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Incidence of Orphanhood before and after the HIV care program implementation in Rakai district, Uganda . Fredrick E Makumbi , Gertrude Nakigozi, Joseph Sekasanvu, Ivan Lukabwe, Joseph Kagaayi, Tom Lutalo, Maria Wawer, Ronald Gray 9 th AGM INDEPTH, PUNE, INDIA

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  1. Incidence of Orphanhood before and after the HIV care program implementation in Rakai district, Uganda Fredrick E Makumbi, Gertrude Nakigozi, Joseph Sekasanvu, Ivan Lukabwe, Joseph Kagaayi, Tom Lutalo, Maria Wawer, Ronald Gray 9th AGM INDEPTH, PUNE, INDIA October 28th 2009

  2. Background • The HIV/AIDS epidemic still remains a huge public challenge especially in SSA • At least two thirds (67%) of the global 33 million infected cases • 60% of the 2.7 million global annual new infections (UNAIDS 2008) • Increased adult mortality and morbidity, producing large number of orphaned children. In Uganda, • 23.3% of children aged 0-14 years have lost at least one parent • A high incidence of orphanhood 2.3-2.7 per 100 person years (py) • 37.3% attributable risk of incident orphanhood due to parental HIV-infection (UDHS 2006; Watts H et al 2005; Makumbi F et al, 2005)

  3. Background • The Advent of HIV care programs • Increased survival and reduced morbidity among HIV+ • Reduction in orphanhood observed and estimated • 93% orphanhood reduction in HIV+ cohort * • 40% orphanhood reduction in Model based estimates** • Effect of HIV care program on the orphanhood not yet fully explored at a population level (*Mermin et al 2004; 2008; **Stove J et al, 2008; Reniers G et al 2009; Abraham J Herbst 2009)

  4. Objective • To compare the incidence of orphanhood among children aged 0-14 years during pre and post HIV care program implementation in Rakai district, Uganda

  5. Methods-1 • A population-based cohort in 50 rural villages since 1994 • Rakai, is a rural district in Southwestern Uganda 471,000 (UBOS, 2002) • Rakai Community Cohort Study (RCCS) • Annual follow-up of all persons aged 15-49 year • Community cohort annual data collection • Census data (marital status, sex, age) • Co-residence and survival status of biological parents • Household possessions, structure and domestic animals and poultry • Detailed survey, with individual interviews and blood for HIV testing • 14,000 consenting resident adults aged 15-49 years

  6. Methods-2 • HIV care program started June 2004 • Supported by President’s Emergency Plan For AIDS Relief (PEPFAR) • Cumulatively provided HIV care to about 5000 individuals • 1900 HIV+ started on ART (CD4≤250 cells/mm3 or WHO Stage IV) • Services offered via 17 mobile community-based out-patient clinics, called Suubi or “Hope” clinics • ARVs to Eligible (CD4≤250 cells/mm3 or WHO Stage IV) • Basic HIV care package consisting of • cotrimoxazole for opportunistic infection prophylaxis, • A clean water vessel and hypochlorite solution for water disinfection • Two insecticide treated bed nets for malaria prevention, and were offered free condoms • CD4 cell count monitoring irrespective ART status

  7. Methods-3 Definitions • Pre-HIV care period was categorized into three levels; • 1-“PreHIVcare1”, 1996/97-1997/98, which is 6-8 years earlier • 2-“PreHIVcare2”, 2001/02-2002/03, which is 1-3 years earlier • 3-“HIVcare-transition” , 2002/03-20003/4, which is 0-1 year earlier • Post-HIVcare, 2005/06-2006/08, which is 1-3 years after HIV care implementation • Incident orphan • Loss of one or both parents on a subsequent visit among non-orphaned children identified in preceding survey visit

  8. Statistical Analysis-1 • Prevalence of orphanhood • proportion of children 0-14yrs with one or both parents deceased • Incident orphanhood • number of children who lost one or both parents/person-years (py) • Py, time between • Censuses: 1996/97, 2001/02, 2002/3, 2005/06 • FUPs: 1997/98, 2002/03, 2003/04, 2006/08 • Incident orphanhood assumed in the mid-point of each FUP • Assumed even distribution of the event throughout the FUP intervals • Out-migrants at FUP were eliminated from this analysis

  9. Statistical Analysis-2 • Orphanhood incidence rate per 100 person-years (py) • Stratified by child’s age and parental HIV status • Unadjusted and adjusted incidence rate ratios (IRR) • 95% confidence intervals (CI) with Huber–White sandwich robust estimator • Poisson regression model via GLM with Poisson distribution and log link function • Statistical significance was determined by the Wald test or the log likelihood ratio test • STATA version 9.2

  10. 25.0 20.0 15.0 10.0 5.0 0.0 Results -1 Prevalence of orphanhood by HIV care period Pre-HIVcare1 Pre-HIVcare2 HIVcare-transition Post-HIVcare 22.1% 17.2% 16.9% Prevalence (%) 14.7% 2001/2 2002/3 2005/6 1996/7 • Prevalence of orphanhoodsignificantly declined across the time periods

  11. Prevalence of orphanhood by type and HIV care period 12.0 Pre-HIVcare1 Pre-HIVcare2 HIVcare-transition Post-HIVcare 10.0 8.0 Double 6.0 Maternal-alone 4.0 Prevalent orphanhood (%) Paternal-alone 2.0 0.0 1996/07 2001/2 2002/3 2005/6 • Paternal-alone was the highest form of orphanhood. • Double orphanhood was higher than maternal-alone • Declines in orphanhood most notable at Post-HIVcare period

  12. 3.00 2.50 2.00 1.50 1.00 0.50 0.00 Results -2 Incidence of orphanhood among children 0-14 years by HIV care period Pre-HIVcare1 Pre-HIVcare2 HIVcare-transition Post-HIVcare 2.47 Incidence/100py 2.12 1.35 1.13 1996/97-1997/98 2001/02-2002/03 2002/03-2003/04 2005/06-2006/08 • Incidence of orphanhood has been declining • Decline at HIVcare-transition wasonly significant for children of uninfected parents • Decline at Post-HIVcare was only significant for children of HIV+ parent (s)

  13. Results -3 Incidence and IRR of orphanhood among Children aged 0-4 years comparing Post-HIVcare to HIVcare-Transition periods * HIV-neg: Both HIV- or HIV- and other unknown; HIV+: At least one parent HIV+; Unknown: Both parents’ status unknown A significant reduction of ~43% among children with at least one HIV+ parent, but not among other parental HIV status

  14. Results -4 Incidence and IRR of orphanhood among Children aged 5-9 years comparing Post-Hcare to Hcare-Transitionperiods A significant reduction of ~40% among children with at least one HIV+ parent, but not among other parental HIV status

  15. Results -5 Incidence and IRR of orphanhood among Children aged 10-14 years comparing Post-Hcare to Hcare-Transitionperiods A significant reduction of ~62% among children with at least one HIV+ parent, but not among other parental HIV status

  16. Summary • Incidence of orphanhood has been declining; • Prior to HIV care among children with uninfected parents • Post HIV care among children with infected parents • Our empirical findings are consistent with • Model estimates of orphanhood incidence • Mortality declines among HIV+ adults on ART or similar populations with HIV care programs in SSA

  17. Recommendation • HIV care programs in sub-Saharan Africa should continue to roll out • To ensure that all the HIV+ individuals are enrolled into these care programs • Declines in incidence of orphanhood • may reduce or at least shorten the duration of the social consequences of orphanhood

  18. Acknowledgements Rakai Health Sciences Management & Staff Rakai district leadership including community leaders Cohort participants Indepth Network Rakai Funders who have enabled research activities

  19. Thank you

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