gender, migration Proportion in clinical range for Proportion in clinical range for psychological disorder psychological disorder AIDS-orphaned children: 2x depression 5x post-traumatic stress 7x peer problems 11

10/12/2009 What accounts for What accounts for associations between AI DS orphanhood and mental health outcomes? Does poverty mediate the association b/w orphanhood and orphanhood and mental health? AIDS Orphanhood Poverty Mental Health 12

10/12/2009 Poverty I ndicators Lack of: AIDS- Other- Non- p orphaned orphaned orphaned orphaned orphaned orphaned food 35% 22% 9% <.001 education 6% 3% 2% <.001 employment employment 50% 50% 40% 40% 23% 23% < 001 <.001 social welfare 54% 40% 23% <.001 Direct Associations AIDS orphanhood p Depression Depression AIDS orphanhood Post-traumatic stress AIDS orphanhood Peer problems AIDS orphanhood Delinquency AIDS orphanhood Conduct problems 13

10/12/2009 Poverty Eliminates Associations AIDS orphanhood p Depression Depression AIDS orphanhood Post-traumatic stress AIDS orphanhood Peer problems AIDS orphanhood Delinquency AIDS orphanhood Conduct problems Cluver et al. (2008). Cluver et al. (2008). AIDS Care AIDS Care Does stigma mediate the association b/w orphanhood and orphanhood and mental health? AIDS Orphanhood Stigma Mental Health 14

10/12/2009 Stigma I ndicators Family Family- AIDS- AIDS Other- Other Non Non- p p related orphaned orphaned orphaned stigma Teased 35% 21% 8% <.001 Treated badly Treated badly 38% 38% 19% 19% 6% 6% <.001 < 001 Gossiping 48% 22% 13% <.001 Stigma Eliminates Associations AIDS orphanhood p Depression Depression AIDS orphanhood Post-traumatic stress AIDS orphanhood Peer problems AIDS orphanhood Delinquency AIDS orphanhood Conduct problems Cluver et al. (2009). JAH Cluver et al. (2009). JAH 15

10/12/2009 Does caregiving mediate the association b/w orphanhood and orphanhood and mental health? AIDS Orphanhood Caregiving Mental Health Caregiving I ndicators AIDS- AIDS Other- Other Non Non- p p orphaned orphaned orphaned Caregiver 14% 7% 4% <.001 sickness >3 hrs 25% 15% 14% <.001 housework/day 16