Two-way associations between relationship quality and uptake of couples health screening including HIV testing and counselling together: quantitative analysis of a couples cohort in rural South Africa.

In the context of a couples cohort established to evaluate an optimised couples-focused behavioural intervention in rural South Africa, we examined: (1) Is couples' relationship quality (RQ) associated with couples HIV testing and counselling (CHTC) uptake? (2) Does CHTC uptake or the intervention components uptake improve subsequent RQ? Enrolled couples, (n = 218), previously naïve to couples HIV testing, were invited to two group sessions and offered four couples counselling sessions (CS1-CS4), as part of the intervention and administered a questionnaire individually at baseline, four weeks, and four months, which included item-scales to measure RQ: satisfaction, intimacy, dyadic trust, conflict, and mutual constructive communication. Logistic models indicated that no baseline RQ measures were significantly associated with CHTC uptake. Linear regression models showed that CHTC uptake before four weeks assessment significantly improved couples' satisfaction and trust at four weeks, and intimacy at four months. Attending at least one CS was associated with increased satisfaction, intimacy, and decreased conflict within couples at four weeks; the improvement in intimacy was sustained at four months. Consistent with the theoretical interdependence model, our findings suggest that CHTC and CS seemed to strengthen aspects of relationship quality, possibly leading to further collaboration in managing lifestyle changes and treatment adherence.

Social Influence and Uptake of Couples HIV Testing and Counselling in KwaZulu-Natal, South Africa.

Social influences may create a barrier to couples HIV testing and counselling (CHTC) uptake in sub-Saharan Africa. This secondary analysis of data collected in the 'Uthando Lwethu' randomised controlled trial used discrete-time survival models to evaluate the association between within-couple average 'peer support' score and uptake of CHTC by the end of nine months' follow-up. Peer support was conceptualised by self-rated strength of agreement with two statements describing friendships outside of the primary partnership. Eighty-eight couples (26.9%) took up CHTC. Results tended towards a dichotomous trend in models adjusted only for trial arm, with uptake significantly less likely amongst couples in the higher of four peer support score categories (OR 0.34, 95% CI 0.18, 0.68 [7-10 points]; OR 0.53, 95% CI 0.28, 0.99 [≥ 11 points]). A similar trend remained in the final multivariable model, but was no longer significant (AOR 0.59, 95% CI 0.25, 1.42 [7-10 points]; AOR 0.88, 95% CI 0.36, 2.10 [≥ 11 points]). Accounting for social influences in the design of couples-focused interventions may increase their success.

Protocol: evaluation of an optimised couples-focused intervention to increase testing for HIV in rural KwaZulu-Natal, South Africa, the Igugu Lethu ('Our treasure') cohort study.

BACKGROUND: Between 2012 and 2015, the Uthando Lwethu (UL) study demonstrated that a theory-based behavioural couples-focused intervention significantly increased participation in couples HIV testing and counselling (CHTC) among South African couples who had never previously tested for HIV together or mutually disclosed their HIV status, 42% compared to 12% of the control group at 9 months follow-up. Although effective, we were nonetheless concerned that in this high prevalence setting the majority (58%) of intervention couples chose not to test together. In response we optimised the UL intervention and in a new study, 'Igugu Lethu', we are evaluating the success of the optimised intervention in promoting CHTC. METHODS: One hundred eighty heterosexual couples, who have been in a relationship together for at least 6 months, are being recruited and offered the optimised couples-focused intervention. In the Igugu Lethu study, we have expanded the health screening visit offered to couples to include other health conditions in addition to CHTC. Enrolled couples who choose to schedule CHTC will also have the opportunity to undertake a random blood glucose test, blood pressure and BMI measurements, and self-sample for STI testing as part of their health screening. Individual surveys are administered at baseline, 4 weeks and 4 months follow-up. The proportion of couples who decide to test together for HIV will be compared to the results of the intervention arm in the UL study (historical controls). To facilitate this comparison, we will use the same recruitment and follow-up strategies in the same community as the previous UL study. DISCUSSION: By strengthening communication and functioning within the relationship, the Igugu Lethu study, like the previous UL study, aims to transform the motivation of individual partners from a focus on their own health to shared health as a couple. The Igugu Lethu study findings will answer whether the optimised couples-focused behavioural intervention and offering CHTC as part of a broader health screening for couples can increase uptake of CHTC by 40%, an outcome that would be highly desirable in populations with high HIV prevalence. TRIAL REGISTRATION: Retrospectively registered. ISRCTN Registry ISRCTN 46162564 Registered on 26th May 2022.

Household composition and child health in Botswana.

BACKGROUND: There is a general lack of research on children's household experiences and child health outcomes in low- and middle-income countries (LMICs). This study examines the relationship between household composition, stunting and diarrhoea prevalence among children younger than 5 years of age in Botswana. METHODS: The analysis uses data from the 2007 Botswana Family Health Survey (BFHS) and multilevel logistic regression models. RESULTS: The findings indicate that stunting varies by whom the child lives with. Stunting is higher among children living with no parents compared to those living with both parents. Stunting is also high among children living with unrelated household members. Similarly, children in households with a mother-only and with a grandparent present, have a higher level of stunting compared to those living with both parents. Conversely, living with an aunt and living with other relatives, protects against stunting. The findings on diarrhoea prevalence show that children living in mother-only households and those living with no parents are less likely to have diarrhoea than those living with both parents. Also, across all households, those who are more affluent have lower rates of child stunting and diarrhoea than those which are more deprived. Finally, the findings show a clustering effect at the household level for both stunting and diarrhoea prevalence. CONCLUSIONS: These findings suggest that policies and programs aimed at reducing stunting and diarrhoea may work best if they target households and other adults co-residing in homes with children besides biological parents. Further, children who live in poorer households deserve special attention.

Alcohol use and relationship quality among South African couples.

OBJECTIVE: The HIV literature has largely ignored the importance of alcohol use in the quality of intimate relationships in sub-Saharan Africa (SSA), despite evidence of alcohol's role in relational behaviors that increase risk for HIV infection and other harms. The present study explored the association of alcohol use with relationship functioning among heterosexual couples from rural South Africa. METHOD: Dyadic analyses were conducted with 443 sexually active, heterosexual, South African couples (886 individuals) to examine the association between male partners' alcohol use (abstinent, nonhazardous, and hazardous), and male and female partners' reports of relationship intimacy, trust, mutually constructive communication, demand/withdraw communication, and satisfaction. Five structural equation models were fit using male partner alcohol use as a predictor of male and female reports of relationship quality. RESULTS: Women with a hazardous-drinking male partner (compared to an abstainer) reported significantly higher levels of intimacy (p <.05) and significantly more demand/withdraw communication (p <.001); men who were hazardous drinkers reported significantly less trust in their relationship compared to men who were abstainers (p < .01). CONCLUSIONS: Hazardous alcohol use among South African couples is positively correlated with women's relationship intimacy and maladaptive communication patterns, yet negatively correlated with men's perceived trust.

HIV testing experiences and their implications for patient engagement with HIV care and treatment on the eve of 'test and treat': findings from a multicountry qualitative study.

OBJECTIVE: In view of expanding 'test and treat' initiatives, we sought to elicit how the experience of HIV testing influenced subsequent engagement in HIV care among people diagnosed with HIV. METHODS: As part of a multisite qualitative study, we conducted in-depth interviews in Uganda, South Africa, Tanzania, Kenya, Malawi and Zimbabwe with 5-10 health workers and 28-59 people living with HIV, per country. Topic guides covered patient and provider experiences of HIV testing and treatment services. Themes were derived through deductive and inductive coding. RESULTS: Various practices and techniques were employed by health workers to increase HIV testing uptake in line with national policies, some of which affected patients' subsequent engagement with HIV services. Provider-initiated testing was generally appreciated, but rarely considered voluntary, with instances of coercion and testing without consent, which could lead to disengagement from care.Conflicting rationalities for HIV testing between health workers and their clients caused tensions that undermined engagement in HIV care among people living with HIV. Although many health workers helped clients to accept their diagnosis and engage in care, some delivered static, morally charged messages regarding sexual behaviours and expectations of clinic use which discouraged future care seeking. Repeat testing was commonly reported, reflecting patients' doubts over the accuracy of prior results and beliefs that antiretroviral therapy may cure HIV. Repeat testing provided an opportunity to develop familiarity with clinical procedures, address concerns about HIV services and build trust with health workers. CONCLUSION: The principles of consent and confidentiality that should underlie HIV testing and counselling practices may be modified or omitted by health workers to achieve perceived public health benefits and policy expectations. While such actions can increase HIV testing rates, they may also jeopardise efforts to connect people diagnosed with HIV to long-term care, and undermine the potential of test and treat interventions.

Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa.

OBJECTIVES: There are concerns that medical pluralism may delay patients' progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade. METHODS: We conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism. RESULTS: Medical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds. CONCLUSION: Medical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa.

Obligation to family during times of transition: care, support and the response to HIV and AIDS in rural South Africa.

In rural South Africa, high HIV prevalence has the potential to affect the care and support that kin are able to provide to those living with HIV. Despite this, families seem to be largely resilient and a key source of care and support to family affected by HIV. In this article, we explore the motivations for the provision of care and support by kin. We use the results of a small-scale in-depth qualitative study conducted in 10 households over 6 months in rural KwaZulu-Natal, South Africa, to show that family obligation and conditional reciprocity operate in varying degrees and build social capital. We highlight the complexity of kin relations where obligation is not guaranteed or is limited, requiring the consideration of policy measures that provide means of social support that are not reliant on the family.

An Approach to Measuring Dispersed Families with a Particular Focus on Children 'Left Behind' by Migrant Parents: Findings from Rural South Africa.

There is growing policy and academic interest in the conditions, experiences, and well-being of migrant families stretched across origin and destination households. In South Africa, the dispersal of children and migrant parents across multiple households is a commonplace childhood experience. However, in common with the broader international context, quantitative analyses of the social and residential connections between children and migrant parents in South Africa have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper describes a new data collection effort in the origin and destination households of migrants from rural KwaZulu-Natal and explains the methodology for using this data to examine multiple household contexts for children and parents. In order to illustrate the contribution that this form of data collection effort could make to family migration studies, the paper also presents results on the living arrangements of children 'left behind' by migrant parents; a potentially vulnerable group whose arrangements are challenging to examine with existing data sources. The empirical results show the majority (75%) of left behind children have previously migrated and a significant proportion of migrants' children (25%) were not living in their parent's origin or destination household. The findings highlight the need for careful measurement of the circumstances of left behind children and demonstrate the contribution of linked data for providing insights into the residential arrangements of migrants' children. © 2014 The Authors. Population, Space and Place published by John Wiley & Sons Ltd.

Understanding Family Migration in Rural South Africa: Exploring Children's Inclusion in the Destination Households of Migrant Parents.

Despite the removal of restrictions on movement and increasing female participation in migration, only a minority of migrant parents in South Africa include their children in their destination household. Quantitative analyses of the circumstances in which children accompany a migrant parent have been limited by the lack of available data that document family arrangements from the perspective of more than one household. This paper uses data about members of rural households in a demographic surveillance population in KwaZulu-Natal and a linked sample survey of adult migrants to examine factors associated with children's inclusion in the destination household of migrant parents, analyse the timing and sequence of children's moves to parental destination households, and describe the composition of parental origin and destination households. The findings confirm that in contemporary South Africa, only a small percentage (14%) of migrants' children who are members of the parental origin household are also members of the parental destination household. Membership of the parental destination household is associated with parental characteristics and the child's age, but not measures of socio-economic status, and children most commonly migrate several years after their migrant parent. Children included in the destination household of migrant fathers frequently live in small households, which also include their mother, whereas children included in the destination household of migrant mothers live in larger households. This study contributes to understanding the contexts of children's inclusion in parental destination households in South Africa and demonstrates the potential of data collected in migrants' origin and destination households.

Are social support and HIV coping strategies associated with lower depression in adults on antiretroviral treatment? Evidence from rural KwaZulu-Natal, South Africa.

We assess depression rates and investigate whether depression among HIV-infected adults receiving antiretroviral treatment (ART) is associated with social support and HIV coping strategies in rural South Africa (SA). The study took place in a decentralised public-sector ART programme in a poor, rural area of KwaZulu-Natal, SA, with high-HIV prevalence and high-ART coverage. The 12-item General Health Questionnaire (GHQ12), validated in this setting, was used to assess depression in 272 adults recently initiated on ART. Estimates of depression prevalence ranged from 33% to 38%, depending on the method used to score the GHQ12. Instrumental social support (providing tangible factors for support, such as financial assistance, material goods or services), but not emotional social support (expressing feelings, such as empathy, love, trust or acceptance, to support a person), was significantly associated with lower likelihood of depression [adjusted odds ratio (aOR) = 0.65, 95% confidence interval (CI) 0.52-0.81, P < 0.001], when controlling for sex, age, marital status, education, household wealth and CD4 cell count. In addition, using "avoidance of people" as a strategy to cope with HIV was associated with an almost three times higher odds of depression (aOR = 2.79, CI: 1.34-5.82, P = 0.006), whereas none of the other five coping strategies we assessed was significantly associated with depression. In addition to antidepressant drug treatment, interventions enhancing instrumental social support and behavioural therapy replacing withdrawal behaviours with active HIV coping strategies may be effective in reducing the burden of depression among patients on ART.

Gendered Patterns of Migration in Rural South Africa.

Gender is increasingly recognized as fundamental to understanding migration processes, causes and consequences. In South Africa, it is intrinsic to the social transformations fueling high levels of internal migration and complex forms of mobility. While female migration in Africa has often been characterized as less prevalent than male migration, and primarily related to marriage, in South Africa a feminization of internal migration is underway, fueled by women's increasing labor market participation. In this paper, we report sex differences in patterns, trends and determinants of internal migration based on data collected in a demographic surveillance system between 2001 and 2006 in rural KwaZulu-Natal. We show that women were somewhat more likely than men to undertake any migration, but sex differences in migration trends differed by migration flow, with women more likely to migrate into the area than men, and men more likely to out-migrate. Out-migration was suppressed by marriage particularly for women, but most women were not married; both men's and women's out-migrations were undertaken mainly for purposes of employment. Over half of female out-migrations (versus 35% of male out-migrations) were to nearby rural areas. The findings highlight the high mobility of this population and the extent to which gender is intimately related to the processes determining migration. We consider the implications of these findings for the measurement of migration and mobility, in particular for health and social policy and research among highly mobile populations in southern Africa.

An investigation of factors associated with the health and well-being of HIV-infected or HIV-affected older people in rural South Africa.

BACKGROUND: Despite the severe impact of HIV in sub-Saharan Africa, the health of older people aged 50+ is often overlooked owing to the dearth of data on the direct and indirect effects of HIV on older people's health status and well-being. The aim of this study was to examine correlates of health and well-being of HIV-infected older people relative to HIV-affected people in rural South Africa, defined as participants with an HIV-infected or death of an adult child due to HIV-related cause. METHODS: Data were collected within the Africa Centre surveillance area using instruments adapted from the World Health Organization (WHO) Study on global AGEing and adult health (SAGE). A stratified random sample of 422 people aged 50+ participated. We compared the health correlates of HIV-infected to HIV-affected participants using ordered logistic regressions. Health status was measured using three instruments: disability index, quality of life and composite health score. RESULTS: Median age of the sample was 60 years (range 50-94). Women HIV-infected (aOR 0.15, 95% confidence interval (CI) 0.08-0.29) and HIV-affected (aOR 0.20, 95% CI 0.08-0.50), were significantly less likely than men to be in good functional ability. Women's adjusted odds of being in good overall health state were similarly lower than men's; while income and household wealth status were stronger correlates of quality of life. HIV-infected participants reported better functional ability, quality of life and overall health state than HIV-affected participants. DISCUSSION AND CONCLUSIONS: The enhanced healthcare received as part of anti-retroviral treatment as well as the considerable resources devoted to HIV care appear to benefit the overall well-being of HIV-infected older people; whereas similar resources have not been devoted to the general health needs of HIV uninfected older people. Given increasing numbers of older people, policy and programme interventions are urgently needed to holistically meet the health and well-being needs of older people beyond the HIV-related care system.

Injury mortality in rural South Africa 2000-2007: rates and associated factors.

OBJECTIVE: To estimate injury mortality rates in a rural population in KwaZulu-Natal, South Africa and to identify socio-demographic risk factors associated with adult injury-related deaths. METHODS: The study used population-based mortality data collected by a demographic surveillance system on all resident and non-resident members of 11,000 households. Deaths and person-years of observation (pyo) were aggregated for individuals between 01 January 2000 and 31 December 2007. Cause of death was determined by verbal autopsy, coded using ICD-10 and further categorised using global burden of disease categories. Socio-demographic risk factors associated with injuries were examined using regression analyses. RESULTS: We analysed data on 133,483 individuals with 717,584.6 person-years of observation (pyo) and 11,467 deaths. Of deaths, 8.9% were because of injury-related causes; 11% occurred in children <15 years old. Homicide, road traffic injuries and suicide were the major causes. The estimated crude injury mortality rate was 142.4 (134.0, 151.4)/100,000 pyo; 116.9 (108.1, 126.5)/100,000 pyo among residents and 216.8 (196.5, 239.2)/100,000 pyo among non-residents. In multivariable analyses, the differences between residents and non-residents remained but were no longer significant for women. In men and women, full-time employment was significantly associated with lower mortality [adjusted rate ratios 0.6 (0.4, 0.9); 0.4 (0.2, 0.9)]; in men, higher asset ownership was independently associated with increased mortality [adjusted rate ratio 1.5 (1.1, 1.9)]. CONCLUSIONS: Reducing the high levels of injury-related mortality in South Africa requires intersectoral primary prevention efforts that redress the root causes of violent and accidental deaths: social inequality, poverty and alcohol abuse.

Optimising a couples-focused intervention to increase couples' HIV testing and counselling using the person-based approach: a qualitative study in Kwa-Zulu Natal, South Africa.

OBJECTIVES: This qualitative study explored how to optimise a couples-focused intervention to promote couples HIV testing and counselling (CHTC). SETTING: Community setting in Kwa-Zulu Natal, South Africa. PARTICIPANTS: Qualitative interviews were conducted with 20 couples who had participated in a couples-focused intervention and five staff members delivering the intervention. Partners were interviewed individually by researchers of the same gender. INTERVENTION: A couples-focused intervention comprised of two group sessions and four couples counselling sessions was previously shown to significantly increase uptake to CHTC in Kwa-Zulu Natal, South Africa. However, more than half of couples participating in the intervention still chose not to test together during follow-up. ANALYSIS: The transcripts were analysed using the table of changes from the person-based approach. Proposed optimisations were discussed with a community group to ensure the intervention was as persuasive and acceptable as possible. RESULTS: Many couples found it challenging to discuss CHTC with their partner due to an implied lack of trust. Optimisations to the intervention were identified to increase readiness to discuss CHTC, including education about serodiscordance, discussions about CHTC by peer mentors and open discussion of personal barriers to CHTC during couples' counselling sessions. Additional training for staff in open questioning techniques could help them feel more comfortable to explore couples' perceived barriers to CHTC, rather than advising couples to test. A logic model was developed to show anticipated mechanisms through which the optimised intervention would increase uptake to CHTC, including increasing knowledge, increasing positive outcome beliefs and managing negative emotions. CONCLUSIONS: In-depth qualitative research informed optimisations to a couples-focused intervention for further evaluation in South Africa to encourage uptake to CHTC. Suggestions are made for optimal methods to gain open feedback on intervention experiences where participants may be reluctant to share negative views.

"No one can ask me 'Why do you take that stuff?'": men's experiences of antiretroviral treatment in South Africa.

This paper examines the way gender shaped the health behaviours, health care experiences and narratives of HIV-positive men initiating antiretroviral treatment in South Africa. We conducted participant observation and in-depth, semi-structured interviews with eight men enrolled in a public HIV treatment programme in a rural health district in KwaZulu-Natal. We also interviewed their family members and programme staff. The study found that men's narratives and experiences of antiretroviral therapy (ART) were complex. Descriptions of control and coping juxtaposed with low self-esteem and guilt. Improvements in health following treatment increased optimism about the future but were readily undermined by men's concerns about being unable to meet strongly gendered expectations in relation to family and work. Alcohol use and abuse by men themselves or by family members was found to be an important issue influencing disclosure, uptake and adherence. Given messages discouraging alcohol use during treatment, men reported self-imposed delays to enrolment while they tried to stop or reduce alcohol use, although none had sought advice or professional help in doing so. Men also felt very threatened by alcohol abuse by family members fearing accidental disclose, insults and violence. With regards to health providers, men held strong views as to appropriate and professional behaviour by programme staff, particularly regarding confidentiality. As ART programmes in Africa become established and evolve, we not only need to identify barriers to men's access and adherence but monitor their health and treatment experiences. These findings suggest that the issue of alcohol and ART warrants further investigation. Additional training for primary health care providers and counsellors on health promotion with men may be useful.

Prenatal development in rural South Africa: relationship between birth weight and access to fathers and grandparents.

Birth weight is an indicator of prenatal development associated with health in infancy and childhood, and may be affected by the family environment experienced by the mother during pregnancy. Using data from KwaZulu-Natal, South Africa, we explore the importance of the mother's access to the father and grandparents of the child during pregnancy. Controlling for household socio-economic indicators and maternal characteristics, the survival and residence of the biological father with the mother are positively associated with birth weight. The type of relationship seems to matter: married women have the heaviest newborns, but co-residence with a non-marital partner is also associated with higher birth weight. Access to the maternal grandmother may also be important: women whose mothers are alive have heavier newborns, but no additional benefit is observed from residing together. Co-residence with any grandparent is not associated with birth weight after controlling for the mother's partnership.

Trends in the prevalence and incidence of orphanhood in children and adolescents <20 years in rural KwaZulu-Natal South Africa, 2000-2014.

BACKGROUND: In South Africa, large increases in early adult mortality during the 1990s and early 2000s have reversed since public HIV treatment rollout in 2004. In a rural population in KwaZulu-Natal, we investigate trends in parental mortality and orphanhood from 2000-2014. METHODS: Using longitudinal demographic surveillance data for a population of approximately 90,000, we calculated annual incidence and prevalence of maternal, paternal and double orphanhood in children and adolescents (<20 years) and, overall and cause-specific mortality of parents by age. RESULTS: The proportion of children and adolescents (<20 years) for whom one or both parents had died rose from 26% in 2000 to peak at 36% in 2010, followed by a decline to 32% in 2014. The burden of orphanhood remains high especially in the oldest age group: in 2014, 53% of adolescents 15-19 years had experienced the death of one or both parents. In all age groups and years, paternal orphan prevalence was three-five times higher than maternal orphan prevalence. Maternal and paternal orphan incidence peaked in 2005 at 17 and 27 per 1,000 person years respectively (<20 years) before declining by half through 2014. The leading cause of parental death throughout the period, HIV/AIDS and TB cause-specific mortality rates declined substantially in mothers and fathers from 2007 and 2009 respectively. CONCLUSIONS: The survival of parents with children and adolescents <20 years has improved in tandem with earlier initiation and higher coverage of HIV treatment. However, comparatively high levels of parental deaths persist in this rural population in KwaZulu-Natal, particularly among fathers. Community-level surveillance to estimate levels of orphanhood remains important for monitoring and evaluation of targeted state welfare support for orphans and their guardians.

The demographic impact of HIV and AIDS across the family and household life-cycle: implications for efforts to strengthen families in sub-Saharan Africa.

HIV is no longer a new or emerging disease in southern Africa. In the era of HIV and AIDS, families and households have continued to form, build, migrate and dissolve. Children born in the 1980s with the risk of mother-to-child HIV transmission have already gone on to start the next generation of families and households. Isolating the impact of HIV and AIDS on families and households is complex given that the epidemic has become part of the direction and force of contemporary demographic, social and economic processes and trends. Cycles of family and household life have occurred in a changing HIV and AIDS public-health environment, one in which HIV treatment access has increased rapidly. As part of an on-going process to assess the relevance and effectiveness of policies and programmes designed to protect and support children affected by HIV and AIDS, it is necessary to update our knowledge about the family and household circumstances in which children live. This paper summarises findings from a review on the "Demographic Evidence of Family and Household Changes in Response to the Effects of HIV/AIDS in Southern Africa: Implications for Efforts to Strengthen Families". The review examined published literature presenting data from empirical studies, primarily large, cross-sectional or longitudinal population-based or sample surveys. The family or household life-cycle is used as a conceptual and organisational framework. The implications of the demographic evidence are discussed in relation to policy and programme responses to strengthen families and households in the region.