HIV/AIDS and Africa’s orphan crisis

Abstract

The number of children orphaned by HIV/AIDS in the developing world has reached crisis proportions. In Sub-Saharan Africa, HIV/AIDS has exacerbated poverty in many communities and has weakened the capacity of many countries to care for their orphaned children. The present article discusses orphanage care and its alternatives in Sub-Saharan Africa. The physical and mental health effects of parental loss are discussed and the psychosocial impacts of institutional care are reviewed. Foster care is discussed as a potential long-term strategy to help communities cope with the rising numbers of HIV/AIDS orphans. The importance of community-based care is highlighted.

The global burden of HIV/AIDS has reached crisis proportions. With 34 to 36 million people estimated to be living with the disease (1), HIV/AIDS has shaken the already weak economic and social infrastructures of many developing countries. While the majority of infections occur in young adults, children have been affected in numerous ways. Almost three million children younger than 15 years of age are estimated to be HIV-positive, with the vast majority of infections occurring in developing nations (1). As home to 10% of the world’s population but 70% of HIV infections, Sub-Saharan Africa carries the largest disease burden (2). Thirteen million children younger than 15 years of age have lost one or both parents to AIDS, with the number expected to rise to 25 million by 2010 (1). In several African countries, 15% of children are expected to be orphaned by the end of this decade (1).

While parental mortality and the associated orphaning of children are not new issues in developing nations, HIV/AIDS has greatly exacerbated the situation. Because disease transmission is primarily through heterosexual intercourse, when one parent dies of HIV/AIDS, there is a high likelihood that the second parent will die as well, creating a large number of so-called ‘double orphans’. In North America, mother-to-child vertical transmission rates of HIV are as low as 1% with appropriate prenatal care and use of antiretroviral agents. However, in the absence of such care in developing nations, estimates of vertical transmission during pregnancy, delivery and breastfeeding range from 14% to greater than 40% (3). Studies in Uganda have shown that the administration of a single dose of an antiretroviral agent before delivery is effective in substantially reducing vertical transmission rates (4). However, in the absence of ongoing antiretroviral therapy for the parents, this strategy only serves to increase the number of orphaned children without altering the parents’ disease course. Furthermore, because HIV/AIDS predominantly affects the young adults who would otherwise comprise the working population, the pandemic is deepening poverty in entire communities and weakening the societies’ traditional means of caring for orphans (5). Given the lag time between HIV infection and death from AIDS, the number of children orphaned will continue to rise, calling for public health strategies that are long term in their scope and funding.

Recognizing the need to support the growing orphan population, many nongovernmental and faith-based organizations have founded orphanages to provide care for children. These orphanages are well-intentioned, but their establishment is based more on western customs than on a thoughtful consideration of their costs and benefits. The potential adverse effects of orphanage care in Africa have not been widely discussed, both because many orphanages already receive significant financial support from international donors and because there are often few other care alternatives. However, given the large number of orphaned children, it is important to consider whether current care strategies are maximizing the physical and mental well-being of as many children as possible. Potential strategies should be cost-effective, long term in scope, culturally appropriate and reliant on resources already available in communities as much as possible. Institutional care, given its high reliance on external resources, significant costs, and psychosocial and physical health consequences, requires scrutiny, especially now, when effective orphan care programs are so desperately needed.

The potential adverse effects of orphanage care have been best documented in the literature, albeit under different social circumstances, in a study of Romanian orphans (6–9). In the study, children younger than two years of age adopted from Romanian orphanages by English families were followed and compared with a sample of within-country adopted children who had not spent time in orphanages. The children were followed to six years of age and compared in terms of growth, development and cognitive functioning. While the political situation and social policies of Romania in the 1980s differed vastly from the current situation in Sub-Saharan Africa, the conclusions of the English and Romanian Adoptees Study (6–9) provide rigorous arguments against reliance on orphanage care. The study found that at entry into the United Kingdom, the Romanian adoptees had severely stunted growth with mean head circumference and weight measurements of more than two SDs below United Kingdom norms (6). On developmental screening, the Romanian adoptee group mean fell into the mildly mentally retarded range, suggesting significant developmental delay in addition to physical growth restriction (6). The study’s key positive finding was significant catch-up growth and development displayed by children who were adopted before six months of age. The authors concluded that the duration of institutionalization was the most important predictor of developmental outcome.

Numerous other studies have documented adverse developmental effects of orphanage care, including attachment difficulties, cognitive delay and autistic-spectrum behaviours (10,11). Current knowledge about the determinants of child development and socialization suggests that appropriate family-based care is preferable over institutional care in most circumstances. Although studies of orphan health in Africa are limited, it has been demonstrated that orphans are significantly less likely to attend or do well in school, more likely to go to bed hungry and more likely to have mental health problems than are nonorphaned children in the same communities (1,12,13). Programs and policies that aim to ameliorate these effects and avoid the adverse consequences of institutionalization are needed.

Foster care, the care of children in home environments by extended family or other community members, provides a more cost-effective and longstanding solution to the orphan crisis. In many African cultures, care for orphaned children by next of kin or other community members is a longstanding practice. However, given the number of HIV/AIDS deaths among young adults and the rising number of orphans, traditional fostering systems have been overwhelmed (5). While studies have shown that extended family members generally treat foster children in the same way as their biological children (14), a lack of resources to provide for the children’s basic needs is a major limitation. The capacity strengthening of families (to care for children), communities (to provide additional support) and governments (to establish appropriate policies to protect vulnerable children) is documented as a priority in The United Nations Children’s Fund/The Joint United Nations Programme on HIV/AIDS (1). Translation of this priority into effective national policy is the next challenge.

Community, national and international support is needed to broaden the fostering system, and to provide social and financial support for both families and children.

Formalization of the foster care system by establishing a registry of orphaned children and of community members willing to provide care could allow resource targeting, such as the provision of financial stipends for food and clothes, as well as school fees, supplies and transportation. Establishment of daycare centres, perhaps at current orphanage facilities, could allow parents to maintain their previous work schedules and may provide further incentives for working adults to foster children. Child protection services are also needed, given the stigma associated with HIV/AIDS and the risk to orphaned children of physical, sexual and emotional abuse.

Community-based care has been shown to cost a fraction of that of orphanage care. A study in Uganda found that community-based care costs 14 times less than orphanage care, while other studies suggest ratios of 1:20 to 1:100 (1). Also, while community groups in many African countries have demonstrated an eagerness to develop and support orphan care programs, their capacity is limited by major financial constraints (14). Further study of ways to channel resources directly and efficiently to affected communities must become an international priority.

As health care professionals in resource-rich countries, we are in a unique position to advocate child and family health and to assist in raising awareness and financial support. Education about child health, orphan care and HIV/AIDS epidemiology is a first step. Ongoing political and economic changes in developing nations will continue to impact the needs of children in particular communities; we must remain cognizant of the challenges and take available opportunities to advocate for orphaned children at provincial, national and international levels. The consequences of action and inaction will be felt.