Predictors of HIV testing among youth 15-24 years in urban Ethiopia, 2017-2018 Ethiopia population-based HIV impact assessment.

INTRODUCTION: Youth (adolescents and young adults) aged 15-24 years comprise approximately 22% of Ethiopia's total population and make up 0.73% of HIV cases in urban Ethiopia. However, only 63% of HIV-positive youth are aware of their HIV status. We describe the HIV testing behaviors of youth 15-24 years and determined the characteristics of those who were most likely to be tested for HIV within the past year. METHODS: Using data from the 2017-2018 Ethiopia Population-based HIV Impact Assessment, we provide survey-weighted estimates and prevalence risk ratios for engagement in HIV testing in the 12 months preceding the survey. We model the likelihood of HIV testing one year or more before the survey compared to never testing, using a multinomial logistic regression model. RESULTS: Among HIV-negative and unaware HIV-positive youth 15-24 years old (N = 7,508), 21.8% [95% Confidence Interval (CI): 20.4-23.3%] reported testing for HIV in the last 12 months. Female youth [Prevalence Ratio (PR) = 1.6, 95% CI: 1.4-1.8], those aged 20-24 years (PR = 2.6, 95% CI:2.3-2.9), and those ever married (PR = 2.8, 95% CI: 2.5-3.1) were more likely to have tested for HIV within the last year. Adjusting for select demographic characteristics, sex with a non-spousal or non-live-in partner [Relative Risk (RR) = 0.3, 95% CI:0.1-0.8] among males did not increase their likelihood to test for HIV in the prior 12 months. Female youth engaged in antenatal care (RR = 3.0, 95% CI: 1.7-5.3) were more likely to test for HIV in the past year. CONCLUSION: The Ethiopian HIV case finding strategy may consider approaches for reaching untested youth, with a specific focus on adolescent males,15-19 years of age. This is critical towards achieving the UNAIDS HIV testing goal of 95% of all individuals living with HIV aware of their status by 2030.

Addressing Current Issues in Vision Rehabilitation as a Specialty Practice of Occupational Therapy.

The purpose of this paper was to examine the low number of occupational therapy practitioners in the United States that possessed specialty or advanced certification in low vision. The discussion explores possible reasons for this finding, including insufficient educational accreditation standards to prepare occupational therapy students to work with people with visual conditions, lack of clarity on the definition of low vision leading to misalignment with the profession's scope of practice, inconsistent requirements for advanced certification, scarcity of post-professional preparation programs, and other issues. We propose several solutions to prepare occupational therapy practitioners to meet the challenges and needs of people of all ages with visual impairments.

Hazardous alcohol use and HIV indicators in six African countries: results from the Population-based HIV Impact Assessments, 2015-2017.

INTRODUCTION: Hazardous alcohol use (HAU), defined as a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others, is associated with an elevated risk of human immunodeficiency virus (HIV) infection and poor health outcomes. We describe the association between people living with HIV (PLHIV) who report HAU and key HIV indicators. Gaps in current literature in estimating HAU on HIV outcomes at the regional level of Eastern and Southern Africa still exist and our analysis aims to address this issue. METHODS: We used weighted pooled data (2015-2017) from the nationally representative Population-based HIV Impact Assessments among adults who provided written consent aged 18-59 years from Eswatini, Malawi, Namibia, Tanzania, Zambia and Zimbabwe. We estimated differences in the prevalence of HIV infection and The Joint United Nations Programme on HIV and AIDS (UNAIDS) 90-90-90 indicators between PLHIV by HAU status using log-binomial regression, stratified by sex. HAU was determined using the Alcohol Use Identification Test-Consumption. RESULTS: Among the 9755 women and 4444 men who tested HIV positive, 6.6% of women and 21.8% of men engaged in HAU. Women who reported HAU were more likely to be HIV positive (adjusted prevalence ratio [aPR] = 1.31, 95% CI: 1.18-1.46) compared to those who did not report HAU. For the UNAIDS 90-90-90 targets, women who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.22, 95% CI: 1.01-1.47) and not on antiretroviral therapy (ART) (aPR = 1.73, 95% CI: 1.26-2.37). Men who engaged in HAU were more likely to be unaware of their HIV-positive status (aPR = 1.56, 95% CI 1.39-1.76) and not on ART (aPR = 1.72, 95% CI: 1.30-2.29). No difference in viral load suppression, defined as <1000 copies/ml of HIV RNA, was seen by sex. CONCLUSIONS: PLHIV who engage in HAU were more likely to have suboptimal outcomes along the HIV care continuum when compared to those who did not engage in HAU. Targeted interventions, such as alcohol screening for HAU in HIV testing and treatment settings and HIV prevention efforts in alcohol-based venues, may help countries reach HIV epidemic control by 2030.

Progress towards the UNAIDS 90-90-90 targets among persons aged 50 and older living with HIV in 13 African countries.

INTRODUCTION: Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe). METHODS: Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata. RESULTS: Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum. CONCLUSIONS: While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH <50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

Correcting for selection bias in HIV prevalence estimates: an application of sample selection models using data from population-based HIV surveys in seven sub-Saharan African countries.

INTRODUCTION: Population-based biomarker surveys are the gold standard for estimating HIV prevalence but are susceptible to substantial non-participation (up to 30%). Analytical missing data methods, including inverse-probability weighting (IPW) and multiple imputation (MI), are biased when data are missing-not-at-random, for example when people living with HIV more frequently decline participation. Heckman-type selection models can, under certain assumptions, recover unbiased prevalence estimates in such scenarios. METHODS: We pooled data from 142,706 participants aged 15-49 years from nationally representative cross-sectional Population-based HIV Impact Assessments in seven countries in sub-Saharan Africa, conducted between 2015 and 2018 in Tanzania, Uganda, Malawi, Zambia, Zimbabwe, Lesotho and Eswatini. We compared sex-stratified HIV prevalence estimates from unadjusted, IPW, MI and selection models, controlling for household and individual-level predictors of non-participation, and assessed the sensitivity of selection models to the copula function specifying the correlation between study participation and HIV status. RESULTS: In total, 84.1% of participants provided a blood sample to determine HIV serostatus (range: 76% in Malawi to 95% in Uganda). HIV prevalence estimates from selection models diverged from IPW and MI models by up to 5% in Lesotho, without substantial precision loss. In Tanzania, the IPW model yielded lower HIV prevalence estimates among males than the best-fitting copula selection model (3.8% vs. 7.9%). CONCLUSIONS: We demonstrate how HIV prevalence estimates from selection models can differ from those obtained under missing-at-random assumptions. Further benefits include exploration of plausible relationships between participation and outcome. While selection models require additional assumptions and careful specification, they are an important tool for triangulating prevalence estimates in surveys with substantial missing data due to non-participation.

Access to Social Protection by People Living with, at Risk of, or Affected by HIV in Eswatini, Malawi, Tanzania, and Zambia: Results from Population-Based HIV Impact Assessments.

We aimed to measure social protection coverage among the general population, women and men living with HIV (WLHIV, MLHV), female and male sex workers (FSW, MSW), men who have sex with men (MSM), adolescent girls young women (AGYW), and orphans vulnerable children (OVC) in Eswatini, Malawi, Tanzania, and Zambia. We used Population-Based HIV Impact Assessment data. We operationalised social protection benefits as external economic support from private and public sources to the household in the last three or 12 months. We estimated survey-weighted proportions and 95% confidence intervals (CI) for each population receiving social protection benefits. The sample size ranged from 10,233 adults ages 15-59 years in Eswatini to 29,638 in Tanzania. In the surveyed countries, social protection coverage among the general population was lower than the global average of 45%, ranging from 7.7% (95% CI 6.7%-8.8%) in Zambia to 39.6% (95% CI 36.8%-42.5%) in Eswatini. In Malawi and Zambia, social protection coverage among OVC, AGYW, SW, MSM, and people living with HIV (PLHIV) was similar to the general population. In Eswatini, more AGWY reported receiving social projection benefits than older women and more men not living with HIV reported receiving social protection benefits than MLHIV. In Tanzania, more WLHIV than women not living with HIV, MLHIV than men not living with HIV, and FSW than women who were not sex workers reported receiving social protection benefits. More data on access to social protection benefits by PLHIV or affected by HIV are needed to estimate better their social protection coverage.

St Georg Sled medial unicompartmental arthroplasty: survivorship analysis and function at 20 years follow up.

PURPOSE: The peri-operative and short-term benefits of unicompartmental knee arthroplasty (UKA) are well supported in the literature. However, there remains concern regarding the higher revision rate when compared with total knee replacement. This manuscript reports the functional outcome and survivorship of a large series of fixed bearing, medial unicompartmental replacements (St Georg Sled), with a minimum of 20 years follow-up. METHODS: Between 1974 and 1994, 399 patients (496 knees) underwent a medial fixed-bearing UKA. Prospective data were collected pre-operatively and at regular intervals post-operatively using the Bristol Knee Score (BKS), Oxford Knee (OKS) and Western Ontario MacMaster (WOMAC) scores. Kaplan-Meier survival analysis was used to determine survivorship, with revision or need for revision as end point, and differences assessed using Mantel-Cox log rank test. RESULTS: Functional knee scores improved post-operatively, but demonstrated a slight decline from 10 years of follow-up onwards. Survivorship is estimated as 86% at 10 years, 80% at 15 years, and 78% at 20 years. Sixty knees were revised, with progression of disease in another compartment the commonest reason. Eighty eight percent were revised using a primary prosthesis. For patients over the age of 65 years at the time of index procedure, 93% died with a functioning prosthesis in situ. CONCLUSION: Medial UKA demonstrates good long-term function and survivorship, and represents an excellent surgical option for patients aged over 65 years of age, where few patients will require a revision procedure. LEVEL OF EVIDENCE: IV.

Is Interview Length Associated With Blood Test Participation? Evidence From Three Population-Based HIV Impact Assessment Surveys Conducted From 2016 to 2017.

BACKGROUND: High response rates in surveys are critical to ensuring that findings are unbiased and representative of the target population. Questionnaire length affects response rates, with long interviews associated with partially complete surveys, higher item nonresponse ("don't know" and "refuse" responses), and willingness to participate in future surveys. Our aim is to determine the impact of questionnaire length on blood test participation in population-based HIV surveys. METHODS: Data are from population-based HIV impact assessments conducted in Zambia, Eswatini, and Lesotho in 2016-2017. The population-based HIV impact assessments consist of an interview followed by a blood draw. Consent for blood draw was obtained before the interview in Eswatini and after the interview in Zambia and Lesotho. Interview length was measured by the survey tablet as the time to complete the survey (interview duration) and the number of questions answered by the participant (questionnaire length). We assessed the effects of questionnaire length and interview duration on blood test participation using logistic regression. RESULTS: Across all 3 surveys, the median interview duration was 16 minutes and the median number of questions was 77. In adjusted analyses, there was a negative impact of interview duration on blood draw consent for individuals with unknown status in Lesotho and a positive relationship between questionnaire length and blood draw consent in Zambia for those with HIV-negative and unknown status. CONCLUSION: Although interview length is an important consideration to reduce respondent burden, a longer questionnaire does not necessarily result in lower consent rates for blood testing.

Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019.

BACKGROUND: Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. METHODS: Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. RESULTS: A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. CONCLUSION: Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

Fixed bearing, all-polyethylene tibia, lateral unicompartmental arthroplasty - A final outcome study with up to 28 year follow-up of a single implant.

BACKGROUND: Lateral unicompartmental arthroplasty (UKA) constitutes only 5-10% of all unicompartmental replacements performed. Whilst the short and medium term benefits are well documented, there remains concern regarding the higher revision rate when compared with total knee replacement. We report the long term clinical outcome and survivorship of a large series of lateral UKA. PATIENTS AND METHODS: Between 1974 and 1994, 71 patients (82 knees) underwent a lateral fixed-bearing St Georg Sled UKA. Prospective data was collected pre-operatively and at regular intervals post-operatively using the Bristol Knee Score (BKS), with later introduction of the Oxford Knee (OKS) and Western Ontario MacMaster (WOMAC) scores. Kaplan Meier survival analysis was used, with revision, or need for revision, as end point. 85% of the patients were female. No patients were lost to follow-up. RESULTS: Functional knee scores improved post-operatively up to 10 years, at which point they demonstrated a steady decline. Survivorship was 72% at 15 years, and 68% at 20 and 25 years. Nineteen knees were revised, with progression of disease in another compartment the commonest reason. There were two revisions due to implant fracture. In patients aged over 70 years at time of index procedure, 81% died with a functioning prosthesis in situ. CONCLUSION: This represents the longest follow-up of a large series of lateral UKA. Results of this early design of fixed bearing UKA demonstrate satisfactory long term survivorship. In elderly patients, further intervention is rarely required. More contemporary designs or techniques may show improved long term survivorship in time.

Correlating the Bethesda System for Reporting Thyroid Cytopathology with Histology and Extent of Surgery: A Review of 21,746 Patients from Four Endocrine Surgery Registries Across Two Continents.

BACKGROUND: The Bethesda system for cytopathology (TBSRTC) is a 6-tier diagnostic framework developed to standardize thyroid cytopathology reporting. The aim of this study was to determine the risk of malignancy (ROM) for each Bethesda category. METHODS: Thyroidectomy-related data from 314 facilities in 22 countries were entered into the following outcome registries: CESQIP (North America), Eurocrine (Europe), SQRTPA (Sweden) and UKRETS (UK). Demographic, cytological, pathologic and extent of surgery data were mapped into one dataset and analyzed. RESULTS: Out of 41,294 thyroidectomy patient entries from January 1, 2015, to June 30, 2017, 21,746 patients underwent both thyroid FNA and surgery. A comparison of cytology and surgical pathology data demonstrated a ROM for Bethesda categories 1 to 6 of 19.2%, 12.7%, 31.9%, 31.4%, 77.8% and 96.0%, respectively. Male patients had a higher rate of malignancy for every Bethesda category. Secondary analysis demonstrated a high ROM in male patients with Bethesda 3 category aged 31-35 years (52.1%, 95% confidence interval (CI) 37.9-66.2%), aged 36-40 years (55.9%, 95% CI 39.2-72.6%) and aged 41-45 years (46.9%, 95% CI 33-60.9%). Patients with Bethesda 5 and 6 scores were more likely to undergo total thyroidectomy (65.9% and 84.6%); for patients with Bethesda scores 2 and 3, a higher percentage of females underwent total thyroidectomy compared to males in spite of a higher ROM for males. CONCLUSIONS: These data demonstrate that Bethesda categories 1-4 are associated with a higher ROM compared to the first edition of TBSRTC, especially in male patients, and validate findings from the second edition of TBSRTC.

"It Has Changed": Understanding Change in a Parenting Program in South Africa.

BACKGROUND: Poor parenting that leads to child maltreatment during adolescence presents a major public health burden. Research from high-income countries indicates that evidence-based parenting program interventions can reduce child maltreatment. Much less is known, however, about how beneficiaries of these programs experience this process of change. Understanding the process that brings about change in child maltreatment practices is essential to understanding intervention mechanisms of change. This is particularly important given the current scale-up of parenting programs across low- and middle-income countries. OBJECTIVES: This study aimed to provide insight into how caregivers and adolescents attending a parenting program in South Africa perceived changes associated with abuse reduction. METHODS: Semi-structured interviews were conducted with caregivers and adolescents (n = 42) after the intervention, as well as observations of sessions (n = 9) and focus group discussions (n = 240 people). Participants were adolescents between the ages of 10-18 and their primary caregiver residing in peri-urban and rural program clusters in the Eastern Cape Province of South Africa. Data were coded in Atlas.ti, and thematic content analysis was conducted. FINDINGS: Based on participant perceptions, the Sinovuyo Teen parenting program workshops catalyzed change into practice by creating an environment that was conducive to learning alternatives. It did so through prioritizing a process of mutual respect, openness, and being valued by others, giving legitimacy to a respectful reciprocity and new ways of spending time together that enabled caregivers and teenagers to shift and normalize more positive behaviors. This in turn led to reductions in physical and verbal abuse. CONCLUSIONS: This study's findings may be of use to policymakers and practitioners who need to understand how parenting programs support parents and teenagers in increasing positive parenting approaches and changing potentially harmful practices. It additionally highlights the importance of assessing the experiences of both parents and teenagers attending such programs.

Disclosure of physical, emotional and sexual child abuse, help-seeking and access to abuse response services in two South African Provinces.

Physical, emotional and sexual child abuse are major problems in South Africa. This study investigates whether children know about post-abuse services, if they disclose and seek services, and what the outcomes of help-seeking behaviour are. It examines factors associated with request and receipt of services. Confidential self-report questionnaires were completed by adolescents aged 10-17 (n = 3515) in South Africa. Prevalence of frequent (>weekly) physical abuse was 7.4%, frequent emotional abuse 12.4%, and lifetime contact sexual abuse 9.0%. 98.6% could name one suitable confidante or formal service for abuse disclosure, but only 20.0% of abuse victims disclosed. Of those, 72% received help. Most common confidantes were caregivers and teachers. Of all abuse victims, 85.6% did not receive help due to non-disclosure or inactivity of services, and 14.4% received help: 4.9% from formal health or social services and 7.1% through community vigilante action. Emotional abuse, sexual abuse and female gender were associated with higher odds of help-seeking. While children in South Africa showed high knowledge of available services, access to and receipt of formal services among abused children was low. Notably fewer children received help from formal services than through community vigilante action. Urgent action is needed to improve service access for child abuse victims.

Early complications of total hip and knee replacement: a comparison of outcomes in a regional orthopaedic hospital and two independent treatment centres.

INTRODUCTION: There is anecdotal evidence of poorer outcomes from prosthetic joint replacement performed in independent treatment centres but very few comparative studies. PATIENTS AND METHODS: We compared the early re-operation, dislocation, re-admission, major wound infection and audit rates of 880 total hip (THA) and 874 total knee (TKA) arthroplasties carried out at a regional orthopaedic hospital (Avon Orthopaedic Centre; AOC) with 368 THAs and 365 TKAs from an NHS (WGH) and 67 THAs and 86 TKAs from a private hospital (CNH) independent treatment centre. RESULTS: Early re-operation rates were 9% at CNH, 1.4% at WGH and 0.6% at AOC after THA and 8% at CNH, 1.9% at WGH and 1% at AOC after TKA. After THA, dislocation rates after THA were 6% at CNH and 1.8% at both WGH and AOC. Re-admission rates were 13% at CNH, 0.6% at WGH and 1.2% at AOC. Major wound problems were 20% at CNH, 3.8% at WGH and 0.4% at AOC after THA and 19% at CNH, 1.9% at WGH and AOC (1.1%) after TKA. After TKA, re-admission rates from CNH were 13%, 1% at WGH and 1.1% at AOC. AOC and WGH audited their outcomes. None were available from CNH. CONCLUSIONS: Results and audit from independent treatment centres are variable and patients should be warned of this before undergoing treatment at them.

How does AIDS illness affect women's residential decisions? Findings from an ethnographic study in a Cape Town township.

This paper explores the nature and consequences of residential decision-making for women on treatment for AIDS illness in a poor urban settlement in South Africa. Drawing on ethnographic data collected over a two-year period, it points to the subtle shifts in 'householding' practices and kinship relationships prompted by women's individual experiences and understanding of their HIV status, illness and treatment. Women's decisions to move or to arrange that other family members move can be explained by pre-existing threats to individual wellbeing or family residential security. But an HIV diagnosis can intensify a mother's thoughts and actions in relation to residential and emotional security, in particular on behalf of her children. In a context where extended periods of childcare by rural relatives is common, mothers with AIDS illness may gather all their children in their home to offer direct care, achieve intimacy and facilitate disclosure. They are likely to avoid making frequent contact with, and demands on, their elderly parents. Siblings are favoured as co-residents and confidants in disclosure, but their long-term support is contingent on reciprocity. Partners, where present, are valued for economic, social and emotional security. Women attempt to balance their children's nurturing, in the short and long term, with care of the self. Their efforts do not always succeed and can incur high costs to their wellbeing and relationships with their children.

Women coping with AIDS in Africa: contributions of a contextually grounded research methodology.

The primary objective of this report is to describe a contextually grounded approach to the investigation of coping and psychological functioning in AIDS-sick mothers. Five AIDS-sick women on antiretroviral therapy who had at least one child under 6 years of age living in their households were interviewed. Among the issues that emerged was the complexity of the women's psychological functioning, the fact that they made strategic decisions about disclosure aimed at protecting important social support networks, and that their well-being was dynamically influenced by factors in the home and community. The study provides evidence for the value of a contextual approach when investigating the psychological functioning of HIV positive mothers living in poor high-HIV prevalence communities in developing countries.

'But where are our moral heroes?' An analysis of South African press reporting on children affected by HIV/AIDS.

Messages conveyed both explicitly and implicitly in the media play an important role in shaping the public's understanding of issues, as well as in shaping associated policy, programmes and popular responses to these issues. This paper applies discourse analysis to a series of articles about children affected by HIV/AIDS published in 2002/2003 in the English-language South African press. The analysis reveals layers of moral messaging present in the reporting, the cumulative effect of which is the communication of a series of moral judgements about who is and who is not performing appropriate roles in relation to children. Discourses of moral transgression, specifically on the part of African parents and 'families' for failing in their moral responsibilities towards their children, coalesce with discourses on anticipated moral decay among (previously innocent) children who lack their due care. A need for moral regeneration among South Africans (but implicitly black South Africans) contrasts with accolades for (usually white), middle-class individuals, who, it is implied, have gone beyond their moral duty to respond. The article argues that in each instance the particular moralism is questionable in light of both empirical evidence and the principles of human dignity that underlie the South African constitution. Children - and particularly 'AIDS orphans' - are often presented in the press as either quintessential, innocent victims of the epidemic or as potential delinquents. While journalists' intentions are likely to be positive when representing children in these ways, the paper argues that this approach is employed at a cost, both to the public's knowledge and attitudes around the impact of HIV/AIDS, and, more importantly, to the lives of children affected by the epidemic.

Predicting the social consequences of orphanhood in South Africa.

This paper examines and questions the predictions found in the academic and policy literature of social breakdown in southern Africa in the wake of anticipated high rates of orphanhood caused by the AIDS epidemic. Analysis of the logic underlying these predictions reveals four causal relationships necessary to fulfil such dramatic and apocalyptic predictions: High AIDS mortality rates will produce high numbers of orphans. These orphans will become children who do not live in appropriate social environments to equip them for adult citizenship. Poor socialisation will mean that children orphaned by AIDS will not live within society's moral codes (becoming, for example, street children or juvenile delinquents). Large numbers of such 'asocial' or 'antisocial' children will precipitate a breakdown in the social fabric. Evidence for each of these steps in the argument is scrutinised using available data from southern Africa and other regions that have moved further through the epidemic's cycle. The paper finds strong evidence for the first step, although variable definitions of 'orphan' make it difficult to draw accurate comparisons over time and space. Evidence for the second step is found to be mixed in terms of outcomes of AIDS orphanhood for child well-being. Moreover the argument takes little account of the social and economic environments onto which AIDS is mapped, including the economic fragility of households and pervading socio-cultural patterns of child-rearing. Data to substantiate the third step are anecdotal at best and no research is able to demonstrate a link between the long term effects of AIDS orphanhood and rising rates of juvenile delinquency. Arguments made towards the fourth step are shown to be based heavily on notions of the 'correct' social and physical environments for children and on unsubstantiated fears of alternatives to these. There is no evidence from countries where numbers of AIDS orphans are already high to suggest that their presence is precipitating social breakdown. The paper argues-somewhat provocatively-that such apocalyptic predictions are unfounded and ill-considered. By misrepresenting the problems faced by children and their families, attention is distracted from the multiple layers of social, economic and psychological disadvantage that affect individual children, families and communities. Consequently, insufficient consideration is given to the multi-faceted supports necessary to assist children to cope with extremely difficult circumstances brought about over the long term by the HIV/AIDS epidemic.