A. Orphanhood by socio-economic characteristics and the risk of HIV infection in rural KwaZulu-Natal (Makandwe Nyirenda)

Background
High HIV prevalence rates and the resultant high adult mortality rates have lead to an increasing number of children growing up without parents.  It is estimated by UNICEF that by 2010 there will be 2.3 million children under 15 years orphaned in South Africa, two-thirds due to AIDS. Data from the Africa Centre longitudinal surveillance system showed that between 2000 and 2005 the proportion of children under 18 years with mother deceased, father deceased and both parents deceased increased from 3% to 6%, 6% to 9%, and 1% to 4%, respectively (Hill et al., 2008).

The question of growing up without parents has been addressed in a book chapter contribution on the state of the population of KwaZulu-Natal being edited by Nzimande and Mturi. The book is supported by United Nations Population Fund (UNFPA) and the South African department of Social Development. In this chapter we explored the socio-economic and household circumstances of orphaned children in comparison to their non-orphaned counterparts.

Research questions
Are there significant differences in the household wealth, education attainment, school attendance, household care arrangements and receipt of government welfare grants among children aged 0-19 years by parental survival status in the Africa Centre Demographic system (ACDIS)?

Methods
In this analysis we use demographic and socio-economic data from the Africa Centre’s bi-annual household surveillance, for children aged 0-19 years at last observation in 2008, and sexual behaviour and HIV data from the annual individual surveillance (for those aged 15-19).

The statistical tool used in this study was logistic regressions to investigate the associations of socio-economic variables with parental survival status. Further, logistic regressions were used to examine the likelihood to ever have had sex and to have HIV infection for adolescents by orphanhood status, adjusting for age, sex, education level attained, household socio-economic status, and place of residency. Chi-square tests and Fisher’s tests, where cell counts were very small, were used to determine associations between categorical variables tabulated as proportions or means. 

Findings
There are distinct levels and patterns of orphanhood in different parts of South Africa. KwaZulu-Natal (KZN) has the highest percentage (23%, n=764,363) of orphaned children aged 0-14 years in South Africa according to estimates obtained from weighted General Household Survey 2007 data. Other provinces with comparable high proportions of orphaned children are Eastern Cape, Free State and Mpumalanga. All four provinces have levels of orphanhood above the national average of 17% (n=26,603,329), likely associated with the high HIV prevalence rate in KZN. In addition to the impact of HIV, the data also appear to suggest a relationship between poverty levels and orphanhood, as the two richest provinces Gauteng and Western Cape had only half the national percentage of orphaned children. 

Results from ACDIS data showed that orphans were significantly less likely to be enrolled in school compared to non-orphans; for those enrolled in school they were more likely to be lagging behind in terms of grade for age. Compared to mothers, fathers are less likely to be co-resident with both orphaned and non-orphaned children, and thus tend to play a limited care-giving role to children. Receiving a government grant was strongly associated with currently being in school. Orphans were less likely to be receiving a child support grant, but more likely to be in receipt of a foster care grant compared to non-orphans. Being orphaned may mean not having an adult to apply on the child’s behalf for a government grant and/or lack of the necessary documentation, hence the lower likelihood to access child support grants. Children 15-19 are further not eligible for child support grants. Grants play an important role in this community of not only enabling the children to remain in school, but also in reducing the likelihood for these adolescents to sell sex for a livelihood. Our results confirm findings from elsewhere that child-headed households are very rare in this area.

Policy implications

Ø  There is need to develop and strengthen women economic empowerment policies and programmes to mitigate the financial constraints associated with father absence due to death or other reasons, given a backdrop of high unemployment among women.

Ø  There should be policy consideration to extend eligibility for child support grants to adolescent children, further they should be enabled to apply for these grants on their own behalf in the absence of adult representatives.

Ø   Generally households headed by children are economically vulnerable. In South Africa about 49% (over 20 million) of the total population are children, implying 1% (20,000) of children live in child-headed households. We urge caution however in placing too much emphasis and targeting of these categories of households as nearly 98% of children live in the so-called “normal” households, which may be equally if not more economically vulnerable and hence in need of state and donor support.

Fit in AC research strategy
This study fits in with the Africa Centre’s interventions research strategy regarding population dynamics and HIV by providing the socio-economic determinants needed for policy and behavioral interventions among young people regarding their risk to HIV infection.

B.  The effect of death of father for boys and death of mother for girls on adolescent’s sexual behaviour and risk of HIV infection in rural South Africa  (Makandwe Nyirenda)

Background
The number of children orphaned as a result of HIV infection among the adult population has increased substantially over the past decade (Connolly & Monasch, 2003; Leyanaar, 2005). In sub-Saharan Africa, the total estimated number of orphans (under 17years old) was 47 million, 12 million as a consequence of HIV infection (Unicef, 2007). Very few studies have attempted to systematically study adolescent orphans over 15 years (Skinner et al., 2006), with regard to their vulnerability to sexual behavior and HIV infection risk. This study contributes to the orphanhood discourse by exploring the effect on sexual behaviour and risk of HIV infection of death of mothers for daughters and that of fathers for sons.

Research questions
Is the likelihood among adolescents (aged 15-19) to ever have had sex, being pregnant or being HIV infected influenced by parental survival status? Is the sexual behaviour and HIV risks of adolescents associated with the gender of the deceased parent?

Methods
These analyses use the Africa Centre Demographic Information System (ACDIS) demographic and socio-economic data from household surveillance, and sexual behaviour and HIV data from the individual surveillance of individuals 15-19 years in 2006. We take a three step approach in the analysis. First using logistic regressions we examine the univariate associations of orphanhood with age, wealth quintiles, self-perceived financial status, education attainment, schooling status, economic activity and place of residency. Second, multiple logistic regressions were used to examine the multivariable associations with orphanhood of these socio-demographic and economic variables. Finally, multiple logistic regressions were applied to examine the associations between orphanhood and risky sexual behaviours including ever having had sex, ever been pregnant, and being HIV infected adjusting for the socio-demographic and economic variables by sex of the adolescent and parent.

Findings
In 2006, of the 8,274 (50.1% male) adolescents analysed, 41.8% (n=3,458) were orphaned. Among orphans, 20% (n=689) were maternal, 55% (n=1,894) paternal and 25% (n=875) dual orphans. On average there were 7.7 members per household; with households containing orphans on average having one more member than those without.

Female paternal orphans reported statistically significant higher likelihood to be currently in a regular partnership. There were no statistically significant differences between non-orphans and orphans with regard to ever having had a casual partner. 92% of females reporting the age difference with the most recent partner reported having had an older partner. Female orphans reported an average age difference with the most recent partner of 2.9 years compared to 3.1 years among non-orphans, but this difference was not statistically significant (p.0.81). Over a fifth of females (n=995) reported ever having had sex, of these 33% (n=327) had ever been pregnant. There were, however, no statistically significant differences in ever having been pregnant by orphanhood status. Female adolescents whose mother had died were 32% more likely to have ever had sex than those whose mother was alive. Age at maternal orphaning was strongly associated with early age at sexual debut. Females who lost their mother before age 15 were more likely to have had first sex at a lower age (p=0.03) than females who lost their mother later in adolescence (15-19 years). There was no evidence that age at paternal orphaning was strongly associated with early sexual experience among female adolescents. There was further evidence of associations between a mother’s death and a daughter’s HIV risk, as female maternal orphans were 50% more likely to be HIV infected than non-orphaned females. The effect of mother’s deaths may also account for the increased likelihood to have ever had sex and being HIV infected among dual orphans (both mother and father died). 

Age at paternal orphaning was strongly associated with early age at sexual debut among male adolescents. Males who lost their father before age 15 were more likely to have ever had first sex at a lower age (p=0.03) than males who lost their father in their adolescence (15-19 years). There was no evidence (p=0.07) that age at maternal orphaning was strongly associated with early sexual experience among male adolescent orphans. Relative to non-orphans, only male paternal orphans were statistically significantly more likely to have ever had sex, adjusted for age, socio-economic status, education attainment, and place of residency. Male paternal orphans were further statistically significantly more likely to report ever having had a casual partner than non-orphans. Among males reporting age difference with the most recent partner, only 9% (n=47) had an older partner, whereas 64% had a younger partner. On average age difference with most recent partner was 1.6 years for orphans and 1.7 years among non-orphans (p=0.68). Male paternal and dual orphans had over three-fold increased likelihood of being HIV infected compared to non-orphaned males, adjusted for age, economic status, education attainment, and residency.

Policy implications
Adolescence, especially when compounded by parental death, is a high HIV risk period and thus plays a major part in the continued spread of the virus. Adjusting for age, sex, socio-economic status, education, being employed and residency, orphaning appears to be associated with earlier age at first sex. Death of the father for boys and of the mother for girls was associated with increased vulnerability of earlier sexual debut and HIV infection. Policy and programme response to the high HIV prevalence and incidence among adolescents should therefore take cognizance of this apparent gender-differential in the impact of parental death on adolescents’ sexual behavior and HIV risk.

Fit in AC research strategy
This study fits in with the Africa Centre’s scientific strategy component of population dynamics and HIV by demonstrating the vulnerability of young people to risk of HIV infection and thus is useful in developing behavioral interventions for young people.

C.  Socio-demographic determinants of condom use among sexually active young adults in rural KwaZulu-Natal, South Africa (Natsayi Chimbindi)

Research question
Condoms are known to prevent HIV infection. However, HIV prevalence and incidence remain high.

We investigated patterns, levels and socio-demographic determinants of condom use and consistency of use among sexually active young adults aged 15-24 years in a largely rural demographic surveillance site in northern KwaZulu-Natal.

Fit of the research question within the AC portfolio/strategic plan
This study was conducted in partial fulfillment of the requirements of a Masters research project at the University of Witwatersrand which was supported in part, by financial assistance from the Belgium Technical Cooperation (BTC) and Canon Collins Educational Trust for Southern Africa (CCTSA).  Africa Centre provides datasets to students who are on an INDEPTH Masters programme in collaboration with University of Witwatersrand for their research report. Data for this analysis came from the Africa Centre Demographic Information System (ACDIS) from the annual HIV and sexual behaviour surveillance forms [Women’s and Men’s General Health forms (WGH and MGH)] for the year 2005.  Demographic variables and household economic information is collected annually in the household survey. The DSS and the HIV surveillance survey are both funded by the Wellcome Trust UK. This project falls under the theme of HIV dynamics: understanding the HIV epidemic in the current Centre’s research strategy. 

Data sources and methods
Data for this analysis came from the Africa Centre Demographic Information System (ACDIS). Approximately 11,000 households, with a total population of about 90,000 resident and non-resident members, are surveyed bi-annually; routine demographic information is collected on births, deaths, migrations and pregnancies.  Since 2003, an annual HIV and sexual behaviour surveillance has also been conducted on resident females aged 15-49 and males aged 15-54 years old. The analysis presented here focuses on data collected in the 2005 HIV and sexual behaviour surveillance round from household members resident in the study area; who were aged between 15-24 years on the 1^st of January 2005 and reported ever having had sex.

The study involved univariable and multivariable analyses of data already collected in the DSA to establish the determinants of condom use and consistency of use among 15-24 year olds. ‘Ever’ condom use was defined as the proportion who reported having used a condom; consistent use among those ever using as “always” using condoms with most recent partner in the last year.

Explanatory variables considered were: age, sex, type of partner, highest educational level reached, household assets (socio-economic status, SES), number of sexual partners in the last year, residence of the most recent partner, age difference with partner (older, younger, same age) and HIV status.

Findings
3,914 participants aged 15-24 years reported ever having sex, of whom 52% reported condom use. More than half (57% 2,248/3,914) of the eligible young adults were females. Overall, the median age among those who had sexually debuted was 17 years (IQR 16; 18), 17 years (range 12-24 years) for females and 16 years (range 9-24 years) for males. Thirteen percent (503/3,914) of young adults who were sexually active in the last year reported having more than one partner.  Adjusting for age, sex, number of partners, residence of partner, partner age difference, type of partner and socio-economic status (SES), having an older partner decreased likelihood (aOR=0.69, p<0.01), while belonging to a household in a higher SES increased likelihood of ever using condoms (aOR=1.82, p<0.01). The likelihood of condom use with a regular partner was significantly decreased for females only (aOR=0.77 p=0.03). Those whose partners resided outside the immediate residential area (isigodi; an area for which a single Induna/chief is responsible) were more likely (aOR =1.64 p<0.01) to use condoms than those residing with their partners in the same household. Being female (aOR=0.61 p<0.01) and having a regular partner (aOR=0.65 p<0.01) were independently associated with low consistent condom use.

Policy implications 
The results of this study point to the need to intensify existing HIV prevention strategies to increase their effectiveness. Prevention messages need to emphasize the importance of condom use in all types of relationships where the HIV status is unknown or where the commitment to being faithful is likely not maintained. Condom use should not only be restricted to “high risk” groups but should be extended to all young adults, and health care facilities should be more ‘welcoming’ to young people.  Empowerment of women to be economically independent could lead to better negotiation skills to use condoms and hence prevent transmission of HIV. The HIV prevalence and incidence in this area does not show any sign of declining; this together with our finding of low uptake of condoms, suggests that targeted supportive interventions need to be developed to increase condom use if HIV prevention programmes are to be successful.