Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study.

BACKGROUND: In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood). METHODS: We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates. FINDINGS: The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7-90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3-76·7) of children were paternal orphans, whereas 23·5% (23·3-23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood. INTERPRETATION: Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally. FUNDING: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Life in a child-headed household: Exploring the quality of life of orphans living in child-headed households in Zimbabwe.

The overwhelming rate of HIV-related mortality in the past decades has eroded traditional safety nets for orphans, of which the extended family is the most critical. This has led to the formation of new household structures, i.e. child- and youth-headed households, as children and youths are left to live alone and look after themselves. These types of households are a growing phenomenon in many African countries and are increasingly being recognised as household structures. However, in the absence of an economically active adult, orphans living in these households experience numerous challenges. The socio-economic challenges in Zimbabwe could further exacerbate the conditions of child-headed households. This article discusses findings of an ethnographic inquiry on orphans living in child- and youth-headed households in Zimbabwe. We identified parentification, lack of income and social isolation as risk factors affecting quality of life. Social capital and agency were identified as protective factors enhancing children's quality of life. Our findings suggest that orphans living in child- and youth-headed households are not only victims but are also resilient and can exercise agency. Therefore, interventions to support this vulnerable group should build on their existing resilience and agency.

Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study.

BACKGROUND: The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation. METHODS: We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60-84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection-fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers. FINDINGS: Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000-1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000-1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15-50 years. Between two and five times more children had deceased fathers than deceased mothers. INTERPRETATION: Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children. FUNDING: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Disciplinary practices among orphaned children in Sub-Saharan Africa.

OBJECTIVES: This study considers whether orphans' experiences with physically and psychologically violent discipline differ from non-orphans in sub-Saharan Africa, and to what extent national, community, household, caretaker, and child characteristics explain those differences. METHODS: We use cross-sectional Multiple Indicator Cluster Surveys (MICS) administered between 2010-2017 in 14 sub-Saharan African countries. The sample included 125,197 children, of which 2,937 were maternal orphans, 9,113 were paternal orphans, and 1,858 were double orphans. We estimate the difference between orphans and non-orphans experience of harsh discipline using multivariable logistic regressions with country fixed effects and clustered standard errors. RESULTS: Findings show that orphaned children experience less harsh discipline in the home. With the exception of double orphans' experience with physically violent discipline, these differences persisted even after controlling for a rich set of child, household, and caretaker characteristics. CONCLUSIONS: We propose two alternative explanations for our surprising findings and provide a supplementary analysis to help arbitrate between them. The evidence suggests that orphaned children (especially those with a deceased mother) are less likely to experience harsh discipline because of lower caretaker investment in their upbringing. We encourage future research to draw on in-depth interviews or household surveys with discipline data from multiple children in a home to further unpack why orphans tend to experience less harsh punishment than other children.

Cognitive and Educational Interventions for Orphans and Vulnerable Children Affected by HIV/AIDS: A Meta-Analysis.

Orphans and vulnerable children affected by HIV/AIDS (HIV OVC) are at risk for cognitive difficulties and lack of access to education. Interventions addressing cognitive or educational outcomes for HIV OVC worldwide were examined through systematic searches conducted from October 2016 to 2019. We examined the summative effectiveness of interventions and the specific effects of participant age and intervention length. Interventions targeting cognitive outcomes had a small, significant effect, with no effect of moderating variables. Interventions targeting educational outcomes had significant effects. Educational interventions over 1 year were effective, but effects of intervention length were not significant. Overall, this review provides support for the effectiveness of interventions targeting cognitive and educational outcomes for OVC and highlights the need for more research on such interventions.

Socio-economic status and hunger among orphans and vulnerable children households in Lagos State, Nigeria.

BACKGROUND: HIV/AIDS has contributed to increasing orphans and vulnerable children in Nigeria. A measure of vulnerability is household hunger. OBJECTIVE: To assess level of household hunger and associated factors among OVC households in Lagos State. METHODS: A cross-sectional survey of 1300 OVC households in 5 selected Local Government Areas. The LGAs were selected using the Household Vulnerability Assessment index. Data collection was by personal interview of households' heads/caregivers using a structured questionnaire capturing socio-demographic, household economic profile and food-related variables. A multivariate logit model was fitted to identify independent predictors of household hunger after adjusting for confounding variables. RESULTS: The population density was 5.1 and 52.8% were females. A larger proportion of females (84.6%) than males (78.3%) reported that they had no food to eat in the last four weeks prior the survey. Poor household economic status (OR=1.41, CI: 1.03-1.92), age and marital status of caregiver were independent predictors of household hunger. The odds of hunger increased with caregiver's age; higher in households headed by never married (OR=3.99, CI: 1.15-13.89) and divorced/separated caregivers (OR=2.39, CI: 1.11-5.12). CONCLUSION: OVC households experienced severe hunger. Household economic strengthening would be useful strategy to mitigate the nutrition challenges of OVC in Lagos state.

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.

Programmatic determinants of successful referral to health and social services for orphans and vulnerable children: A longitudinal study in Tanzania.

BACKGROUND: Trained community workers (CWs) successfully deliver health and social services, especially due to greater community acceptance. Orphans and vulnerable children (OVC) and their caregivers (CG) often need support from several sectors. We identified CW, program and referral characteristics that were associated with success of referrals provided to OVC and their CG in Tanzania in a cross-sectoral bi-directional referral system. METHODS: Data for this secondary analysis come from the first two years (2017-2018) of the USAID funded Kizazi Kipya project. Referral success was defined as feedback and service received within 90 days post-referral provision. We analyzed factors that are associated with the referral success of HIV related, education, nutrition, parenting, household economic strengthening, and child protection services among OVC and CG, using generalized estimating equations. RESULTS: During the study period, 19,502 CWs in 68 councils provided 146,996 referrals to 132,640 beneficiaries. OVC had much lower referral success for HIV related services (48.1%) than CG (81.2%). Adjusted for other covariates, CW age (26-49 versus 18-25 years, for OVC aOR = 0.83, 95%CI (0.78, 0.87) and CW gender (males versus females, for OVC aOR = 1.12, 95%CI (1.08, 1.16); CG aOR = 0.84, 95%CI (0.78, 0.90)) were associated with referral success. CWs who had worked > 1 year in the project (aOR = 1.52, 95%CI 1.46, 1.58) and those with previous work experience as CW (aOR = 1.57, 95%CI (1.42, 1.74) more successfully referred OVC. Referrals provided to OVC for all other services were more successful compared to HIV referrals, with aORs ranging from 2.99 to 7.22. Longer project duration in the district council was associated with increased referral success for OVC (aOR = 1.16 per month 95%CI 1.15,1.17), but decreased for CG (aOR = 0.96, 95%CI 0.94, 0.97). Referral success was higher for OVC and CGs with multiple (versus single) referrals provided within the past 30 days (aOR = 1.28 95%CI 1.21, 1.36) and (aOR = 1.17, 95%CI (1.06, 1.30)) respectively. CONCLUSION: CW characteristics, referral type and project maturity had different and often contrasting associations with referral success for OVC versus for CG. These findings could help policymakers decide on the recruitment and allocation of CWs in community based multi-sectoral intervention programs to improve referral successes especially for OVC.

ART use and associated factors among HIV positive caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. METHODS: Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. RESULTS: In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61-0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15-1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45-0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11-1.83). Caregivers aged 40-49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13-1.41). CONCLUSIONS: Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Determinants of undisclosed HIV status to a community-based HIV program: findings from caregivers of orphans and vulnerable children in Tanzania.

BACKGROUND: HIV status disclosure facilitates receipt of HIV prevention and treatment services. Although disclosure to sexual partners, family members or friends has been extensively studied, disclosure to community-based HIV programs is missing. This study assesses the magnitude of, and factors associated with undisclosed HIV status to a community-based HIV prevention program among caregivers of orphans and vulnerable children (OVC) in Tanzania. METHODS: Data are from the USAID-funded Kizazi Kipya project that seeks to increase uptake of HIV, health, and social services by OVC and their caregivers in Tanzania. Data on OVC caregivers who were enrolled in the project during January-March 2017 in 18 regions of Tanzania were analyzed. Caregivers included were those who had complete information on their HIV status disclosure, household socioeconomic status, and sociodemographic characteristics. HIV status was self-reported, with undisclosed status representing all those who knew their HIV status but did not disclose it. Multilevel mixed-effects logistic regression, with caregivers' HIV status disclosure being the outcome variable was conducted. RESULTS: The analysis was based on 59,683 OVC caregivers (mean age = 50.4 years), 71.2% of whom were female. Of these, 37.2% did not disclose their HIV status to the USAID Kizazi Kipya program at the time of enrollment. Multivariate analysis showed that the likelihood of HIV status non-disclosure was significantly higher among: male caregivers (odds ratio (OR) = 1.22, 95% confidence interval (CI) 1.16-1.28); unmarried (OR = 1.12, 95% CI 1.03-1.23); widowed (OR = 1.12, 95% CI 1.07-1.18); those without health insurance (OR = 1.36, 95% CI 1.28-1.45); age 61 + years (OR = 1.72, 95% CI 1.59-1.88); those with physical or mental disability (OR = 1.14, 95% CI 1.04-1.25); and rural residents (OR = 1.58, 95% CI 1.34-1.86). HIV status non-disclosure was less likely with higher education (p < 0.001); and with better economic status (p < 0.001). CONCLUSION: While improved education, economic strengthening support and expanding health insurance coverage appear to improve HIV status disclosure, greater attention may be required for men, unmarried, widowed, rural residents, and the elderly populations for their higher likelihood to conceal HIV status. This is a clear missed opportunity for timely care and treatment services for those that may be HIV positive. Further support is needed to support disclosure in this population.

High levels of scabies and malnutrition amongst orphans referred to a hospital in Addis Ababa, Ethiopia.

INTRODUCTION: Orphans are at high risk for neglected tropical diseases (NTDs) and other comorbidities such as malnutrition. We investigated how many orphans suffered from scabies, other NTDs and malnutrition. METHODOLOGY: A descriptive study using medical records of orphans referred to a teaching hospital in Addis Ababa, Ethiopia from December 2014 to December 2018 was done. Files documenting NTDs were reviewed in detail for age, referral diagnosis, and nutritional status. Nutritional assessment was done using the WHO Standard growth curve, classifying children as stunted (height for age Z score < -2SD or wasted (weight for length Z score < -2SD). RESULTS: Of the 852 orphans referred, 23.1% (196/852) was diagnosed with scabies, amongst which 28.1% (55/196) had multiple episodes. The median age (interquartile range) of the children with scabies was 3 (2-5) months. 85.2% (169/196) of the orphans with scabies were stunted and /or wasted. No other NTDs were reported. All of the scabies cases identified were not documented in the referral letter of the orphanage. CONCLUSIONS: There is ongoing transmission of scabies among children in the orphanage. Amongst orphans with scabies, an alarmingly high percentage was malnourished. Referrals from orphanages may provide an opportunity to detect NTDs and this is being missed.

Estimated Prevalence of Elder Orphans Using National Health and Aging Trends Study.

Objectives: By 2050, individuals aged 65 years and older will comprise over 20% of the American population. A portion is at risk for becoming elder orphans: older adults living in the community who lack caregivers or surrogates. Methods: Using the first wave of the National Health and Aging Trends Survey, we estimated the prevalence of older adults who reside in the community, who are socially or physically isolated, and who lack caregivers. Individuals who are "at risk" meet all of these criteria, with the exception that they live with and receive caregiving from their spouse. Results: We estimated the elder orphan prevalence for this population to be 2.62% (2.24-3.00), with an additional 21.29% determined to be at risk. Discussion: As the population of the United States ages, an understanding of the prevalence and demographics of elder orphans will be useful to guide policies and services to assist this population.

EEG oscillation evidences of altered resting-state brain activity in children orphaned by parental HIV/AIDS.

Early life adverse events in children orphaned by parental HIV/AIDS can have long-lasting effects on brain function. However, data are limited regarding the brain activation during resting state in these children. The current study aims to investigate the brain oscillation at rest in children orphaned by HIV/AIDS using resting-state EEG data. Data were derived from a larger neurodevelopmental study in which 90 children aged 9-17 years orphaned by AIDS and 66 matched controls were recruited through the local communities and school system. Children (63 orphans and 65 controls) who had resting-state EEG data and completed the Teacher-Child Rating Scale (T-CRS) were included in the current analysis. EEG results showed that children orphaned by HIV/AIDS had increased theta activity in the midline region, decreased beta activity in left hemisphere and overall increased theta/beta power ratio. Furthermore, the theta/beta ratio is positively correlated with learning problem and acting out scores, and negatively correlated with task orientation and peer social skill activities. Findings support that children orphaned by HIV/AIDS demonstrate different brain activity compared to non-orphan controls and also suggest that the EEG activities in resting state may serve as useful indicators of children's behavioral problems.

Challenges of developing a district child welfare plan in South Africa: lessons from a community-engaged HIV/AIDS research project.

The Amajuba Child Health and Wellbeing Research Project measured the impact of orphaning due to HIV/AIDS on South African households between 2004 and 2007. Community engagement was a central component of the project and extended through 2010. We describe researcher engagement with the community to recruit participants, build local buy-in, stimulate interest in study findings, and promote integration of government social welfare services for families and children affected by HIV/AIDS. This narrative documents the experience of researchers, drawing also on project reports, public documents, and published articles, with the objective of documenting lessons learned in this collaboration between researchers from two universities and a community in South Africa during a period that spanned seven years. This experience is then analyzed within the context of an applied research, community-engagement framework.

Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood.

BACKGROUND: The population effects of armed conflict on non-combatant vulnerable populations are incompletely understood. We aimed to study the effects of conflict on mortality among women of childbearing age (15-49 years) and on orphanhood among children younger than 15 years in Africa. METHODS: We tested the extent to which mortality among women aged 15-49 years, and orphanhood among children younger than 15 years, increased in response to nearby armed conflict in Africa. Data on location, timing, and intensity of armed conflicts were obtained from the Uppsala Conflict Data Program, and data on the location, timing, and outcomes of women and children from Demographic and Health Surveys done in 35 African countries from 1990 to 2016. Mortality among women was obtained from sibling survival data. We used cluster-area fixed-effects regression models to compare survival of women during periods of nearby conflict (within 50 km) to survival of women in the same area during times without conflict. We used similar methods to examine the extent to which children living near armed conflicts are at increased risk of becoming orphans. We examined the effects of varying conflict intensity using number of direct battle deaths and duration of consecutive conflict exposure. FINDINGS: We analysed data on 1 629 352 women (19 286 387 person-years), of which 103 011 (6·3%) died (534·1 deaths per 100 000 women-years), and 2 354 041 children younger than 15 years, of which 204 276 (8·7%) had lost a parent. On average, conflict within 50 km increased women's mortality by 112 deaths per 100 000 person-years (95% CI 97-128; a 21% increase above baseline), and the probability that a child has lost at least one parent by 6·0% (95% CI 3-8). This effect was driven by high-intensity conflicts: exposure to the highest (tenth) decile conflict in terms of conflict-related deaths increased the probability of female mortality by 202% (187-218) and increased the likelihood of orphanhood by 42% compared with a conflict-free period. Among the conflict-attributed deaths, 10% were due to maternal mortality. INTERPRETATION: African women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations. FUNDING: Bill & Melinda Gates Foundation to the BRANCH Consortium.

Treatment outcomes among HIV-positive orphaned and non-orphaned children on antiretroviral therapy in Johannesburg, South Africa.

BACKGROUND: Limited research investigating treatment outcomes for HIV-positive orphans compared with non-orphans has shown mixed results, with several studies indicating that HIV-positive orphans are at greater risk of delayed access to HIV care and poor antiretroviral therapy (ART) adherence, while other data suggest that ART outcomes of orphans can be similar to those of non-orphans. Understanding the impact of orphan status on short-term ART outcomes could improve targeted intervention strategies, and subsequent long-term treatment and developmental outcomes, for HIV-positive infants, children and adolescents. OBJECTIVES: To evaluate the relationship between orphan status and ART outcomes among HIV-positive infants, children and adolescents initiating ART at two large public sector HIV clinics in Johannesburg, South Africa. METHODS: This was a retrospective cohort study of HIV-positive children aged <18 years initiating standard first-line ART between June 2004 and May 2013. Using propensity scores, orphans and non-orphans were matched for age, sex, World Health Organization stage and ART regimen. The effect of orphanhood on attrition from care (all-cause mortality and loss to follow-up) was evaluated using Cox proportional hazards regression analysis, and its effect on having a detectable viral load (≥400 copies/mL) at 12 months on ART using binomial regression analysis with modified Poisson distribution. RESULTS: A total of 251 (29.4%) orphans (maternal, paternal or both) and 603 (70.6%) non-orphans were included at ART initiation. Following multiple imputation for missing data and propensity score matching, 222 orphans and 222 non-orphans were included. Orphans had a median age of 8.0 years (interquartile range (IQR) 4.9 - 10.7) and non-orphans 7.4 years (IQR 4.2 - 10.2). A total of 12 (5.4%) orphans and 33 (14.9%) non-orphans experienced attrition from care during the first 12 months on ART (adjusted hazard ratio 0.32, 95% confidence interval (CI) 0.17 - 0.63). Among those alive and in care, with a viral load at 12 months on ART, 18.0% of orphans (33/183) and 14.8% of non-orphans (24/162) had a detectable viral load (adjusted risk ratio 1.15, 95% CI 1.04 - 1.28). CONCLUSIONS: Orphans were less likely than non-orphans to experience attrition, but among those in care at 12 months, orphans were more likely to have detectable viral loads. Lower attrition among orphans may be due to their being in institutional or foster care, ensuring that they make their visits; however, their higher rates of non-suppression may result from lack of psychosocial support or stigma resulting in struggles to adhere. Additional research investigating age-specific outcomes will be important to elucidate these effects further.

An evidence-based nutrition education programme for orphans and vulnerable children: protocol on the development of nutrition education intervention for orphans in Soweto, South Africa using mixed methods research.

BACKGROUND: Focus on interventions for orphans and vulnerable children (OVC) in South Africa on education, quality of life (QoL) and nutrition-related matters have been reported diminutive. The risk of dropping out of school for an OVC with poor QoL and without varied food intake is very high. The problem with poor; QoL, nutritional care and academic performance (AP) of the OVC is that it sets the foundation for their adults' life. The purpose of this longitudinal study is to develop, implement and to test the efficacy of an evidence-based nutrition education programme (NEP) for OVC that will integrate their families/caregivers, schools and communities. METHODS: A longitudinal study, and a mixed-methods approach steered by action research will be used. This study will be in three phases. Phase 1 will be the needs assessment; Phase 2 will be the development of nutritional education materials, and Phase 3 is the intervention. QoL, dietary intakes, body composition, and anthropometric status, physical activities, and AP of 520 OVC in Soweto will be assessed using standard techniques. Nutrition knowledge, attitude and practices (KAP) of the caregivers will be assessed using previously validated questionnaires. Focus group discussion (FGD) will be conducted to gain an in-depth understanding of what OVC eat and factors affecting their food intakes. Data will be collected at baseline, week 12 and week 24. Generalised Least Squares (GLS) regression model will be used to test the study hypotheses. Atlas-ti and Thematic Framework Analysis (TFA) will be used for qualitative data analysis. DISCUSSION: This study will provide detailed information on the QoL, food intakes concerning academic performance and general well-being of OVC in an Africa setting. The participatory mixed methods nature of the study will provide valuable insights into the drivers and challenges to QoL, AP, and nutritional status of this group. This approach will assist the policymakers' and other stakeholders in decision making regarding the general well-being of the OVC. TRIAL REGISTRATION: ISRCTN12835783 . Date registered 14.01.2019.

Poverty, economic strengthening, and mental health among AIDS orphaned children in Uganda: Mediation model in a randomized clinical trial.

Some evidence points to the positive effects of asset accumulation programs on mental health of children living in low-resource contexts. However, no evidence exists as to why and how such impact occurs. Our study aims to understand whether child poverty, child work, and household wealth serve as pathways through which the economic strengthening intervention affects the mental health of AIDS-orphaned children. The study employed a cluster-randomized experimental design with a family-based economic strengthening intervention conducted among 1410 school-going AIDS-orphaned children ages 10 and 16 years old in 48 primary schools in South Western Uganda. To test the hypothesized relationships between the intervention, mediators (household wealth, child poverty, and child's work) and mental health, we ran structural equation models that adjust for clustering of individuals within schools and account for potential correlation among the mediators. We found significant unmediated effect of the intervention on children's mental health at 24 months (B = -0.59; 95% CI: 0.93, -0.25; p < 0.001; ß = -0.33). Furthermore, the results suggest that participation in the intervention reduced child poverty at 12 months, which in turn improved latent mental health outcome at 24 months (B = -0.14; 95% CI: -0.29, -0.01; p < 0.06; ß = -0.08). In addition, though not statistically significant at the 0.05 level, at 36 and 48 months, mental health of children in the treatment group improved by 0.13 and 0.16 standard deviation points correspondingly with no evidence of mediation. Our findings suggest that anti-poverty programs that aim solely to improve household income may be less advantageous to children's mental health as compared to those that are specifically targeted towards reducing the impact of poverty on children. Further studies using more comprehensive measures of child work and age-appropriate child mental health may shed more light on understanding the link between asset accumulation interventions, child labor and children's mental health.