Living with HIV or AIDS increases risk for poor mental health

among adults caring for orphaned children in South Africa

Caroline Kuo, Lucie Cluver, Marisa Casale, Tyler Lane, Lebo Sello

AIDS 2012, Washington DC

HIV and AIDS in South Africa

Source: http://www.unaids.org/globalreport/HIV_prevalence_map.htm http://www.unaids.org/globalreport http://www.unaids.org/en/regionscountries/countries/southafrica/

South Africa

310,000 AIDS deaths17.2% of global total

5.6 million living with HIV16.8% of global total

1.9 million children orphaned by AIDS13.0% of global total

What do we know about caregivers of AIDS-orphaned children?Caregiver type: extended family, primarily women

Child placement: decisions to care influenced by children’s traits (gender, age), economic challenges

Care challenges: poverty, nutrition, children’s educational and other needs

Health: chronic illness, grief, stress, depression, anxiety, PTSD

Sources: Kuo, C. et al., 2009, 2010, 2012; Ice, G. et al., 2012; Govender, K. et al., 2012; Boon et al., 2010

Young Carers KwaZulu Natal Study ObjectivesChild and caregiver outcomesi.e., mental health, chronic illness,

HIV/AIDS-ill, sexual risk behaviour

Relationship between caregiver and child health outcomes

i.e., caregiver and child mental health outcomes; caregiver illness and child outcomes

Role of family factors in child risk behaviours

i.e., parenting behaviours

Methods• Sites: Lamontville and Manguzi

• Sampling: stratified random sampling of census size enumeration areas with door-to-door household sampling using GIS

• Participants: N= 5238 (2600 matched child-caregiver pairs)

Children aged 10-17, Caregivers aged 18+

• Ethical Approval: University of Oxford and KwaZulu Natal, South African Departments of Health and Education

• Measures: CESD, Beck Anxiety Index, Verbal autopsy

Collaborative research

Young Carers Projec

t

Universities: Oxford, Brown, UKZN

National Department of

Education

National Department of

Heath

National Department of

Social Development

National Department of Agriculture, Forestry and

Fisheries

National Action Committee for

Children Affected by

HIV and AIDS

Tholulwazi NGO

Teen Advisory Group & PLWHA

WHO ARE PARTICIPANTS?

All photos used with consent

Who are participants?CAREGIVERS CHILDREN

Age 44 (Range 18-92, SD=13) 13 (Range 10-17, SD=2)

Education 82% did not finish high school

18% high school diploma or higher

Mean education: 6th grade

Gender 88% female11% male

54% female46% male

Ethnicity 99% African/Black 99% African/Black

Language 96% isiZulu 96% isiZulu

Children and/or caregivers affected by HIV and AIDS

53.5%

35.7%

4.8%6.0%

Type of HouseholdHealthy caregiver, no child(ren) orphaned by AIDS

HIV/AIDS ill caregiver, no child(ren) orphaned by AIDS

Healthy caregiver, child(ren) orphaned by AIDS

HIV/AIDS ill caregiver, child(ren) orphaned by AIDS

CAREGIVER HEALTH

Caregiver mental healthDepression: 35.6% clinically significant

symptoms for depression

Anxiety: 49.5% clinically significant symptoms for anxiety

Depression and/or Anxiety: 56.8%

Depression Anxiety.000%

10.000%

20.000%

30.000%

40.000%

50.000%

60.000%

70.000%

35.200%

48.700%41.8%*

58.7%***

Household has no children orphaned by AIDSHousehold has child(ren) orphaned by AIDS

Caregivers of children orphaned by AIDS have worse mental health

Chi square level of significance at p<0.01*, p<0.001***

Among caregivers of children orphaned by AIDS, HIV/AIDS-ill caregivers have worse mental health

Depression Anxiety.000%

10.000%20.000%30.000%40.000%50.000%60.000%70.000%80.000%90.000%

29.200%

48.400%

65.6%***

78.2%***

Healthy caregiver for household with child(ren) orphaned by AIDSHIV/AIDS-ill caregiver for household has child(ren) orphaned by AIDS

Chi square level of significance at p<0.001***

Familial HIV or AIDS increases risk for caregiver’s poor mental health

Healthy caregiver, no children or-phaned by AIDS

Healthy caregiver, child(ren) or-

phaned by AIDS

HIV/AIDS ill care-giver, no children orphaned by AIDS

HIV/AIDS ill care-giver, child(ren)

orphaned by AIDS

.000%

20.000%

40.000%

60.000%

80.000%

100.000%

35.9%***46.4%***

74.4%***87.1%***

Percentage of caregivers with depression and anxiety

Chi square level of significance at p<0.001***

Relationship between Familial HIV/AIDS and caregiver mental health remains

Relative Risk for Caregiver Depression and/or Anxiety (95%

CI)

Household with HIV/AIDS-ill caregiver and child(ren) orphaned by AIDS

4.26 (1.42-12.76)

Household socioeconomic status 0.71 (0.55-0.93)

Caregiver age 1.41 (1.09-1.81)

Caregiver gender 1.69 (1.17-2.42)

Caregiver education 0.51 (0.40-0.66)

Child age 1.47 (1.07-2.04)

Child gender 1.14 (0.90-1.44)

Child education 0.94 (0.87-1.00)

Statistically significant associations are shown in bold

Stigma a risk factor for mental health of HIV/AIDS-ill caregivers of orphaned children

Relative Risk for Caregiver Depression and/or Anxiety (95%

CI)

Household with HIV/AIDS-ill caregiver and child(ren) orphaned by AIDS

3.43 (1.13-10.38)

Household socioeconomic status 0.84 (0.64-1.11)

Caregiver age 1.40 (1.08-1.81)

Caregiver gender 1.69 (1.16-2.44)

Caregiver education 0.50 (0.39-0.65)

Child age 1.46 (1.05-2.04)

Child gender 1.13 (0.89-1.44)

Child education 0.94 (0.88-1.01)

Caregiver stigma 2.44 (1.86-3.18)Statistically significant associations are shown in bold

Food security a protective factor for mental health of HIV/AIDS-ill caregivers

Relative Risk for Caregiver Depression and/or Anxiety (95%

CI)

Household with HIV/AIDS-ill caregiver and child(ren) orphaned by AIDS

3.41 (1.13-10.36)

Household socioeconomic status 0.85 (0.64-1.12)

Caregiver age 1.40 (1.08-1.81)

Caregiver gender 1.68 (1.16-2.43)

Caregiver education 0.51 (0.40-0.66)

Child age 1.44 (1.03-2.00)

Child gender 1.13 (0.89-1.44)

Child education 0.94 (0.88-1.01)

Caregiver stigma 2.35 (1.79-3.08)

Household food insecurity 1.46 (1.05-2.03)Statistically significant associations are shown in bold

ConclusionsCaregivers of children orphaned by AIDS at high

risk for psychological distressThis risk increases if these caregivers are living with

HIV or AIDSRisk and protective factors for psychological

distress among HIV/AIDS-ill caregivers Stigma a risk factorFood security a protective factor

Interventions needed to address psychological distress, and may need to be paired with community interventions (to address stigma) and structural interventions (to address food insecurity)

Acknowledgments

Additional generous support from: NIMH T32 (PI: Brown)

Alcohol Research Center on HIV

CFAR Tufts/Brown/Lifespan