Dr Lucie Cluver, Dr Don Operario, Dr Frances Gardner

1
AIDS-orphanhood Psychological and sexual health
risks?

• Dr Lucie Cluver, Dr Don Operario, Dr Frances
  Gardner
• Oxford University, UK
• Cape Town Child Welfare, SA
• Joint Learning Initiative for Children affected
  by AIDS

2
Non-perinatally infected orphaned children

• Physical health (Ainsworth and Semali 2000
  Nyamukapa, Gresgson et al. 2006 Watts, Gregson
  et al. 2007)
• Malnutrition (Ainsworth Semali, 2000 Cluver,
  Gardner, Operario, in press G. Gray et al.,
  2006 Lindblade, Odhiambo, Rosen, DeCock,
  2003, Campbell et al, 2008)
• Education (Case Ardington, 2005 G. Gray et
  al., 2006 Mishra, Arnold, Otieno, Cross, Hong,
  2005 Muller, Sen, Nsubuga, 1999 Oleke,
  Blystad, Fylkesnes, Tumwine, 2007 Operario,
  Pettifor, Cluver, MacPhail, Rees, 2008,
  Campbell et al. 2008)
• Mental health (Atwine et al, 2005 Bhargava,
  2005 Watts et al, 2008, Poulter, 1996, Forehand
  et al, 1998, Makame et al, 2004,
  Rotheram-Borus et al, 2004, Cluver et al, 2007a
  2007b, 2008a, 2008b)
• HIV risk (Birdthistle et al., 2008 Cluver
  Operario, 2008 Gregson et al., 2005 Kissin et
  al., 2007 Operario, Pettifor, Cluver,
  MacPhail, Rees, 2007)
• Disagreement on extent of disadvantage
• Poor understanding of mechanisms
• Lack of data distinguishing AIDS-orphanhood/other-
  orphanhood
• Simultaneous policy recognition of dangers of
  targeting
• Need for effective interventions even if not
  overtly targeted

3

• Study 1 Psychological Health of AIDS-
• orphaned children in Cape Town, SA
• Q1 Does AIDS-orphanhood cause psychological
  distress?
• Q2 What are mechanisms of risk?
• N1200
• Pilot, qualitative and quantitative stages
• i) AIDS-orphaned, ii) other-orphaned, iii)
  non-orphaned children
• Additional purposive sampling hard-to-reach
  groups ie streetchildren
• Verbal autopsy method (Hosegood, Vanneste,
  Timaeus, 2004, Kahn, Tollman, Garenne, Gear,
  2000)
• Standardised psychological questionnaires
• Depression, anxiety, PTSD, peer problems,
  behaviour problems
• (CDI, R-CMAS, Child PTSD Checklist,
  SDQ and CBCL)
• Child-friendly, face-to-face interviews

4
1. AIDS-orphaned children have more psychological
problems
Multivariate associations between AIDS-orphanhood
, other-orphanhood, and psychological outcomes,
controlling for sociodemographic cofactors
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,
gt2 moves between homes 4 Adjusted model controls
for age, gender, household size, gt2 moves between
homes 5 Adjusted model controls for age, gender,
informal dwelling, migration, gt2 moves between
homes 6 Adjusted model controls for age, gender,
migration
5
2. AIDS-orphaned children show higher levels of
clinical-level disorder
AIDS-orphaned children 2x depression 5x
post-traumatic stress 7x peer problems
6
3. mediators poverty
Orphanhood By AIDS
Mental health problems
Poverty Factors
Highly significant (plt.001) Significant
(plt.05) Non-significant
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4. mediators caregiver illness
Mental health problems
Orphanhood By AIDS
Caregiver sickness
Highly significant (plt.001) Significant
(plt.05) Non-significant
8
5. mediatorsAIDS-related stigma
Orphanhood By AIDS
Mental health problems
AIDS-related stigma
Highly significant (plt.001) Significant
(plt.05) Non-significant
9
6. Cumulative risk effects
Likelihood of clinical depression,
anxiety, PTSD (clinical range)
Multivariate logistic regression and hierarchical
log-linear analysis, all plt.001 as multiple
comparisons. Weighted sample using GHS 2005.
Cluver Orkin.
10
Study 2 Review of risk for HIV-infection
AIDS-orphaned other-orphaned adolescents

• Q1. Do orphaned adolescents show higher HIV-risk?
• Q2. If so, what are the mechanisms of risk?
• Paucity of studies
• All cross-sectional
• No studies examine non-sexual mechanisms

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• Findings
• 4 large cross-sectional studies show
• Higher HIV prevalence Zimbabwe-Birdthistle et al
  (2007), Gregson et al 2005), Russia-
  Kissin et al (2007), SA- Operario et al (2007)
• 7 cross-sectional studies show increased risk
  for
• Ever having sex Kenya-Juma et al SA- Operario et
  al 2007 Zimbabwe-Nyamukapa et al
  2008 Lesotho, Malawi, Mozambique, Rwanda and
  Tanzania- Campbell et al 2008
• Early sexual debut SA-Thurman et al 2006. Hallman
  2004
• Multiple partners SA-Operario et al 2007, Hallman
  et al 2008
• Unprotected sex SA-Operario et al 2007, Hallman
  et al 2008

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Hypothesised mechanisms

• 1. Poverty
• Malnutrition (mixed evidence)
• Reduced healthcare, STI care access
• Reduced access to schooling
• Reduced access to HIV/AIDS education
• 2. Mental health
• Mental health problems
• Alcohol and substance use
• (hypothesised)
• AIDS-related stigma
• 3. Caregiving stress
• Exposure to HIV-infection when
• caring (hypothesised)
• Sick caregivers reduced capacity to
• monitor children
• Domestic violence
• Physical abuse (anecdotal)

• 4. Sexual Abuse
• Sexual abuse in and outside home
• (anecdotal)
• Living on the streets, forced sex
• (anecdotal)
• 5. Risky sexual dynamics
• Transactional sex (1 study)
• Older sexual partners (anecdotal)
• Younger age at first sex (5 studies)

13
Implications

• Evidence suggestive (but not conclusive) of high
  HIV risk for orphaned children
• Caution against labelling orphaned children as a
  high risk group may increase stigma (and thus
  HIV-risk)
• Essential to understand and target mechanisms
• Crucial need for more evidence, including
  longitudinal designs, biological assessment of
  HIV-status, randomised trials
• With thanks to the JLICA Learning Group 4,
  particularly Doug Webb,
• Alex DeWaal, Masuma Mamdani, Jerker Edstrom,
  Debbie Budlender

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Where do we go from here?

• Q1. What are the mechanisms of risk for orphaned
  children?
• Q2. What interventions can target these
  mechanisms without
• targeting orphans?
• Q3. How can research directly inform and support
  policy?
• Partnership with SA government (Department of
  Social Development), NGOs, Child Advisory Groups
• National level mental health study
• Longitudinal follow-up of mental health study
• New study of Young Carers and orphaned
  children longitudinal, 4 provinces
• Randomised controlled trials of NGO interventions

OXFORD UNIVERSITY DEPARTMENT OF SOCIAL
DEVELOPMENT BROWN UNIVERSITY
15

• Cluver, L, Gardner, F Operario, D (2008)
  Effects of stigma on the mental health of
  adolescents orphaned by AIDS. Journal of
  Adolescent Health 42 (4) 410-418
• Cluver, L, Operario, D (2008) The
  intergenerational link between the impacts of
  AIDS on children, and their subsequent
  vulnerability to HIV infection a study of the
  evidence to inform policy on HIV prevention and
  child and adolescent protection. Commissioned
  paper Joint Learning Initiative for Children
  affected by AIDS. www.jlica.org.
• Cluver, L, Gardner, F Operario, D (2007).
  Psychological distress amongst AIDS-orphaned
  children in urban South Africa. Journal of Child
  Psychiatry Psychology Allied Disciplines
  48(8) 755-763
• Cluver, L Gardner, F (2007) The Mental Health
  of Children orphaned by AIDS A review of
  International and South African Research. Journal
  of Child and Adolescent Mental Health. 19(1) 1-17
• Cluver, L. Gardner, F. (2007) Risk and
  protective factors for well-being of children
  orphaned by AIDS in Cape Town, South Africa a
  qualitative study of childrens views. AIDS Care
  19(3) 318-325.
• Operario, D, Pettifor, A, Cluver, L, MacPhail, C
  and Rees, H (2007), Prevalence of Parental Death
  among young people in South Africa and Risk for
  HIV Infection Results from a National
  Representative Sample. Journal of Acquired Immune
  Deficiency Syndromes (JAIDS) 44, 93-98.
• Operario, D, Cluver, L, Pettifor, A, MacPhail, C
  and Rees, H (2008) Orphanhood and Completion of
  Compulsory School Education Among Young People in
  South Africa. Journal of Research on Adolescence.
  18(1), 173-186
• Cluver, L. Gardner, F. (2006) Psychological
  well-being of children orphaned by AIDS in Cape
  Town, South Africa Annals of General Psychiatry.
  5, 8. BioMed Press.
• Cluver, L, Gardner, F Operario, D, Effects of
  poverty on the psychological health of
  AIDS-orphaned children (invited reubmission, AIDS
  Care)
• Cluver, L Orkin, M, Stigma, bullying, poverty
  and AIDS-orphanhood Interactions mediating
  psychological problems for children in South
  Africa (invited resubmission, B J Psychiatry)
• Cluver, L, Gardner, F Operario, D, Effects of
  caregiving on psychological distress amongst
  AIDS-orphaned children in South Africa (invited
  resubmission, Vulnerable Children and Youth
  Studies)
• Cluver, L, Finch, D, Seedat, S, Predictors of
  post-traumatic stress symptomology amongst
  AIDS-orphaned children (in review)

Thank you. lucie.cluver_at_socres.ox.ac.uk