Nigerian Journal of Paediatrics 2011;38(1):4-8
ORIGINAL
R. E. Oladokun
HIV infection in orphanages in South
B. J. Brown
Western Nigeria
N. E. Jacob
K. Osinusi
Accepted: 23 February 2011
Keywords:
HIV; Prevalence;
Results:
A total of 190 children
Children; Orphanages; Admission
were enrolled from 7 homes with
policies; Caregivers
males accounting for 89 (46.8%).
R. E. Oladokun ( ), B. J. Brown
Running Head: HIV infection in
The main reasons for admission
N. E. Jacob, K. Osinusi
orphanages
into the orphanages were; orphaned
Department of Paediatrics
85 (44.7%), abandoned 79 (41.6%)
College of Medicine University of Abstract Background: As a result
and mental illness in mother
Ibadan.
of the expanding HIV epidemic,
11(5.8%). Two children were HIV
E-mail:
affected children may end up in
positive, giving a prevalence rate of
ginaoladokun@yahoo.com
institutionalized care.
1.05%. All the homes (100%) had a
Tel: +2348038067511
Objectives:
To determine the
policy which excluded admission of
prevalence of HIV infection
HIV positive children but seldom
among children into orphanages in
carried out HIV testing at entry.
S o u t h
We s t e r n
N i g e r i a .
Fear of disease transmission to
Admission policies, knowledge
others was the reason given for not
and attitude of caregivers with
admitting such children.
respect to HIV were also assessed
Conclusion:
The policy which
Design: This was a cross sectional
excluded admission of HIV
study in which interviewer
infected children may have
administered questionnaires were
contributed to the low prevalence of
used to collect information on
the infection in the orphanages.
consecutive children, heads of the
There needs to be a reform on the
orphanages and caregivers. Rapid
current policies in order to reduce
HIV antibody testing was carried
discrimination against HIV
out.
orphans.
Background
orphaned as a result of AIDS and around 11.6 million
of these children live in sub-SaharanAfrica. 2
Orphans, abandoned and some other vulnerable
Nigeria has the highest burden of mother to child
children are deprived of their first line of protection
transmission and paediatric HIV disease in the world
which is their parents. Although this is a worldwide
with an estimated 240,000 children <15 years old
phenomenon, the problem is more prevalent in
accounting for 14% of total African burden . 3 One of
developing countries which are areas more directly
the impacts of HIV in children in Nigeria is the
affected by war, AIDS, and natural disasters. 1 There
emerging cohort of AIDS orphans and other
is an increase in the number of orphans which is
vulnerable children (OVCs), who have lost one or
mainly fuelled by the increasing HIV/AIDS
both of their parents to AIDS . 4 The estimated number
pandemic that has slowed down or reversed the gains
of AIDS orphans in Nigeria at the end of 2007 was
of the child survival efforts of the last decade in
1,200,000. 5 These children, who are either infected or
many African countries. It is estimated that more
affected, are often in need of social support. The
than 15 million children under 18 have been
extended family system would usually absorb the
5
care of such children. 6 Although children are best
had a thorough physical examination and a double
cared for in the family setting, the current extended
rapid HIV antibody testing in parallel using
family system may not be able to cope with the care
Determine R HIV 1/2 (manufactured for Abbott
of children affected by the expanding HIV epidemic.
Laboratories by Abbott Co., Ltd. Minto-Ku, Tokyo,
However as a result of the increasing number of
Japan) and Stat pak R (by Chembio Diagnostics
orphans, the system may be overwhelmed and some
systems, Inc. Medford, New York 11763 USA).
of the orphans may end up in institutionalized care.
Reactive test results were confirmed by western blot.
The social circumstances that resulted in the
The policy of the homes in relation to admission of
placement of these children in institutionalized care
children with suspected or confirmed HIV infection
including abandonment and maternal death, place
was documented based on an interview with the
them at high risk for perinatally acquired HIV
heads of the institution enquiring whether the
infection. Therefore determining the status of these
children were screened for HIV before admission
children is pertinent.
Nicholas et al in their inner
into the homes and the homes' decision in the event
city New York study reported that newborns placed
that a child tested positive. Structured questionnaires
in foster care at the time of hospital discharge were 8
were administered to the caregivers by trained
times more likely to have been born to HIV-infected
interviewers. The information sought included their
women than were newborns discharged to the care of
demographic characteristics, knowledge about risk
their mothers. 7
of transmission of HIV infection, through the routine
As a result of the recent advances in medical
activities of the home including; playing with the
management of HIV-exposed and HIV-infected
children,
carrying,
feeding
and
changing
their
children, it is necessary to test children in orphanages
nappies. There were 10 questions and a score of one
in order to provide care where necessary. Without
was assigned to each item bringing the total to 10. A
intervention, at least a third of children born with
score of = 8 was ascribed as “good” and less than 8
HIV will die from an HIV-related cause by their first
was ascribed as “poor”. T he caregivers' beliefs and
birthday, and half will die before their second. 8 Older
attitude were ascertained through questions asked
children should also be screened since studies have
about care of HIV positive children. For instance
shown that HIV-infected children may remain
whether they would care for an HIV positive child, if
asymptomatic for years or have mild non-specific
they were aware of the status and whether they would
symptoms that are not recognized as secondary to
continue working in the home if they became aware
HIV infection. 9
that a child was HIV positive.
The aim of this study was to determine the HIV
Consent was granted by the head of each institution.
prevalence of the children currently admitted in
Informed consent was obtained from the caregivers.
orphanages in South Western Nigeria.
The
Permission was obtained from the boards of
admission policy of the homes with regards to HIV
managements of the institutions and the project was
positive children was examined.
The study also
approved by Oyo State Ethical Research Committee.
accessed the knowledge and attitude of caregivers
Data were analyzed using SPSS 16.0 version of
towards care of such children. The results may
windows. Means and standard deviations were
provide valuable data which could be used to
computed for age and frequencies used in
improve attitudes and practices of caregivers in
presentation of categorical variables.
caring forAIDS orphans.
Results
Methods
Permission was denied by one of the homes for its
The study was carried out between September and
children to be enrolled into the study but the
November 2008. By convenience sampling, a total
caregivers were allowed to participate as long as
of seven institutions in Ibadan and one in Ijebu-Ode
individual consents were obtained from them.
in South Western Nigeria were selected for the study
One hundred and ninety children were studied in the
on the basis of their being registered by the
seven institutions. Males accounted for 89(46.8%)
government and being well established.
An
and females 101 (53.2%) of the inmates. The number
institution in this study refers to orphanages or
of children in each institution ranged between 12 and
motherless babies' homes as they are sometimes
92. The ages of the children ranged between 1.1 and
called.
They are managed by private governing
180 months with a median of 108 months. Of the
councils, religious or other voluntary organizations.
total number, 10 (5.3%) were less than 1 year; 40(21.
There was total sampling of the children from the
%) were aged 1-4 years while 140 (73.7%) were
institutions. Information on the circumstances of the
between 5-15 years (Table 1).
admission of the children was obtained. Every child
The reasons for admission of the children included
6
orphans 85 (44.7%), abandoned 79 (41.6%), mental
And 4 (11.4%) males. Nineteen (54.3%) had at least
illness in mother 11 (5.8% and others 15 (7.9%).
secondary education. Out of 35 respondents, 5
Included among the others were history of rape in
(14.3%) of the caregivers had prior HIV testing.
mother, separation of parents and indigence.
Eighteen caregivers were screened fro HIV during
Among 154 children with available information on
the study and two were positive.
Among the
the age at admission, 62 (40.3%) were admitted into
caregivers, knowledge about the risk of transmission
the institutions in infancy.
of HIV infection was poor in 21 (60.0%). Only 8
(22.9%) of the caregivers had participated in an
organized workshop on HIV/AIDS.
Prevalence of HIV infection
Table 3 shows the caregivers' attitude and beliefs
towards care of HIV infected children.
The prevalence of HIV infection was 1.05% (2/190)
Among the caregivers, 16 (45.7%) would care for an
and both were males who had advanced clinical
HIV positive child.
All the caregivers (100%)
disease. The younger child had been abandoned by
believed that HIV positive children should not be
the mother at a bus terminal and the age was
admitted into the home and only 29% believed that if
estimated as 3years. He was not acutely ill but was
a child already residing in the home was diagnosed to
small for age, stunted and had skin lesions.
The
have HIV, he/she be allowed to continue residing in
second child, who was aged 14years at the time of the
the home. Only 9 (26%) were aware that HIV
study, was brought to the institution four years
medicine was available for treatment of children with
before. His older sibling who was also residing in the
the disease.
orphanage was HIV negative.
Their mother was
reported to be a commercial sex worker who had died
from unknown illness.
He became symptomatic
Table 1:
Age, sex and reasons for admission of
with oral thrush and chronic cough only within the
children admitted into the institutions (n = 190)
last two months. He was also reported to have been
sexually active. The two children commenced HIV
Variable
No
%
care including Anti Retroviral Therapy (ART) in an
(N=190)
HIV programme in a health facility.
Care givers
Age
were identified by the programme from each of their
0 – 11months
10
5.3
institutions and educated on adherence and other
12-59 months
40
21.0
aspects of the required care of the children.
The
60-180 months
140
73.6
older child was relocated from the orphanage after
Sex
six months.
Male
89
46.8
Female
101
53.2
Institutional policies on admission of HIV infected
Reasons for admission
children
Orphans
85
44.7
Abandoned
79
41.6
Among the eight institutions enrolled into the study,
Mental illness in mother
11
5.8
all had an exclusion policy towards HIV positive
Others
15
7.9
children.
Enquiries were usually made as to the
cause of death of the mother and for motherless
babies, death certificates of their mothers were
Table 2: Care givers' characteristics and knowledge
requested. Children suspected or confirmed to have
about HIV transmission (N = 35)
HIV infection were not accepted into the institutions
Characteristic
N=35
%
but only five of them occasionally carried out
Sex
irregular routine HIV screening on new entrants.
Female
31
88.6
Fear of disease transmission to other children and
care givers was the major reason given by all the
No with = secondary
19
54.2
eight heads of the institutions for not accepting such
education
children.
No with prior HIV test?
5
14.3
Care givers' characteristics, knowledge and attitude
towards care of HIV infected children
Good knowledge of
14
40.0
HIV/AIDS transmission
There were a total of 35 care givers involved in the
direct care of the children.
Their ages ranged
between 18 and 58 years with a mean of 35years.
Participation in HIV/AIDS
8
22.9
Table 2 shows that there were 31 (88.6%) females
workshop
7
into the homes but only 14% of them had themselves
needs to be a reform on the current policies in order to
been tested for HIV. Discrimination against children
reduce discrimination against HIV orphans. Policies
with HIV had been reported in similar settings.
that will impact positively on AIDS orphans are
Marrow et al, 19 in their study of knowledge and
required in order to reduce the stigma and
attitudes of day care providers regarding children
discrimination that lead to exclusion of the children
and infection with the HIV, reported that 48% of
from admission into institutions. Majority of the
caregivers would care for a child infected with HIV
caregivers involved in direct care of the
in their classroom. Ohnishi et al 20 had shown some
institutionalized children were reluctant to care for
correlation between caregivers' knowledge
HIV positive children.
All persons who care for
regarding HIV/AIDS and positive attitudes towards
children in these childcare institutions should also
HIV/AIDS orphans. Caregivers need to be educated
receive education about HIV infection.
on HIV/AIDS in order to correct misconceptions.
The management of orphanage homes should ensure
that all the staff taking care of the children, as part of
the orientation at recruitment, should be educated on
Acknowledgements
HIV infection; modes of transmission and infection
control guidelines appropriate in the home setting.
We appreciate all the children and caregivers in the
institutions that participated in the study. We wish to
thank Miss Gbemi Olawoye for assisting in data
Conclusion
collection. We are grateful to the University of
Ibadan which provided the funds for the study
The policy which excluded admission of HIV
through its senate grant.
infected children may have contributed to the low
prevalence of the infection in the orphanages. There
1
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8
Table 3: Care givers' attitude and beliefs towards
rate of 13.6%. 15 The large difference between the
caring for HIV infected children (N=35)
prevalence rates from the two studies may have
resulted from the fact that the Port Harcourt study
Question
Yes
was conducted amongst abandoned children who
( N=35)
were institutionalized. Children may be abandoned
Would you care for a child in the home if
as a result of varied social circumstances, debilities
he/she is HIV positive?
16(46%)
and illnesses. One of the social issues raised was that
If a child already residing in the home is
their mothers might have had HIV infection and thus
diagnosed to have HIV, should he/she be
abandoned them for fear of stigmatization,
allowed to continue residing in the home?
10(29%)
Should HIV positive children be admitted into
discrimination and burden of care. While abandoned
the home?
0 (0%)
children constituted only 41.6% of the study
All children admitted into the home should
population, there were other categories of children
have HIV test?
24(69%)
admitted into the institutions that were studied.
HIV medicine is available for treatment of
Orphans accounted for 44.7%. In the study by
Malabika et al , in central Kampala, Uganda, it was
16
children with the disease
9(26%)
reported that 41% of the young orphans were AIDS
orphans. In a population-based survey in a city in
southern Brazil which set out to study factors
Discussion
associated with the institutionalization of AIDS
orphans, out of 1131 orphans identified, only 5%
Our study found that the prevalence of HIV among
lived in institutions. The study also reported that the
the children admitted into the institutions was 1.05%.
orphans who were HIV positive were more likely to
This was lower than the prevalence of HIV in the
be institutionalized. 17
state which was 2.2% in the 2008 sentinel survey that
It is recommended in some settings that HIV-infected
derived its estimate from pregnant women attending
children should be admitted without restriction to
antenatal clinics. 10 It would have been expected that
child care centers. 18 The current policy for all the
with the high morbidity and mortality related to HIV
institutions studied was that HIV positive children
among women of child bearing age, 11 that there will
were excluded from admission into the homes. The
be a corresponding increase in the number of
implication of this is that these institutions may not
infected orphans in the institutions.
Vertical
be the place to search for HIV positive children.
transmission accounts for 90% of paediatric HIV
Another implication is that abandoned children with
infection 12 and
i n the absence of PMTCT
no known family relations and who are found to be
interventions, transmission rates of perinatally
HIV positive may have difficulty with placement in
acquired HIV infection have been estimated to be 25
institutions. A previous study that compared orphans
40% .
13
The policy which existed in all the
and non orphans in an HIV programme corroborated
institutions against admission of HIV positive
this as it reported that out of the 110 children, orphans
children might have contributed to the low HIV
constituted 36.4% and none was in institutional care. 6
prevalence among institutionalized children in this
It may then mean that currently, care of most of the
study. However, the orphanages were not carrying
children made vulnerable by AIDS rests mainly on
out routine HIV screening regularly and HIV
the traditional extended family system.
The
infected children may be asymptomatic, thus
extended family is the traditional social security
escaping detection at entry. In a Rwandan Study, the
system in many developing countries but the AIDS
prevalence 2.6% of HIV infection in institutions was
epidemic may be stretching most communities to a
equally low. 14 In the latter study, HIV screening was
breaking point such that many affected children may
also not carried out routinely except in symptomatic
later end up in institutional care.
Access to optimal
children. The actual prevalence of HIV infection
HIV care for adults and improved PMTCT coverage
might have been higher in that community. HIV
are crucial in reducing morbidity and mortality
infected children need to be identified early in order
among individuals with the infection especially the
to institute interventions that improve the outcome of
women.
The orphan crisis and the need for
the disease including combination antiretroviral
institutionalization of such children will ultimately
therapy where necessary. Early identification had
be reduced.
been missed in the two HIV infected children in our
With regards to the care givers who were responsible
study as they were both in advanced stages of the
for the direct care of the children, only 40.0% had
disease at the time they were diagnosed.
good knowledge about risk of transmission of HIV
A comparable study carried out in Port Harcourt in
infection, a small percentage (22.9%) had training on
the South-South region of the country, which
HIV/AIDS and 45.7% would care for HIV infected
evaluated the sero-prevalence of HIV infection
children. Interestingly, all the caregivers believed
amongst abandoned children reported a prevalence
that HIV positive children should not be admitted
9
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