THE IMPACT OF HIV/AIDS ON EARLY CHiLDHOOD A CASE OF HOME CARE OF NSAMBYA HOSPITAL. MAKINDYL MUNICIpALITy

BY NA1GA HELLEN BSW/41504/133/DU

DiSSERTATION SUBMITTED TO THE COLLEGE OF HUMANITIES AND SOCIAL SCIENCES IN PARTIAL FULFILLMENT OF THE REQUIRLMENTS FOR THE AWARD OF A BACHELORS DEGREE IN SOCIL WORK AND SOCIL ADMINJ5Tp~j~~~ OF ~

UNIVEj~SJTy

OCTOBER, 2016 DECLARATION “This dissertation is my original work and has not been presented for a Degree or any other academic award in any University or Institution of Learning?.

NAIGA HELLEN

Signature:

Date APPROVAL “I confirm that the work reported in this dissertation is carried out by the candidate under my/our supervisio&t,

OKIMAJT~OLAKI DAVID “p/I ~4~’/W Signature:

~ DEDICATION I dedicate this dissertation to my beloved parents MR&MRS Muyomba James Bosco, My Sisters Nakakeeto Moureen, Namuyomba Cissy, Namirimu Winnie and my two brothers Ssemugambi Drake and Muyomba Lyton. Not forgetting all my friends Brenda, Enock, Sarah, Joan, Kasime Rogers, Kasozi Fred and Mugume for all their emotional, financial and spiritual support. May the almighty God (Allah) reward them abundantly

III ACKNOWLEDGE~r1~r I thank all the key informants like the Hospital administrator, the hospital staff like the Doctors, counselors ,care takers, managers in Nsambye hospital and the local people who willingly provided lntbrmatlpn that enabled this research become a success.

Special thanks go to my beloved parents for their financial and emotional support and my sisters for their encouragement

Finally I acknowledge the academic support and knowledge given to me by my academic supervisor who continually corrected and guided me academically making this piece of work reality and everyone who contributed towards the compilation and completion of this dissertation may the almighty God bless you abundantly..

Iv TABLE OF CONTENTS

Contents

DECLARATION . APPROVAL

DEDICATION

ACKNOWLEDGEMENT iv TABLE OF CONTENTS

LISTOFTABLES ix

LIST OF ACCRONMyS

ABSTRACT

CHAPTER ONE

INTRODUCTION 1 1.0. Introduction

1.1 Background of the HIV

1 .2 Problem statement 6

1.3 General objective 7

1.4. Specific objectives

1 .5 Research questions 7

1.6 Scope of the study 8

1.6.1 Content scope 8

1.6.2 Geographical scope 8

.6.3 Time scope 8

.8 Significance of the study 8

.9 Operational definitions of key terms 8

v CHAPTER TWO .10

LITERATURE REVIEW 10 2.0 Introduction 10

2.1 The effect of HI V/AIDS on early childhood development in Uganda 10

2.2 Special Vulnerabjljties of Early childhood under Five Nutrition 13

2.2. 1 Early childhood ages 0—6 months of age: breastfeeding 15

2.2.2 Early childhood ages six to thirty-six months of age: complementary feeding 16

2.2.3 Early childhood ages three—four: family foods 17

2.2.4 Food discrimination 17

2.2.5 Health coj~cel•ns 18

2.2.6 Common infections 1 8

2.2.7 Immunjsable diseases 19

2.2.8 Psychosocial concerns 19

2.2.9 Consistency of caregive 20

2.3 Psychosocial impacts on health and survival 22

2.3.1 General aspects olcare 23

2.3.2 Coping ~~ith grief 23

2.4 Measures to reduce HI V/AIDS infection on early childhood 25

CHAPTER THREE 28

METFIODOLOCy 28 3.0 Introduction 28

3. 1 Research design 28

3.2 Study area 28

3.3 Population of the study 28 3.4 Sample size .29 3.5 Sampling techniques 30 3.5.1 Simple Random Sampling 30 3.5.2 Purposive Sampling 30

3.6. Data collection techniques 30

3.6. 1 Questionnaire Survey 30

3.6.2 Documentary Review Method 3 1

3.7 Data Analysis and interpretation techniques 3 1

3.9 Data quality control 3 1

3. 10 Ethical considerations 32

3.11 Limitation to the study 32

CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND INTERPRETATION 34

4.1 Introduction 34

4. 1 Back Ground information 34

4.1.1 Age of the respondent 35

4.1.2 Sex of the respondent 35

4.1.3 Which Department do you belong9 36

4. 1 .5 1—low long have you v.. orked with Home Care’2 37

4.2 The effect of HIV/AIDS on early childhood development in Uganda 37

4.2.1 1-las HIV/AIDS greatly affected the development of early childhood in Uganda’2 37

4.2.2 If Yes ~~hat are some of the effects of HI V/AIDS on early childhood’? 38

4.3 The challenges HI V/AIDS poses to early childhood development in Uganda 39

4.3.1 Has HIV/AIDS posse a challenge to early childhood development in Uganda’? 39 4.3.2 If Yes What are the major challenges that I-IlV/AIDS posse to early childhood in Home care? 40

4.3.3 Which of the challenges mentioned above is common in home care 41 4.4 Measures to reduce the effects of HI V/AIDS on early childhood in Uganda 42

4.4. 1 Are there any measures taken to reduce the effects of HI V/AIDS on early childhood in Uganda’? 42

4.4.2 If Yes What are the measures taken to reduce the effects ofHIV/AIDS on early childhood in Home care’?

4.4.3 Which of the mentioned measures above have been adopted in Home care Nsarnbya 43

CHAPTER FIVE 45

SUMMERY, DISCUSSIONS, CONCLUSION AND RECOMMADATIONS 45

5.0 Introduction 45

5.2 Conclusion 46

5.3 Recommendations 48

5.3 Area for further study 49

REFERENCES 50

APPENDICES

~~PPENDIX A: RESEARCH QUESTIONNAIRE 55

‘~PPENDIX B: BUDGET 58

~PPENDIX C: THE PROPOSED TIME FRAME 59

VIII LIST OF TABLES Table I: Showing Highest Academic Qualification of the respondent34 Table 2: Showing the Age of the respondent 35 Table 3: Showing the Sex of the respondent 35 Table 4: Showing Which Department the respondents belong 36 Table 5: Showing the position respondents hold in the organization 36 Table 6: Showing How long respondents have worked with Home Care 37 Table 7: Showing whether HI V/AIDS has greatly affected the development of early childhood in Uganda Table 8: Showing whether HI V/AIDS posses a challenge to early childhood development in Uganda Table 9: Showing the major challenges that HI V/AiDS posse to early childhood in Home care.40 Table 10: Showing the measures taken to reduce the effects of HI V/AIDS on early childhood in Uganda 42 Table 11: Showing the measures taken to reduce the effects of HI V/AIDS on early childhood in I-Iome care

ix LIST OF ACCRONMyS AIDS Acquired Immune Deficiency Syndrome

WHO World Health Organizations

UNAIDS United Nations programme on HIV and AIDS

UNICEF United Nations international children’s emergency fluid

MOH Ministry of Health

UN United Nations

PMTCT Preventing Mother To child Transmission

VCT Voluntary Counselling and Testing

NRM National Resistance Movement

USAID United States Agency For international Development

HAART highly active antiretroviral therapy

‘C ABSTRACF

HIV infection and AIDS among early childhood continues to be a significant problem in developing countrIes despite the progress that has been made in HIV preventIon and AIDS treatment elsewhere during the past two decades. The reasons fbr this difference are complex and multithctorial. They include the higher background prevalence of infection among adults in some communities in developing countries, the slow implementation in many countries of prenatal HIV screening programs and prophylaxis which can reduce the transmission to infhnts during labor and delivery, the social and health consequences of not breastfeeding, and the economic realities associated with expensive diagnostic testing and antiretroviral treatment. While the world waits for an effective HIV/AIDS vaccine, to reduce the prevalence of HIV in the community, public health programs need to continue to emphasize proven methods of HIV transmission prevention among groups with a high-risk of HIV acquisition, as well as provide counselling for the general population about personal protection and the provision of compassionate care for those affected.

xi CHAPTER ONE INTRODUCTION 1.0. Introduction Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) is a dangerous disease that has become a global pandemic since 1982. It poses one of the greatest challenges of the 21 century, It is among the highest killer diseases in the world, it discriminates no one. It kills early childhood, young people, and economically productive people, brings socio-economic suffering to households and adversely affects economic development. Estimates of HI V/AIDS incidence in the USA in 2006 is 56300 new infections annually (World Bank report, 2002). This chapter comprises the background to the study, problem statement, objectives, study scope, conceptual framework and the definition of terms.

1.1 Background of the H1V The HIV epidemic has transformed the childhood, youth and adulthood of millions globally. Over three million early childhood and 38 million adults are infected with HIV worldwide.(Uganda Aids Commission Net work (2013) The epidemic affects early childhood both through the illness and death of early childhood themselves and through the illness and death of parents. teachers. and other caretakers,

While the footprint of the HIV pandemic is felt globally, the impact is currently greatest in the southern coner of Africa. In the last year 2015 alone, there were 3.5 million new HIV infections among adults and early childhood in sub-Saharan Africa (WHO 201 5). Yet countries well beyond Africa are afTected. Recently. attention has been focused on the rapid rise of infection rates in Asia and in Central and Eastern Europe. In Eastern Europe and Central Asia, 1.2 million adults and early childhood are living with HIV. India has four million infected adults and early childhood, a total second only to South Africa UNAIDS (2015)

Globally the worst epidemic is in Africa. UNAIDS estimates that 24.5 million of the 34.3 million global infections are in Africa (UNAIDS, 2000: 56). In 2000 it was estimated that 8.57% of African adults (defined as those aged I 5~49 years) were infected. South and Southeast Asia has the highest rate, with 5.6 million infected people. Them are smaller epidemics in a number of Central American and Caribbean countries In Eastern Europe them is concern that HIV may spread beyond the drug-using populations, creating a generalized epidemic. However, 20 years Into the epidemic, Africa is the epicenter, with 26 of the 28 worst affected countries (UNAID5, 2013).

The overall impact of AIDS on the global population has not yet reached its peak, and its demographic effects will likely be felt well into the second half of the 21 century. Current projections suggest that by 2015, in the 60 countries most affected by AIDS, the total population will be 115 million less than it would be in the absence of AIDS. Africa will account for nearly three-quarters ofthis difference in 2050, and although life expectancy for the entire continent will have risen to 65.4 years from the current 49.1 years, it will still be almost 12 to 17 years less than life expectancy in other regions ofthe world (UN Population Division, 2005b).

In Uganda, the generalized HIV epidemic has a prevalence of 7% in adults and 0.7% in early childhoocj (UAC June, 2016.) Oleke (19%), as cited by Izama (2003), contend that it has been demonstrated that women have a higher vulnerability to HIV&AIDS as compared to men in heterosexual relationships.

The impact of AIDS is still not fully Understood, particularly when the long term is considered. The epidemic comes in successive waves, with the first wave being HIV infection, followed several years later by a wave of opportunistic diseases, and later still by a wave of AIDS Illness and then death (Barnett and Whiteside, 2002). The final wave affects societies and economies at various levels, from the family and community to the national and international levels. None ofthe highly affected countries have yet hit the peak of the third wave nor advanced very far into the fourth, and as one study put it (Bell et al., 2003):

The very high rate of HIV infection experienced in Uganda during the 1 980s and early I 990s ~reated an urgent need for people to know their HIV status. The only option available to them was fThred by the National Blood Transfbsion Service, which carries out routine HIV tests on all the lood that is donated for transfusion purposes. Because the need for testing and counseling was

2 great, a group of local non-governmental organizations such as The AIDS Support Organ isation (TASO), Uganda Red Cross, Nsarnbya Home Care, the National Blood Bank, the Uganda Virus Research Institute together with the Ministry of Health established the AIDS Information Centre in 1990 to provide HIV testing and counseling services with the knowledge and consent of the client involved. In Uganda. HIV/AID5 has been approached as more than a health issue and in 1992 a Multi-sectoral AIDS Control Approach was adopted. In addition, the Uganda AIDS Commission, also founded in 1992, has helped develop a national HI V/AIDS policy. A variety of approaches to AIDS education have been employed, ranging from the promotion of condom use to ‘abstinence only programmes. To further Uganda’s efforts in establishing a comprehensive Hi V/AIDS program, in 2000 the MOH implemented birth practices and safe infant feeding counseling. According to the WHO, around 41,000 women received Preventing Mother To child Transmission (PMTCT) services in 2001. Uganda was the first country to open a Voluntary Counselling and Testing (VCT) clinic in Africa called AIDS Information Centre and pioneered the concept of voluntary HIV testing centers in Sub-Saharan Africa.

The Ugandan government, through President Yoweri Museveni, has promoted this as a success story in the Pght against HIV and AIDS, arguing it has been the most effective national response to the pandemic in sub-Saharan Africa. Though equally there has in recent years been growing criticism that these claims are exaggerated, and that the HIV infection rate in Uganda is on the rise.

The scale of the epidemic’s impact. highly varied from place to place, has been documented with increasing precision over the years as surveillance and analytical tools have improved. As a result. the interrelationship of AIDS with other problems of human development has become clearer. Jonathan Mann’s insight from the early I 990s that AIDS shines a spotlight on human rights and societal issues has been borne out in many ways, particularly in the epidemic’s interactions with poverty, gender inequality and social exclusion (Mann et al., 1994). Research over the past few years has shown how it exacerbates other major challenges to development, from the deterioration of public services and governance to humanitarian emergencies such as food insecurity and conflict. As a recent study of the relationship between AIDS and famine in southern Africa states, “HTV/AIDS accentuates existing difficulties, compelling us to confront many simultaneous problems, all ofwhich need resolution” (de Weal and Whkeslde, 2003).

The impact of AIDS is still not filly understood, particularly when the long term Is considered. The epidemic comes in successive waves, with the first wave being HIV infection, followed several years later by a wave ofopportunistic diseases, and later still by a wave ofAIDS illness and then death (Barnett and Whiteside, 2002). The final wave affects societies and economies at various levels, from the thmily and community to the national and international levels. None ofthe highly affected countries have yet hit the peak of the third wave nor advanced very far into the fourth, and as one study put it (Bell et al., 2003):

Eariy chiidhood who have been orphaned by AIDS are forced to ieave school, engage in child labor or prostitution, suffer from depression and anger, or engage in high-risk behavior that makes them vuinerable to contracting H1V. Early childhood who lives in homes that take in orphans may see a decline in the quantity and quality of food, education, loves, nurturing and may be stigmatized. The demand for educationai services deciines because of reduced family resources that are available for schooling in AIDS affected households HIV~AIDS also changes the trend of school age population as it causes a rise in the number of orphans in the country who may not afford education. Many orphans live in child headed families that lack basic human needs because of the death of parents who were the source of financial support (UNAIDS, UNICEF, USA1D, 2004).

The Human Immunodeficiency Virus [HIV] that ieads to Acquired Immune Deficiency Syndrome [AIDSJ is the most severe epidemic facing the entire world today. lzama (2013), once a person has deveioped AIDS, a variety of other aiiments occur because the body is incapable of combating other bacteria or virus that causes diseases. HIV/AIDS epidemic aiso reduces the demand for education. Families that are affected wiii have fewer resources available for medication and school fees. Consequently, few early childhood will be able to affbrd or complete schooling. Girls are likely to be affected more because they are forced out ofschooi more than boys to take care ofsick family members, or to work in order to make up for lost fhmiiy income.

4 Since the first incident in Uganda, cases ofHIV had been reported throughout the country, and the scale of the epidemic has been severe. Of a total population of 22 million people, it was estimated that 1.9 million had been infected with the HIV about 67,000 of them early childhood. Approximately 500,000 people have died of HIV/AIDS-related causes, and 1.7 millIon early childhood have been orphaned (UNAIDS 2001). SAS (2009), asserts that when the first HIV &AIDS case was reported, superstitions and witchcraft characterized the initial response from communities amidst lack of clear government response to HIV/AIDS. As a result, the epidemic escalated very fast to a national prevalence of 18.3% with some centers registering prevalence above 30% by the end of 1992. Spontaneous community responses and obvious response from the health care establishments were reinforced in 1986 when the new National Resistance Movement (NRM) government established the first AIDS Control Program in the Ministry of Health.

The Ministry of Health Surveillance Unit estimated that there are 1,055,555 people living with HIV/AIDS by the end of December 2001, and over 940,000 HIV/AIDS related deaths have occurred since the onset of the epidemic in the country. At the end of 2002, the national HIV prevalence was estimated at an average of6.2% ofthe total Uganda population, following a history of declining national prevalence average of 18% with about 30% in the worst hit areas of the country in the early l990s. The Ministry of Health estimated new infections in 2002 alone at 70,170, those that were newly infected with HIV virus at 73,830 and deaths at 75,290. These figures however could be higher due to constraints in AIDS reporting from the sentinel surveillance system many cases are not documented (SAS, 2009).

Due to the aggressive campaigns spearheaded by the Ugandan government the spread of the disease was curtailed. Uganda became known as a beacon of light in the fight against HIV&AIDS. In fact, its methods were hailed by the international community as the best in combating the disease and encouraged other African countries to emulate them. Aside from winning the battle against HIV&AIDS Uganda especially among early childhood also gained support from the international community at large. Unfortunately, Ugandan government thiled to put structures in place to maintain and sustain the momentum they had gained in raising awareness and educating the community about safe sex behavior. As a result, in 2007 new infections started and this time there was a shift to older age groups. Prevalence and incidence of Uganda’s mature HIV epidemic

5 stopped declining around 2000 there by remaining stable (Kirungi et at, 2014 and Shafer et al, 2015).

Sexual transmission continues to contribute 76% of new HIV infections while mother to child HIV transmission contributed 22%. (MOH, 2015) By 2014, estimates indicated that over 100,000 new infections were occurring annually. During 2008, an estimated 110,694 new HIV infections occurred countrywide and approximately 61,306 people died from AIDS related illness in 2015 (MoH 2015). There is also evidence to suggest that despite a significant decline in HIV prevalence between 2012 and 201 5, HIV prevalence has stagnated over the last 5-9 years between 6. 1 and 6.5% and would be on the rise in some parts of the country or specific population groups (ibid).

1.2 Problem statement AIDS-affected early childhood from birth to eight especially those affected by 1-IIV/AIDS through infection or the illness/loss ofone or both parents and/or family members; orphaned due to AIDS; or made vulnerable by the AIDS pandemic face threats to normal hLlman development beyond those of physical survival. The deprivation of consistent, responsive care and interpersonal and environmental stimulation in early childhood ‘s critical early years of life leads to measurable increases in malnutrition. morbidity, and mortality; this neglect also inhibits healthy psychosocial and cognitive development. Over the long-term, deficient psychosocial and cognitive development among AIDS affected early childhood will have very real significance for the societies in which they live. Meeting young early childhood’s developmental needs is essential to produce the sound and stable citizens that every society needs especially those societies hard hit by AIDS. (USA ID, 2000, 2013: UNAIDS, UNICEF, USAID 2015)

Within the AIDS crisis, there is a virtual absence of attention to and information on the impact of

HIV/AIDS to early childhood under the age of five and their ‘~ arious caregi~ ers. Although there is considerable attention to important issues such as prevention and treatment, maternal! child transmissions, and the impact on the broader education system, there is virtually total neglect of the broader and longer-term issue of the care and nurturing of the youngest early childhood (and especially’ early childhood under three years) in families and communities impacted by’ HI V/AIDS. (GoU 2015)

6 The number of young early childhood affected by AIDS in MaklndyeDlvlslon Nsambya Is, and will be, greater still. Many are very directly affected; others less directly. Early childhood who have not yet been orphaned live with parents who are ill, and bear not only the grief, worry, and reduced cIrcumstances that sick parents InevItably brIng, but these early chIldhood often become primary caregivers for both parents and younger siblings during their parent’s illness. The early childhood of adult caregivers of AIDS patients most caregivers are poor women (Participatory Assessment Group 1999) lose the time, attention, energy, and income their mother used to provide. Thus the need for this research

1.3 General objective The general objective was to investigate the impact of HIV&AIDS on early childhood and the challenges it poses in dealing with the group in question.

1.4. Specific objectives The specific objectives was: a) To examine the effect of HIV/AIDS on early childhood development in Uganda b) To identi& the challenges HIV/AIDS poses to early childhood development in Uganda. c) To establish measures to reduce the effects of HIV/AIDS on early childhood in Uganda

1.5 Research questions The study was guided by the following questions: a) What are the effect of HIV/AIDS on early childhood development in Uganda b) What are the challenges HIV/AIDS poses to early childhood development in Uganda. c) What are the measures to reduce the efThcts of HIV/AIDS on early childhood in Uganda

7 1.6 Scope of the study 1.6.1 Content scope The study attempted to discover the impact of HIV/AIDS on early childhood. The independent variable was the Impact of HIV/AIDS whereas the dependent variable was early childhood.

1.6.2 GeographIcal scope The study was carried out in Makindye Municipality at the Home care of Nsambya hospital. Makindye Municipality is one of the divisions that make up Kampala Capital City Authority. It was located in the southern part of Kampala; it boarders central division in the North Rubaga, to the West Nakawa and Wakiso district in the south. This area was chosen because it houses the biggest outlet of HIV/AIDS infected early childhood, in the Makindye Division.

1.63 Time scope This study was covered in the period between June 2016 to August 2016.

1.8 SIgnificance of the study The study will help the researcher obtain more knowledge and better understanding about the HIV/AiDS, spread and prevalence among early childhood

The research will be used as reference material for students and other researchers who will be interested to research more on the topic of HIV/AIDS and its impact on early childhood The study will also add value to the existing body of knowledge by stimulating new areas for further research through the findings and subsequent recommendations for the impact of HIV/AIDS on early childhood.

1.9 Operational definitions of key terms my Human Immuno deficiency Virus, a virus which causes AIDS when it enters the human body. HIV weakens the body’s immune system while in the body making it succumb to several opportunistic infections. AIDS is the final stage of H1V infection.

8 AIDS Stands for Acquired Immuno Deficiency Syndrome. This is a stage when an I-IIV infected person begins to suffer many illnesses as a result of a weakened immune system due to HIV.

9 CHAPTER TWO UTERATIJRE REVIEW 2.0 IntroductIon This chapter shows the literature review based on the objectives of the study. It Involves different understanding and points ofviews ofthe different authors pertaining to the impact ofHIV&AIDS on early childhood.

2.1 The effect of HIV/AIDS on early childhood development in Uganda Enrolment figures have declined as HIV/AIDS spread. The overall demand for general childhood education, vocational and tertiary education has dropped. This has implication on learner participation in that most classes have no teachers, while others have large classes and this makes it difficult for the teacher to give attention to all early childhood especially the slow learners. In addition, AIDS has reversed progress in reducing infant and child mortality, drastically affecting the actual population entering school in the most affected areas. According to UNICEF (2004) the number of young people who drop out of school has increased, and school attendance has dropped due to various HIV related phenomena affecting early childhood such as having to cope with personal illness, caring for family member’s trauma related to illness and sudden death of a member of the family. Discrimination and stigma decline financial support from parents and the need to work to earn some income affects the infected persons. The estimated 10 million orphans exacerbate such problems under 15 years of age in the African region. A few incentives should be introduced in order to attract early childhood to come to school. Lack of essential learning resources and basic human needs result in poor performance in class. Studies have shown that parents value for education has declined as parents perceive the early death oftheir early childhood as likely and thus are unwilling to spend their limited resources on education. This attitude has negative implication on early childhood living with HIV/AIDS as most ofthem fall to join school. The strain of poverty also appears to push early childhood into early employment rather than chooling in order to boost family income, especially in families that are economically unstable. JNAID5 (2006) cited that grades in gender equity in education can be a setback for many reasons, ncluding early marriages and pregnancies ofgirls as early as 13 years. The study noted that due to he infections of young girls by men, infection rates among girls as young as thirteen years have isen, hence reducing their likelihood of completing and benefiting from schooling.

10 Primary prevention of HIV infection. Avoiding infection in women will contribute significantly to the prevention of HIV transmission to infants and young early childhood, as well as to other prevention goals. I-HV prevention programmes need to be directed at a broad range of women at

risk — and their partners. A particular effort is required to reach young people with relevant services. Because primary HIV infection during pregnancy and breastfeeding poses an increased threat of mother-to-child transmission, HIV prevention efforts should also address the needs of pregnant and lactating women, especially in high prevalence areas.

Prevention of unintended pregnancies among HIV-infected women. Most HIV infected women in the developing v~orld are unaware of their serostatus. Family planning services need to be strengthened so that all women, including those infected, can receive support and services to prevent unintended pregnancies. ~v\ omen known to be infected ~ ith HIV should receive essential care and support services, including family planning and other reproductive health services, so that the)’ can make informed decisions about their future reproductive lives.

Prevention of HIV transmission from HIV-infected women to their infants. A package of specific interventions has been identified to prevent HIV transmission from an infected mother to her child, It includes antiretroviral drug use, safer delivery practices, and infant-feeding counselling and support. Here too, counselling and testing plays a key role so that HI V-infected women can learn their status in good time to dra~~ the full benefits of this package.

Antiretroviral drug use. A number of antiretroviral drug regimens — based on zidovudine, zidovudine and lamivudine or nevirapine, or combinations used in highly active antiretroviral therapy (HAART) — have been shown to be effective in reducing mother-to-child transmission of HIV. The choice of antiretroviral regimen should be made locally, taking into account issues of feasibility, efficacy and cost.

Safer delivery practices. It has been shown that elective Caesarean section can help to reduce the isk of mother-to-child HIV transmission, This, however, may not be an appropriate intervention

Ii resource—consti’ajjied settings, because of limited availability, cost and the risk olcomplications. nvasive obstetrical pi’ocedtires, such as artificial l’upture of membranes, fetal scalp monitoring and

II episiotomy, may increase the risk of transmission of HIV to the infant. Their use in HI V-infected women should be limited to eases of absolute necessity.

Infant-feeding counselling and support. Breastfeeding can add to the risk of HIV transmission by 10-20%. Lack of breastfeeding, however, can expose early childhood to an increased risk of malnutrition or infectious diseases other than l-IIV, While avoiding breastfeeding would seem logical when the mother is HIV-infected, striking the necessary balance of risks is in fact more complicated. All H TV-infected mothers should receive counselling that includes information about the risks and beneOts of various infant feeding options, and guidance in selecting the most suitable option for their situation. When replacement feeding is acceptable, feasible, affordable, sustainable and safe. avoidance of all breastfeeding by HI V-infected mothers is recommended. Otherwise, exclusive hreastlèeding is recommended during the drst months of life and should then be discontinued as soon as it is feasible,

In summary, the main impact of HIV/AIDS on early childhood found in the studies described in

this section can he divided into three main areas — psycho-emotional impact, social impact and material impact:

Loss of social / family support, or ‘psycho-emotional impact.’ Possibly the most important direct consequence of AIDS for early childhood and young people is the loss of their family unit, and with it their natural economic, social and emotional ‘safety net.’ Apart from the problem of P11 V-positive mothers abandoning their newborns out of despair, this usually means grown-up early childhood in families affected by AIDS have to put up with living in a foster family or in either state or religious institutions. This may lead them to he less well-supervised than would be the case in a nuclear family situation, which could result in dropping out from school or attachment to unfavorable role models (gang leaders), or even entry into the sex industry or into crime All this is based on the severe consequences to early childhood’s psychological well-being and self-esteem that result from the loss of their parents to AIDS.

Stigma and discrimination, or ‘social impact.’ Stigma and discrimination are caused by ignorance and fear of AIDS in the community and the moralistic and often judgmental views

12 community members (including many people with AIDS, themselves) have about AIDS — equaling ‘bad’ with HIV-positive and ‘good’ with HIV-negative. Addressing these misconceptions not only would tackle one of the heaviest burdens on the well-being of persons with AIDS, but also would make sense from a prevention perspective. After all, people often make judgments about the need to use condoms based on a similar moralistic argument 11w example, “this person is ‘good’ so them is no need to use a condom,” or “this person is a sex worker, therefore ‘bad’, so we’d better use a condom.”

Decreased access to education, health care and social services, or ‘material impact’ As a consequence of losing the fkmily unit, as well as ofstigma and discrimination, early childhood and young people end up having less access to education, health care and social services. In many

instances, they are shunned by community members and are actively discriminatecj against — this is called ‘enacted stigma.’ The saddest examples of this are community members forcing head masters of local schools to expel early childhood from families afThcted by AIDS from the school.

More often than that, and strongly related to the moralistic prejudices surrounding AIDS mentioned above, people affected by AIDS feel shunned by community members, and this ‘perceived stigma’ leads to similar, be it self-imposed, barriers to seeking access to services or allowing early childhood to go to school. [See examples of tNt and enacted stigma among AIDS patients in Thailand (Ngamvithayapong 2000) and in Cambodia (Wijngaarden 2001, p. 30)]. Merrigan and Yi, in their study on landlessness related to AIDS in northwestern Cambodia, describe what they call ‘self-stigmatization’ as “occurring when a PLWA treats him or herself in a manner consistent with stigmatization, making their lives more difficult than is necessary, because they are afraid of the effect they may have on others” (Merrigan and Yi 2001, p. 16). Illness in the

family also leads families to take early childhood — especially girls — out of schools to tlinction as caregivers. A worse scenario is experienced by disabled AIDS orphans who are usually ignored because they often require extra care vis a vis more expensive facilities (Groce 2004).

2.2 Special Vulnerabilifles of Early childhood under Five Nutrition The prevalent feeding patterns in much of Africa and Asia are particularly dangerous for the welfare ofHIV affected early childhood. These patterns are characterized by premature (before six

13 months of age) introduction of foods that have little nutritional value, that often are vehicles for infections, and that reduce the nutritional and disease-preventive properties of breastfeeding. Beliefs and practices about foods and feeding of young early childhood makes good nutrition for healthy early childhood relatively rare, and even more rare for early childhood who are ill or thought to be ill.

Several studies have reported that orphans under five are more likely to be stunted or malnourished than non-orphans (Tembo and Kakungu 1999: Sernali et al. 1995; Poulter 1997; Nduati et al. 1993). Foster (1993) found no difference. Cultural beliefs concerning the importance of good treatment 1~r orphans will impact results, along with careful controls for HIV infection and mortality in the age group. Rates of malnutrition, which mostly affects under-fives, are expected to increase sharply in AIDS-affected communities as medical costs, loss of labour, and the selling or dispersal of assets due to medical and funeral costs reduce households’ ability to buy and produce food.

A researcher of hreastfeeding practices in a heavily AIDS-affected region of Zambia reports the special difficulties faced by the under-five age group: “Nutritionally, the under-fives are very, very vulnerable.., families can’t afford to feed them... Everyone is assuming that the younger kids are being taken care of~.. This is Africa and Africans take care of kids.” but, “Little kids fall through the cracks” (Piwoz 2000).

Households Ibstering orphans do have reduced ability to provide food. lKraak et al (1999) found that when families care for orphans they lost time working at income-producing and food-producing activities, Food consumption has been found to drop by as much as forty percent in families and communities affected by AIDS (UNICEF and UNAIDS 1999). Traditions that require the sacrificing of livestock and other assets for male funerals further deplete the financial resources available for orphan care. Among the Baganda in Uganda “one cannot attend to farm work or other income generating activities after a death within the close relative circle until all the rituals are completed.”

14 When this requires waiting for travelling relatives to arrive, the lack of labour “only worsens the already threatened food security of the bereaved” (Ayleko 1998). The nutritional needs ofevery age group under five are threatened in unique ways by the epidemic:

2.2.1 Early childhood ages 0—6 months of age: breastfeedilng Breast&eciing provides optimum energy, protein, and micronutrients for young infhnts and toddlers; its anti-infective properties help prevent or reduce the severity of common illnesses, including the diarrhoea and pneumonia that are major causes of death in developing countries. Maternal orphans, early childhood ofmothers who are too sick to breastfeed, and early childhood of mothers who know they are HIV-positive and choose not to breastteecj, are deprived of the essential nutrition in breast milk, its protection against common diseases, and the physical and psychosocial interaction that accompany breastfeeding.

Because of the high costs of special milk or formula to replace breast milk, it is difficult for families to provide them in sufficient amounts for infant feeding. Likewise, ensuring that replacement milk is fed to early childhood under hygienic conditions is extremely difficult in most developing countries. The thel, utensils, water and soap needed for hygienic preparation add monetary, time, and energy costs beyond the means of impoverished and over-stretched caregivers. Caregivers in child-headed households or elder headed households of AIDS affected early childhood often lack knowledge, as well as funds and time, to provide adequate replacement feeding.

Burkina-Faso caregivers believe that the breast milk of infected mothers automatically infects early childhood. Wet-nursing is not seen as an option because this group also believes, correctly, that healthy women can become infected by wet-nursing infants born to infected mothers (Taverne 1999). Changing wet-nursing practices are reported in rural Kenya (O’Gara 2001) and Zambia (Piwoz 2000).

Similar beliefs were recorded in the Ndola district ofZambia. Researchers reported that “The risks due to breastfeeding are believed to be very high, and most men, women, and traditional birth attendants had the impression that all HIV-positive mothers pass the virus through breast milk.” At

15 the same time, babies who are not breastfèd are “thought to be at high risk of dying.” The alternatives to breastfeeding are also ruled virtually impossible: “All providers felt that it would be very difficult or impossible for women in their communities to safely offer replacement food to newborn babies. Most felt that people could not afford intint formula, and the time needed to boil water and clean utensils would be too great” (National Food and Nutrition Commission Ndola District Health Management Team 1999).

In Rwanda a traditional good wish after the birth of a baby is “May you breastfeed well.” Not breastfeeding signals incomplete motherhood, and, now, may signal HIV infection. In Zambia, women in a recent study (Piwoz 2000) told researchers that refraining from breastfeeding was almost not an option to do so would make Ibmily and community members suspect HIV infection and could result in spousal violence or ejection from the home. The unhappy compromise is most often mixed feeding, a combination of breastfeeding with substitute feeding. This, the most prevalent pattern, is the most dangerous and the most likely to fhcilitate transmission of HIV from mother to child.

2.2.2 Early childhood ages six to thirty-six months of age: complementary feeding Because most intints and toddlers are normally breastfed. there is often little understanding of the nutritional needs of a non-breastfed child over six months of age, who needs additional foods beyond milk substitutes as well as frequent feeding suited to child-sized stomachs. Child and elder-headed households in particular may lack knowledge of appropriate foods, or because of time and financial constraints, shift early childhood in their care too quickly to adult foods and eating patterns.

In some African countries, feeding follows a hierarchy, with adults eating the good food first and the remains passed from the oldest to the youngest child (Evans 1997). Once toddlers walk stably and especially once a younger child joins the family, the “lap child” is often left to fend for itselfat mealtime. These traditional patterns have always meant that conditions of scarcity are hardest on young early childhood. Fostered orphans may fare worse yet

Beliefs about what food is good for young early childhood also affect their nutrition. In Zambia it

16 (‘I is thought that the sauce rather than the solids in the family meal is best for young early childhood, and families need encouragement to teed some of the most nourishing solids to young early childhood (Piwoz 2000). In many cultures, food, and even fluids, are withdrawn from early childhood who are ill. Active feeding when anorexia sets in is not practiced in these cultures or not initiated soon enough.

2.2.3 Early childhood ages three—four: flhmily foods High rates of anemia and other nutrient deficiencies such as vitamin A and zinc have been observed among many early childhood under age five; few affordable foods contain sufficient iron and zinc (meat is a particularly good source) to meet their needs. The increased poverty associated with AIDS makes anemia and nutrient deficiencies more likely because high quality foods become less available. StLldies in Cote d’Ivoire showed that when a iCmily member has AIDS. average income falls by fifty-two to sixty-seven percent, while expenditures on health care quadruple (UNICEF and UNAIDS 1999).

Early childhood aged three to I~ur eat best when supervised during meals, and when they are given snacks during the day in order to meet their energy requirements. Caregivers in AIDS-affectedi households are more likely to lack time and resources to procure and prepare energy dense, micronutrient rich fhods, to ollCr food at sufficiently frequent intervals for small stomachs, to monitor eating, and to responsively feed young early childhood. Even in the best of circumstances early childhood under five can be fussy, disorganised, slow, and erratic eaters. easily thrown off track by colds, distractions, and minor discomforts. Giving vouna early childhood time and attention around eating when time is scarce and food scarcer presents tremendous challenges to carecivers.

2.2.4 Food discrjnijiiatjoii Orphans in focus grotips have reported that what food is available in the household is Often not shared with them. One orphan reported: “When my relatives cooked food they used to hide it from us.” Another orphan told how he was sent to collect firewood and in his absence the food there was given out to the non-orphan early childhood. One orphan summarised the situation in the following words: “We [orphans] do not mind not having enough food or clothing. After all everybody else is

17 in this situation because of poverty. What we mind is being regarded different by the rest of the fhmily” (Ayieko 1998).

2.2.5 Health concerns As Foster (1998) points out, early childhood under five who are maternal orphans are extremely vulnerable to serious illness “since elderly and juvenile caregivers are frequently uninformed about nutrition, oral rehydration, immunisation, and diagnosing serious illness.” Kamenga et al.(2013 found higher rates ofmissed clinic visits among infants born to HIV-positive mothers due to “premature maternal death from HIV infection and lack of a suitable guardian” (1990). These same issues may apply to all AIDS-affected early childhood under five, not just maternal orphans, as many mothers transfer care concerns to older early childhood and grandparents while they attend to or work to replace lost income from very sick family members.

Improved survival rates in an orphan hospice in Nairobi suggest that malnutrition and lack of attention to health issues plays a significant role in under-five orphan mortality. The hospice cares for abandoned early childhood born to HIV-positive mothers, ordinarily a high-mortality group in Kenya The feeding and prompt treatment for opportunistic infections offered at the hospice makes a difference: fifty-six out ofsixty early childhood admitted in the first year and half remained alive and well (Mwangi 1994).

2.2.6 Common InfectIons Diarrhoea and acute respiratory infections are the major causes ofdeath for young early childhood in developing countries. Maternal orphans and early childhood whose mothers are too sick to breastfeed or choose not to because of HIV concerns will be at much greater risk of contracting these illnesses. A recent meta-analysis was conducted to assess the risk of mortality among non-breastfed infhnts compared to breastfrd infants in developing countries. This study illustrated that when all deaths occurring after the first week were included, the pooled odds ratios of risk of dying from diarrhea and acute respiratory infections were four to six times as high for inthnts ages birth to three months who were not breastfed compared to those receiving any breast milk. The benefits of breastfeeding remained throughout the first year of life. Severity of diarrhea has been shown to be less among breastfed early childhood even into the third year of life. Non-breastfed

18 early childhood may be at extra risk of death during each episode because caregivers may believe that these illnesses are the first signs of AIDS and therefore may be even less likely to seek treatment,

2.2.7 Imrnuiijsabje diseases In AIDS affected areas, the demands placed on health services may mean that fewer resources are available to provide immunisations, In addition, when young early childhood are stigmatised because they have lost a parent to illness and are themselves considered to be at risk of having AIDS as well, some health services are unwilling to vaccinate them. The greater susceptibility to common infections by orphans and other vulnerable early childhood may also lead to a lower immunisatioi~ rate. Mast et al. (I 966) found that fewer than half of the caretakers surveyed believed a child with any symptoms of illness should not be immunised, Since coughs. fevers, and diarrhea are common among African early childhood, especially in poorer families, it seems all too likely that many orphans are not receiving full immunisatioiis Field staff in Kenya report that it is difficult to get informatjoj~ about the immunisatjoii status ol’ many orphans because records have been lost during early childhood’s relocations after the death of a parent. Records are also lost due to maternal deaths as it is mothers who deal with early childhood’s immunisations

Health concerns may be likely to get little attention in orphan households in general. Child heads of household may not know what to do or where to go. nor to be able to determine when, action is seriously required. When the location of health clinics require transportatjoi~ and waiting time as well as fees for services from already over-stretched caregivers, the direct and opportunity costs of health care mitigate against any action. Where caregivers believe that sYmptoms are early signs of AIDS. they are forced to ask themselves: why invest in a dying child? Unfortunate’y such attitudes can lead to care which make the threat of disease more likely to become a reality.

2.2.8 Psychosocial COaceUIis Psychosocial issues for orphans older than five involve grief over the loss of parents, as ~vell as over separation from siblings. stigmatisation, and isolation, Issues of physical, mental, and sexual

19 abuse are also prevalent in foster households, In a situation analysis conducted in Zambia. the Participatory Assessment Group (1999j reported that orphan focus groups identified the following as signiflcant problems Ibr the early childhood: lack of love, being victims ofdiscrirnjnatioi~ and exclusion. In problem_rankii~g exercises this lack of love/discriii~indjtioi~ was ranked higher in importance than either lack of clothing or shelter, In a study by

Bochow (1999) in Tanzania, older orphans expressed the need for someone who could be trusted and relied upon and who was capable of understanding the early childhood after the loss of their parents. Early childhood under five have even more urgent needs for love and trust from Consistent caregivers, and are less able than older early childhood to manage or satisfy those needs in other ways. Very young early childhood are less able to he helped by the kinds of counselling and group supports useful to older early childhood. The primary. addressable psychosocial issues for early childhood under five involve consistency ofcaregiyers in addition to basic stimulatioj~ of all kinds.

2.2,9 Consistency of caregivei’ As noted in a recent report on supporting orphan care in Kenya, “Infants and young early

Childhood .. need to establish secure attachments to an adult care Provider and develop a sense of trust, self-worth and autonomy. Accomplishing these developmental tasks helps shape the child into the person he or she will become” (Donahue et al. 1999). Orphans by definitioi~ have lost at least one primary attachment to an adult caregivei’, and their situation is usually worsened by having to leave their homes after a parental death. In Zimbabwe, seventeeii Percent of orphans were moved to the homes of relatives after the death of a parent (Poster et al. 1995). Thirty~thi’ee percent of eai’ly childhood in child-headed households mostly double orphans, were relocated within the two years Prior to the study (Fostei’ 1998). A study of 1,100 orphans in Kenya found that forty_eight percent of orphans moved at least once upon the death of parents (Ayieko 1998).

As orphans are frequently distributed amond several households in order to ease the bul’dlefl of care, during the move, oung orphans often lose not only parents, but the older siblings and cousins who have spent the most time caring for them, and who were objects of attachments as

20 well. Foster et at, (1997) reports that early childhood under five are especially likely to be fostereci out while older siblings are left to live by themselves. Although understa,Idable these practic~ result in a maximum disruption of attschments.

Early childhood who are paternal orphans may be forced to move, with or without their mothers, because of witchcraft fears. Young widows among the Luo of western Kenya are encouraged to remarry within the extended family, regardle~ of the cause of the first husband’s death. If their new husbands die, however, the widows are labelled “husband killers,” accused of witchcra~ mistreated, and “encouraged” to leave their marital homes. Child-headed households in this same community may also be forced to move because of traditional behiefb: among the L.uo, when both parents die the roof of a house may not be repaired unless the wife was inherited by customary laws and this “causes many early childhood to move into different houses for shelter” (Ayieko 1998). The lack of prior arrangements mean that early childhood can experience a long period of uncertainty about who will care for them and where. Many parents fail to make any preparation for their deaths in terms of wills, child care arrangemen~, or transfer of agricultu~~ and other production knowledge because of the belief that talking about death hastens it (Ayieko 1998). Drew et al. (1996) found that only two percent of thmilies in northeast Zimbabwe wrote a will prior to death. Fears of witchcraft make planning for death difficult in many areas of Africa because a person who talks to another about their impending death can be charged with witchcraft (Foster et al. 2000).

The grandmother8, widows and widowers, or older siblings of newly orphaned households have such greatly increased responsibjliti~ that a crushing workload prevents much consistency in care. This workload may disrupt caregivers’ availability for their own young early childhood. Caregivers in Zimbabwe frequently complained of the lack of time to attend to young early childhood (O’Gara 2001). Piwoz reports that young orphans in Zambia are frequently cared for by rotating teenagers taking shifts not a prescription for secure attachments (Piwoz 2000).

Stimulation Maternal orphans under two years of age are inevitably deprived of the natural stimulation provided by breastfreding since wet-nursing, especially of infants born to mothers

21 suspected of having died of AIDS, is no longer thought safe in most regions. Breastfeeding gives infants and toddlers the tactile stimulation of being held, the auditory stimulation of mothers’ voices: they feel their mother’s warmth and learn basic patterns ofcommunication For both older infants and toddlers, breastfeeding promotes normal cognitive and social development through stimulation and through ensuring that the child gets individualized attention and affection. Maternal orphans and early childhood whose mothers are too ill to breastfeed miss out on this support for normal development. What will replace it?

Early childhood old enough to talk in Africa have a variety of caregivers to stimulate and nurture their growth, In households not overburdened with grief and unusual workloads, caregivers have time and energy to tell young early childhood stories, challenge them with riddles, make them toys. sing and dance with them, and show them how to do simple tasks that stimulate their mental capacities, In AIDS-affected households, this time and energy may be missing altogether,

Nursery school, an important alternative source of stimulation for young early childhood, is not an option for most young orphans. Even the minimal tees are beyond the reach of fostering families with suddenly many more mouths to teed and many older early childhood to educate. Stigma and witchcraft fears also play a role. Even when AIDS is not attributed strictly to promiscuity or prostitution, it is still a cause for shame, and ICr shunning of entire tCmil ies, A community based stirvey conducted in 1989 in the Mpigi District of Uganda revealed that seventy-one percent of the respondents regarded AIDS as shameful, partly because traditional beliefs held that wronged relatives may seek revenge by inflicting illness (Konde-Lule and Rwakaikare 1989).

Ayieko (1998) tells the story of an orphan boy in Kenya who no longer attends school. The boy believes that his educated Parents died of AIDS because members of their extended family, envying them this education. used witchcraft to sicken them. He does not want to be bewitched because of attending classes himselk

2.3 Psychosocial impacts on health and survival Early childhood’s psychosocial environments affect their survival as well as their development, In a study of nutritional resilience in a hostile environment Zeitl in (1 991) found greater weight gain

22 and development among early childhood who had received more physical interaction, affection, and praise from their mothers and relatives, as well as among those who received more verbal and environmental stimulation. More recently, Long and others (1998) found that caring practices at the Kisangani Therapeutic Feeding Centres, which included “conversing with the early childhood” and “play and exercise,” increased the speed and quality of recovery among severely malnourished orphans. Disruption of attachments, lack of stimulation, and lack of the humanising pattems of talk, play, and leaming all represent serious physical health dangers for young orphans.

2,3.1 General aspects of care Some traditional beliefs protect orphans. The Luyha of western Kenya believe that mistreatment of early childhood angers the spirits of dead parents and brings bad luck. The neighboring Lao, however, believe that orphans. especially boys, are likely to thrive and crowd out other sons; this belief has led many to mistreat orphans or to accept only girls as foster early childhood. Girl orphans not only become household helpers, but are likely to marry and move away and thus “do not pose long term competition for family resources with caregivers’ own early childhood (Ayieko 1998).

The belief that early childhood are the shared responsibility of a whole network of adults is widespread in A frica, and a positive factor for young early childhood Hunter and Williamson note in Early childhood on the Brink that “In Africa, despite their poverty, early childhood benefit from,. .a stronger safety net than in other regions. These include multigenerational families, single mothers living in sub-households, customs for exchanging early childhood among kin, and the sharing of child support and child rearing. Many of these patterns and customs differ in Asia or Latin America” (Hunter and Williamson 1997). The AIDS epidemic and increasing orphan crisis, however, continues to deplete extended fLmilies’ resources. The extended family “is not a social sponge with an infinite capacity to soak up orphans” (Poster et al. 2000).

2.3.2 Coning with grief The symptoms of grief related distress in early childhood under live depend significantly on their experience of death and on how they are being cared for in general, as well as on their personality.

Li Early childhood aged birth—three demonstrate their grief physically through: Crying, regressive behaviour In the areas of language, mobility, and self-help, feartbi and clinging behavior, difficulties eating, toileting, and sleeping, development of comfort habits such as thumb sucking and hair-pulling

Strategies include the need for consistent caregivers who will comfort early childhood physically by holding and rocking them and who will give attention to them through games, stories, music and play opportunities (Ramsden 2001). Early childhood aged three-five may express their grief physically (outbursts, tantrums, aggression) or through withdrawal (nightmares, apathy, anxiety). It is important to provide opportunities for the expression of their grief through play, music, drawing, role playing and the creation of memory books and boxes (Ramsden 2001). Information to caregivers about young early childhood’s grief should include: Acknowledging a death to early childhood, Explaining caregivers/adul~ own net Explaining that parent’s death was due to illness, not child, Talking honestly and briefly about what is and isn’t known about the child’s own future at least once, and then in response to questions

The “egocentrism” ofthis age group means they cannot imagine that everything is not about them, so a special burden is guilt they are often very sure that everything (which may extend specifically to individual bouts of adult crying, or to the departure of the parent) is their fiult. The anxiety is hard to dispel unless you can get a child to talk to you about it but this will be exceedingly hard to do in rural Africa because taboos about talking about death are strong in many places, and early childhood are not likely to confide in strangers. The guilt is hard to dispel in rural Africa because so many adults believe that illness and death ARE caused by the social actions of others and may not be able to bring themselves to completely excuse the child from guilt (Lusk 2001).

It would be very important for anyone attempting grief work with caregivers around young early childhood to learn what the specific beliefs in each area are in terms of what is appropriate to say when talking about death; what do people ordinarily believe early childhood should be told; how much of illness and death tends to be credited to witchcraft or failed social obligations or bad behaviouq and what fbnerals look like in that area and how adults are expected to behave at them.

24 (Lusk 2001).

2.4 Measures to reduce HIV/AIDS infection on early childhood The task of helping countries prepare to engage in this eftbrt is enormous, and WHO is committed

to working with its traditional pailners — ministries of health, international agencies,

nongovernmental organizations and people living with HI V/AIDS — to make the prevention of HIV in infants a reality, especially in the hardest hit developing countries,

Highlighting the importance of prevention WHO is committed to keeping the focus on the best and most humane ways to prevent transmission of HIV to infants and young children that is, keeping young women free from infection. HIV prevention, in general, is a key focus for WHO’s Department of I-li V/AIDS.

•including H1V in family planning programiues Through the efl~rts of its Department of Reproductive Health and Research, WHO will build on its long history of supporting countries to improve the quality and coverage of their family planning and other reproductive health services. It will also Continue to advocate for a shift in emphasis in family planning programmes, with greater attention being given to simultaneously preventing infection and pregnancy (dual protection). In some cases, this will entail greater emphasis being placed on the use of condoms, both male and female, as a primary family planning method.

Strengthening the infrastructure for preventing liv infection in infants Expanding antenatal care services, If preventing H1V infection in infants and young children is to be successful, women must have expanded access to antenatal care and must use the services more frequently and earlier in pregnancy than is currently the case. To address this issue. WHO will support matemal and reproductive health programmes in countries through its Making Pregnancy Safer Initiative,

Increasing access to voluntary counselling and testing. Even if women use antenatal care services, they must have access to voluntary counselling and testing to detect any HIV infection

25 and must be offered specific Interventions to prevent vertical transmission of HIV. Expanding access to voluntary counselling and testing is a major challenge, and WHO is contributing to address it by developing guidelines and tools for the implementation of those services, whether they be free standing or linked to antenatal care and other reproductive health services.

Extending skilled attendance to all births. Another important focus of WHO’s Making Pregnancy Safer Initiative is increasing the number ofpregnant women assisted by a skilled health care worker during childbirth. This is vital to ensuring the appropriate use of antiretroviral drugs for preventing perinatai transmission and to ensuring timely inlentfeeding counselling and support.

Promoting the integration in health systems. To be successflui on the scale that is needed and hoped for, the prevention of HIV infection among infants and young children must become an integral part of the health system of a country, especially in those countries most heavily affected by HIV. The relevant departments in WHO are working together to strengthen health systems, to faciiitate this integration.

Increasing access to lilY care WHO is intensif~ting efforts to increase access to HIV care in resource-limited settings, while

strengthening linkages between prevention and care activities — to maximize the impact of both.

Programmes for the prevention ofHIV in infints and young children are identifying large numbers of women infected with HIV. WHO is developing guidance on key elements of a comprehensive approach to care, treatment and support for these women, their infants and their families.

Providing guidance Keeping abreast of the science. WHO actively reviews developments in the science that underlies the prevention of HIV infection in infants and young children, assessing the strength of evidence and highlighting key gaps in the research base. This is an important service to countries, many ofwhich do not have timely access to complete information on scientific developments and are thus at a disadvantage in developing and improving prevention policies and programmes.

26 Choice and use of antiretroviral drugs. WHO is reviewing the evidence and developing guidance that countries need to enable them to choose among a range of options for the use of antiretroviral drugs for preventing mother-to-child transmission, and for treating HIV/ AIDS-related conditions. WHO has developed guidelines for a public health approach to scaling up antiretroviral therapy in resource-limited settings.

Support for infant feeding programmes. How best to feed an infint when the mother is HIV-infected is a complicated issue. WHO is supporting research that explores ways to make breastfeeding safer, which will facilitate the decisions mothers must make about feeding options. Tools that support counselling of HIV-positive mothers on replacement feeding are also being developed.

Monitoring and evaluation. The cost and complexity of the interventions for preventing mother-to-child transmission make it essential to assure that the effort and expense are justified. WHO is working with its partners to develop the indicators that will assess the performance of programmes in developing countries and will monitor the progress made towards reaching the UNGASS goal. In addition, the long-term safety of antiretroviral drug use (for both mother and child), the possibility of developing resistance to antiretroviral drugs and the continuing efficacy of chosen regimens all require caretbl monitoring and evaluation. WHO is committed to helping its partners implement monitoring and evaluation systems capable of tracking these important issues.

Modelling impact. While most ofthe world’s attention is focused on providing antiretroviral drugs to decrease perinatal transmission, it is possible that the greatest prevention impact may come from investments in preventing HIV infection in young women and in assisting HIV-positive women to prevent unintended pregnancy. WHO is developing models to assess under what conditions investments in prevention of HIV infection in infents and young children will yield the most substantial and cost-effective results.

27 CHAPTER THREE: METHODOLoGy 3.0 Introduction This chapter presents the research design, the study population, sample sIze, sample techniques and procedures, data collection methods and instruments, validity and reliability, data analysis, measurement ofvariables, and ethical considerations.

3.1 Research design The study adopt a case study design. According Amin (2005), studies of this nature may be more productively undertaken because data can be collected from a cross section of a population in a short time from a large number ofcases for purposes ofdrawing valid conclusions to represent the entire population of the study. In addition, a case study is an intensive and detailed study of a certain case and enlightens a general phenomenon or problem ofthe study to deeply understanding and/or explanation of one single specific and complex phenomenon (GoU, 2010). A case can be individuals, groups, movements, a specific event, geographical units (Brante & Korsnes, 2001; (ioU, 2010). In this study, the case is Makindye Municipality, in Nsambya Home care with a focus on the HIV/AIDS and how it can affect early childhood in Uganda.

3.2 Study area This study was carried out in Makindye Municipality, in Nsambya Home care. The researcher chose this area because it was the area with large number of patients attending for Anti retrieval therapy. Secondly, being a resident of this area for the last 33 years, the researcher has fhir geographical knowledge and relevant contacts which was so helptbl in the smooth collection of data as well as helping to minimize the costs of movements.

3.3 Population of the study The study population composed of 200 people, out of which, 120 are patients attending therapy at Home care found in Makindye division, Kampala. Makindye being found in Buganda, there majority ethnic group here are the Baganda, However, being found in KCCA area, which was as well the capital of Uganda, it is therefore a cosmopolitan with people from all walks of life, backgrounds, and nationalities. Makindye Division is one of the major five divisions in Kampala

28 with a total Maldndye division has an annual growth rate of 3.8%. Ofthe total population, women and early childhood account for the largest proportion of the population with 51.3% and 37.9% respectively (KCCA, 2009:63). With an increasing population, the division was characterized by an IncreasIng number of slum households within the various Parishes.

The area of study has clients from other areas such as Nsambya, Kabalagala, Kansanga, Bbunga, Munyonyo and Ggaba. This area is a host of universities, entertainment centers, hospitals, hotels and the American embassy. The place was synonymous with eccentric liIb as led by prostitutes and students as compared to other modest ones alongside whom they live.

3.4 Sample size According to Azizi (2007), sampling size was important because it gave a good result for the purpose of research. The target population of the study was be 120 early childhood from Nsambya Home Care health ficility. Since the target population is so big the study used Sloven’s fbrmula to select the respondents of the study. Prem, (2006), reports that for a higher degree of accuracy, a larger sample needs to be drawn. The researcher carried out the study at Home Care Nsambya as it was the biggest facility delivering services to HI V/AIDS child patients in Makindye Division. The researchers’ target population was 120 respondents,. The selection of the sample was based on the Slovens formula. N

I +n (e)2

Where: N = Target population (120)

n = Sample size. (e)=Desired level of significance (0.05) l+n (0.0025) 120 1+ (0.5)2

120 = 92 respondents 1+ 120 (0.0025)

29 3.5 Sampling techniques In this study, the researcher will use; 3.5.1 Simple Random Sampling The participants in the study was selected through simple random sampling method for respondents among them administrators and directors of Home care Nsambya to have an equal chance of being selected to be part of the study. Simple random sampling was best because it was easy to collect data when the population members are similar to one another on important variable (Gay, 1996). It also ensured a high degree of representatjveness and ease of assembling the sample (Thompson, 2002; Levy& Lemeshow, 2008).

3,5,2 Purposive Sampling Purposi~ sampling was used for selecting the particular groups of people in the population especially early childhood respondents, This sampling procedure was used for its cost efficiency and effectiveness to collect specific information and allows for probing for clarity (Kothari. 2004).

3.6. Data collection techniques The researcher used two data collection techniques to obtain relevant data as follows:

3.6.1 Questionnaire Survey These were designed objective by objective (Mugenda & Mugenda, 1 999) for 92 respondents, The questionnaires were used to collect data because they were practical; allows large amounts of information can be collected from a large number of people in a short period of time and in a relatively cost effective way, can be carried out by the researcher, the results of the questionnaires are usually be quickly and easily quantified by either a researcher or through the use of a software package (Sekaran. 2003). Questionnaires help gather information on knowledge, attitudes, opinions, behaviors, facts. and other information. 3.6.2 Documenta,.3. Review Method This method alloweci a researcher to obtain Information related to the study from Journals, magazi~ governme~~ reports textboob, legal Instruments and perlodicaj reports among others to gain an understanding of Impact ofHIV/AIDS on early childh~j in Uganda.

3.7 Data Analysis and lnterpr tation techniques This was the process of bring understa.iding and meaning to data collec~,j for validity and reliability (Sekaran, 2003). Data collect~j from the field was first of all sorted, edited, coded and entered into in the computer using SPSS. This package was useful to the researcher to present data using tables, graphics and frequency tables and further help the reseascher gener~e descriptive statistics such as means and standard deviations.

Qualitative data was analyzed and presented in form of texts and interviews, impressions, words, photos, symbols were examined and presented using descriptive or narrative method where the researcher presentej detailed literature description of the responde~~’ views for the reader to make their opinions (Bell, 1993). While quanti~i~~ data was present~,J using a Percentage distribution technique (Creswell, 1993). Closed.ended questions were record and then the answers to each question were checked for every questionnai~ for used for calculating the percentage of participan~ who gave each response.

3.9 Data quality control The researcher discussed with supervisors and sought approval on validity and reliability of the instruments. Then an introductory letter was obtained from the College of humanities and social sciences for the researcher to present in the field in Nsambya Hospital so as to create rapport with the respondents. The procedure helped to improve the usefuln~, timeliness, accuracy, comparability and collection ofhigh quality for better analysis and reporting.

The data collecting instruments were in English and interpret~ for those who do not understand English. The items in the instruments were assigned a scale value to each of the responses. This was essential in evaluating the response of the respondents to yield the total score to each esponde~~ and measure the livorableness of the views given The goal of administering the

31 pre-testing sample was to establish the validity and reliability ofthe instrument. The pm-test to be found from the questionnaire will be Interpreted correctly and space provIded will be adequate to ensure its suitability.

3.10 Ethical considerations The researcher will consider two guiding aspects; the ethical aspects and accessibility of information to the respondents. The researcher will design an informed consent form for respondents which they will be given to sign as proof oftheir consent to take part in this study. This will be used alongside an introductory letter from the university which will aim at making the researcher’s work in the field formal. The researcher will also seek formal permission from the respective authorities where the study will be conducted. The researcher will also make it clear to the respondents that the study will purely be an academic endeavor and not a profit making venture hence no monetary or tangible benefits will be expected for taking part..

3.11 Limitation to the study I. Intervening or confounding variables were beyond the researcher control such honesty of the respondent and personal biases. To minimize such conditions, the researcher requested the respondent to be as honest as possible and to be impartial! unbiased when answering the questionnaire. 2. The research environments was classified and controlled since setting where there. Extraneous variables was influence on the data gathered such as comments from other respondent, anxiety, stress, motivation on the part of respondent while on the process of answering the questionnaire. Although these was beyond the researcher control, effort was made to request the respondent to be as subjective as possible in answering the questionnaire. 3. There can be inconsistency in the time when the data obtained from respondent. This was minimized by orienting the data and briefing the research assistants on the data gathering procedures. 4. Instrumental the research tool will not be standardized hence validility and reliability test will be conducted to arrive at a reasonable measuring tool.

32 S. Attrition ; A representative sample might not be reached as computed due to circumstan~ within the respondents and beyond the control of the researcher however beyond the minimum size will be done by the researcher to avoid such a situation. 6. The problem might be of respondent taking long with the questionnaire but however this will be minimized by contently remaindering the respondent about the urgency of the questionnaire

33 CHAPTER FOUR DATA PRESENTATION, ANALYSIS ANI) INTERPRETATION

4.1 Introduction This chapter presents the information on the background information of respondents including; gender, position of the respondent and duration of’ service, The chapter presents findings, summery, discussions, conclusion and recommendations, limitations of the study, contribution of the study and areas recommended for further research all done objective by objective as

4.1 Back Ground information Table 1: Showing Highest Academic Qualification of the respondent.

Category Qualification Frequency f~i~esponse 1 Professional 8 8.7

2 — Masters 9 9.8 3 Bachelors 13 14,1 4 Diploma 28 30.4 5 High school 25 27.2 6 Others 9 9.8 Total 92 100 Source: Primary data 2016

Majority of the respondents were Diploma holders with 30.4% response followed by High School holders with 27.2% and 14.1% were Bachelors holders and the rest were professionals and masters with 8.7% and 9% response 4.1.1 Age of the respondeait Table 2: Showing the Age of the responde~it

Source: Primary data 2016

The flndings revealed that the majority of the respondents were in the age bracket of 36 40 years with 30,4% followed by those in the age bracket of 27,2% and the rest were in the age brackets of below 25 years

4.1.2 Sex of the respondent Table 3: Showing the Sex of the respolidejit

Majority’ of the respondents were female with 65.2% response followed by male who were the minority with 34.8% response respectively 4.L3 Which Departn~e11~ (10 YOU belong? Table 4: Showing Which Departnient the respondents belong

Source: Primary data 2016

The Ondings in the table 4 above revealed that the majority of the respondents were in the special

needs department with 30.4% response followed by those in the child care department with 27.3% response and the rest were in the counselii~g department health department

Table 5: Showing the position respondents hold in the organization

Total Source: Primary Data 2016 The findings in the table 5 above revealed that the majorities were counselors with 54.3% response followed by Doctors with 43.3% response and lastly managers with 2.2% response since these are the people who take care of the home 4.1.5 How long have you worked with Home Care? Table 6: Showing how long respond~,1~5 have worked with Home Care

Total Source: Primary Data 2016 The findings in table 6 above revealed that the majority of the responde,~ts have worked for the

organizatio,~ for a period of 5 — 10 years with 54.3% followed by those who had worked for 1 —4 years with 32.6% response and the rest had worked for less than 1 year and I 0 and above years respectively

4.2 The effect of HI V/AIDS on early chuldhoo~l development in Uganda The responcleiits were requested to identify and establish the effects of HIV/AIDS on early Childhood in Uganda and the responses were as fellows

4.2.1 Has HIV/AIDS greatly affected the developmeat of early childhood in Uganda? Table 7: Showing wliethei~ HIV/AIDS has greatly affected the development of early childhood in Uganda

Total Source: Primary Data 2016 The findings in table 7 above revealed that Majority of the respondejits said that l-llV/AIDS had ~reatly affected the development of early Childhood in Uganda with 65.2% respoI~se while the ninority were not in favour and responded No that HIV/AIDS had greatly affected the eveloprnent of early childhood in Uganda with 34.8% response

37 4.2.2 If Yes what are sonic of the effects ofHfl~/~&~so11 early childhowj? Majority of the respondent., respond~g that; Psychoi~j~~ In one long-term study, as many as 80 percent of early childhoorj who had been orpha,wJ at age of two years and abused, met the diagnostic criteria for at least one psychiatric disorder at age 21. These young adults exhibited many problems, including depression, anxiety, eating disorders, and suicide attempts. In addition to physical and developmental problems, the stress of chronic abuse may result in anxiety and may make victims more vulnerable to problems such as post-traumatic stress disorder, conduct disorder, and learning, attention, and memory difficulties

Other responde~~ said that; Behavioural found out that early childhood who experien~ maltreatment and are deprived ofcare and support at an early age, are at increas~J risk for smoking, alcoholism, and drug abuse as adults, as well as engaging in high-risk sexual behaviours Those with a history of child abuse and neglect are 1.5 times more likely to use illicit drugs, especially marijuana, in middle adulthood. Maltreatment during intkncy or early childhood can cause important regions ofthe brain to form and fiincUon improperly with long-term consequen~ on cognitive, language, and socioemotional development, and mental health

While others said that; Physical Maltreatment during infancy or early childhood can cause important regions of the brain to form and function improperly with long-term conseqt,enc~ on cognitive, language, and socloemotional development:, and mental health. For example, the stress of chronic abuse may cause a “hyperarou~j” response in certain areas of the brain, which may result in hyperactivity and sleep disturbances.Early childhood who experien~ maltreatment are also at increased risk for adverse health effects and certain chronic diseases as adults, including heart disease, cancer, chronic lung disease, liver disease, obesity, high blood pressure, high cholesterol, and high levels of C-reactive protein

38 4,3 The challenges HIV/AIDS poses to early childhood development in Uganda. The respondents were requested to identify and establish the challenges HI V/AIDS posses to early childhood in Uganda and the responses were as Ibilows;

4.3.1 Has HIV/AIDS posse a challenge to early childhood development in Uganda? Table 8: Showing whether HI V/AIDS posses a challenge to early chuldhoo~l development in Uga iid a

Tota I Source: Primary Data 2016 The findings in table 8 above shows that Majority of the respondents responded yes that HI V/AIDs poses a challenge to early childhood development in Uganda with 65.2% followed by the minority who said no with 34.8%. 4.3.2 If Yes What are the major challenges that H1V/AIDS posse to early childhood in Home care? Table 9: Showing the major challenges that HTV/AIDS posse to early childhood in Home care

Category Challenges Frequency 1 They aie infected since they weie boin but often neglected 2 and unidentified until they are seriously ill. They carry the burden ot stigma and discrimination due to 30 their parents’ HIV status.

I hey need medical and nutritional care; however their I 10 parents/caregiver cannot afford to provide for them. 1 heir parents may have passed away or are sick; they have 50 to be taken care by extended Dmily members. Due to stigma and discrimination, they may not have appropriate access to health and education services. They may be stigmatized or rejected by their own family.

Source: primary Data 2016 Majority of the respondents 54.3% said that Their parents may have passed away or are sick; they have to be taken care by extended thmily members was the biggest challenge HI V/AIDS Possess to early childhood in the home care followed by They carry the burden of stigma and discrimination due to their parents’ HIV status with 32.6% response the others said that They need medical and nutritional care; however their parents/caregi\1ei~ cannot aflhrd to provide for them and They are infected since they were horn but often neglected and unidentified until they are seriously ill with 2.2% and 10.9%.

40 4.3.3 Which of the challenges mentioned above Is common in borne care Majority of the respondents said that Sadness, depression and hopelessness was the major challenge that HIV/AIDS posses on early child hood The perceptions of pupils and students from all the study sites was that HIV/AIDS has created a situation where early childhood are suffering sadness, depression and hopelessness. This is being caused by death of parents and friends as well as the many problems and suffering in the wake of HIV/AIDS. They are quite uncomfortthle and lose morale to work hard in school. Boys and girls from secondary schools in urban areas Nsambya school boys from rural schools reported that infected pupils become depressed and demoralized when they realise they are infected as they see they have no future and leave school. Pupils also stated that they felt hopeless when their parents die. Their heart is broken especially given the possibilities ofquitting school. These were views expressed by primary and secondary school girls from Nsambya. Again because of the hopelessness accompanying HIV/AIDS, pupils reported that infected pupils feel like they want to kill themselves especially because people tease them and therefore feel that they have no life. A 15 year old primary school girl from Nsambya stated, ‘HIV/AIDS has made many of us to stop learning in such a way others want to kill themselves before it can cause serious illness’. Another student, an 18 year old secondary school boy from Nsambya Gogonya put it thus, ‘Many students who have HIV/AIDS have committed suicide to escape the real life situation’.

Another respondent also said that; They also feel like committing suicide because they feel unwanted and unloved and also want to do this before people know of their infection. These views were expressed by secondary school boys and girls from Nsambya primary school. Indeed a 15 year old secondary school boy from Nsambya Gogonya also indicated that some parents may want

to kill their infected early childhood . He stated that ‘Many early childhood have been infected by the disease and if the parent saw the student is having a disease they will destroy (kill) the person and will not take care for them’. However, the issue of committing suicide before people knew of their infection was very prominent amongst primary and secondary school girls in Nsambya indicated that they felt hopeless and humiliated about

41 infections. Below is an essay written by an 1 8 year old secondary school girl indicating hopelessness experienced by an infected child.

4.4 Measures to reduce the effects of HIV/AIDS on early childhood in Uganda The respondents were requested to identify and establish the measures established to reduce HI V/AIDS on early childhood in Uganda and the responses were as follows

4.4.1 Are there any measures taken to reduce the effects of HIV/AIDS on early Childhood in Uganda? Table 10: Showing the measures takeii to reduce the effects of HIV/A1DS on early childhood in Uganda

Total Source: primary data 2016 Majority of the reSpondents 65,2% \Vere in favour of the questions that there are measures taken to reduce the et1Cct of HI V/AIDS on early childhood in Uganda while the minority said that they were not in favour of the response that there are measures taken to reduce the effect of HI V/Al DS on early childhood in Uganda with 34.8% response

42 4.4.2 If Yes What are the measures taken to reduce the effects of HIV/AIDS on early childhood in Home care? Table 11: Showing the measures taken to reduce the effects of Fli V/AIDS on early childhood in Home care

Category ~ Frequency Response 1 J Primary prevention of HIV infection 2 2.2 2 ~ 30 32.6 ~ HI V-infected women 3 Prevention of 1-NV transmission from l-IIV-infected 10 10.9 women to their in fants. 4 Provision of care and support to l-IIV-infected women, 50 54.3 their infants and flimily. Total j 92 100

Source: Primary Data 2016 The majority of the respondents said that Provision of care and support to HI V-infected women, their infants and ft~mily was the best measure taken to reduce the effect of I-IIV/AIDS on early childhood in Rome care with 54,3% response followed by Prevention of unintended pregnancies among HI\!-infected women with 32.6% response and the rest of the respondents said that Prevention of 1-11V transmission from l-llV-infected women to their infants and Primary prevention of HIV infection were the best measures taken to reduce the effect of HI V/AIDs on early childhood

4.4.3 Which of the mentioned measures above have been adopted in Flome care Nsambya IVlajority of the respondents said that Provision of care and support to I-lI V-infected women, their infants and family was the major measure adopted by the home care to reduce the risk of l-IIV/AIDS infection in earlychildhood. Programmes for the prevention of I-llV in infants and young early childhood will help identify large numbers of I-IIV-infected women who need special attention. Strengthening the linkages among those programmes and programmes for the

43 care and support services ofHiV infected women, their intbnt and their families will ensure that the women themselves also get access to the services they need. Such services might include the prevention and treatment of opportunistic Infections, the use of antiretroviral drug therapy, psychosocial and nutritional support, and reproductive health care, including tbmily planning. With improvements in the mother’s survival and quality of life, the child too will accrue important benefits. Access to care and support should also enhance community support for programmes to prevent mother-to-child transmission and increase the uptake ofcritical interventions, such as HIV testing.

44 CHAPTER FIVE SUMMERY, DISCUSSIONS, CONCLUSION AND RECOMMADATIONS

5.0 Introduction This chapter discusses the findings from the field reported in chapter four, In addition it composed of the summery of the key findings, discussions of the findings, conclusion and recommenclatioi~s which are presented objective by objective and the limitations to the study and further areas of further,

5.1 Summary Majority of the respondents were Diploma holders with 30.4% response followed by High School holders with 27.2% and 14. 1% were Bachelors holders and the rest were professionals and masters with 8.7% and 9% response

The findings revealed that the majority of the respondents were in the age bracket of 36—40 years with 30.4% Ibllowed by those in the age bracket of 27.2% and the rest were in the age brackets of below 25 years

Majority of the respondents were female with 65.2% response followed by male who were the minority with 34,8% response respectively

The findings revealed that the majority of the respondents were in the special needs department with 30.4% response followed by those in the child care department with 27.3% response and the rest were in the counseling department, health department

The findings revealed that the majorities were counselors with 54.3% response follo\ved by Doctors with 43.3% response and lastly managers with 2.2% response since these are the people who take care of the home

65.2% of the respondents said that I-Il V/AIDS had greatly affected the development of early childhood in Uganda while the minority were not in favour and responded No that HI V/AIDS had

45 greatly affecteci the development ofearly chlldhowj in Uganda wIth 34.8% response

65.2% of the responde~~s responded yes that WV/AIDs poses a challenge to early childhootj development in Uganda followed by the minority who said no with 34.8% Majority ofthe responden~~ 54.3% said that Their parents may have passed away or are sick; they have to be taken care by extended family members was the biggest challenge HIV/AIDS possen to early childhood in the home care followed by They carry the burden ofstigma and discrimination due to their parents’ HIV status with 32.6% response the others said that They need medical and nutritional care; however their parents/caiegjver cannot afford to provide for them and They are infected since they were born but often neglected and unidentified until they are seriously ill with 2.2% and 10.9%.

Majority ofthe responden~ 65.2% were in favour ofthe questions that there are measures taken to reduce the effect of HIV/AIDS on early childhood in Uganda while the minority said that they were not in fhvour ofthe response that there are measu,.~ taken to reduce the effect ofHIV/AIDS on early childhood in Uganda with 34.8% response

5.2 Conclusion

There are obviously large obstacles to the universal provision ofspecific antiretrovi~J treatment to early childhood in the developing world. As for adults, the issue of the cost of the drugs pales in compasiscn with the cost ofthe infrastrn~re development needed for even minimal monitoring of therapeutic side efThctj and drug eftbctiven~ on plasma viremia and immune status. However, therapy is slowly becoming available. In addition, there is a need to improve the general health of early childhood in these areas. One solution is to expand the childhood immunization progra,~ to include the newer vaccines against common bacterial and viral pathogens. This intervention would benefit both HIV-infec~ed and uninfected early childhood.

-lowever, despite the advances that have been made, the following observation remains as true oday as it was when AIDS was first recognized as a disease of early childhood 2 years ago: the est way to manage paediatrjc HIV/AIDS in all areas is to prevent early childhood from quiring HIV by Preventing the infection of their mothers. Efforts that result in the reduction of

46 the prevalence of lIly among corn groups, such as commercial sex workers who have high levels of transmission, will limit the risk of other groups, such as pregna~g women who are not commercial sex workers, and slow the progression of the epidemic in the general populatlo~, In addition, provision of approprIate education and counselling regarding sexually transmftterj diseases to youth betbre their sexual debut may help some reduce their personal risk. However, if this is to be successful, there also needs to be active programs to teach parenting skills and to emphasize to those who care for early childhood that they serve as role models for healthy living choices. AIDS needs to be discussed openly. it is hoped that there will ultimately be an eflèctjve vaccine to prevent either WV infection or the development of AIDS in those intècted, In the meantime, prevention of HIV infection of infants, early childhood and adolescents needs to be a priority, along with care and compassion for those affected.

Why is there such a great diflbrence? Although some early childhood may still acquire the virus from injections received from reusable needles, contaminat~J blood or blood products (despite the implemenwtion of recommendations to prevent this), or from sexual activity, the primary mode of II1V transm~O~ to a child in the developing world is from the infected mother during delivery or from her breast milk. The magnitude of the epidemic among early childhood is therefore directly related to the epidemiology of the infection among adults, in particular, women of childbearing age. In most developing countries, women and men are equally affected, with most ofthe infect~J women being those ofchildbearing age.

IllV-infected early childhood reside in communities where infectious diseases are common and the background death rate is already high. Ihe estimated infant mortality rate among Ill V-infect~J infants is thought to be at least two- to threefold higher than the background rate. Although the prospective studies conducted hne some limitations, early childhood in developing countries seem to have a bimodal pattern of AIDS development with approxinmtely one4bjrd of early childhood becoming ill and dying of AIDS in the first year of life and the remainder having a slower rateofpro~ssi~~ over the next five years

47 5.3 RecOmmendations It is important for researchers and Organiza~ion~ working with early childhood to listen to early childhood’s voices and to Involve them during project design, implementat~~~, and evaluation.

Communities and institutions working with affected early childhood should be sensitized on the

psychosocial impacts and needs ofearly childhood . This will enable care providers and structures for affected early childhood to incorporate appropriate interventions, besides providing basic needs. There is also need to build capacities for addressing these needs. In the school system, it is imperative that all teachers and specifically those involved in guidance and counseling are trained to address some of the psycho social needs of infbcted and affected early childhood.

There is need to address the stigma associated with the disease and to educate communities so that they can accept and assist affected early childhood. Communities also need to be educated on the rights ofall early childhood and in particular on the rights of those affected by HIV/AIDS.

Although the Early childhood’s Act provides for the protection of early childhood from sexual exploitation and abuse, there is need to enforce these laws to protect all early childhood and in particular those living in difficult circumstances. Owing to the reported sexual abuse and exploitation that child laborers and street early childhood are exposed to, it is important that they are educated on the risks of HIV/AIDS infection so that they can protect themselves.

HIV/AIDS interventions should encourage communities to integrate safe procedures in socio-culturai practices that could expose early childhood to HIV/AIDS infection. Communities should be encouraged to conceive alternative rituals and rites of passages.

Recommendations for the educational sector It is important that there should be immediate interventions in schools, in guidance and counseling for infected and affected early childhood, who are experiencing the many psychosocial impacts, of HIV/AIDS in their learning.

Schools and communities should be made sensitive to the provision of special needs for the

48 infected and affected early childhood.

The government should take the initiative of training teachers to specifically teach issues pertaining to HIV/AIDS, and to make available resources for the dissemination of information to all areas. It is recommended that there is an urgent need for HtV/AIDS awareness and education in schools, given that teachers and pupils are getting intbcted and dying.

There is need for follow up on the implementation ofpolicy on HIV/AIDS education Despite the existing HIV/AIDS messages and campaigns, people are getting infected and dying, therefore there is need to re-evaluate and re-target existing HIWAIDS messages and campaigns. There is need to design and disseminate appropriate HIV/AIDS messages targeting early childhood in and out of schools.

Early childhood need education in life skills, drugs and substance abuse and clear information on condoms so that they can protect themselves and educate other. There is need to train core groups of young people who can serve as peer educators and counselors in communities.

5.3 Area for further study The researcher recommends that further study be made on the influence of HIV/AIDS on the development of early childhood and the impact of HIV/AIDS on the educational levels of early childhood

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54 APPENDICES APPENDIX A: RESEARCH QUESTIONNAIRE

Dear respondent; I am a final year student of Kampala International University conducting a purely academic study on the topic “THE IMPACT OF HIM/AIDS ON EARLY CHILDHOOD. A CASE OF HOME CARE OF NSAMBYA HOSPITAL. MAKINDYE MUNICIPALITY”. It’s a partial requirement for the fulfillment of the award of the Degree of Bachelor in Social work and social administration of Kampala International University Responses provided will be treated with utmost confidentiality and used for only academic purposes. I therefore kindly request you to spare some time and truly answer this questionnaire.

SECTION A: BACK GROUND INFORMATION (Please tick as appropriate) I. I-Iighest Academic QualiI~cation of the respondent. High ~

2. Age of the respondent

3. Sex of the respondent (a) Male ______(b) Female

5. Which Department do you belong?

(a) Counseling ______(b) Child care (c) Special needs (ci) Child education (e) Health ~~~1

55 6. ‘What position do you hold in the organization? (a) Manager I (b) Doctor (c) counselor

7. How have you worked with Home Care?

(a) Less than year ______(b) 1-4 years

(c) 5-10 years ______(d) 1 0 years and above

SECTION B: The effect of HIV/AIDS on early childhood development in Uganda

I. Has HIV/AIDS greatly af1~cted the development of early childhood in Uganda? Yes No

2. if Yes what are some of the effects of HIV/AIDS on early childhood?

3. Which of the effect mentioned above are very common here in the Home care

56 SECTION C: The challenges HIV/AIDS poses to early childhood development in Uganda.

1. Has HIV?AIDS posse a challenge to early childhood development in Uganda?

Yes ______No ______

2. If Yes What are the major challenges that HI V/AIDS posse to early childhood in Home care?

3. Which of the challenges mentioned above is common in home care

SECTION D: Measures to reduce the efiècts of HIV/AIDS on earl childhood in Uganda

I. Are there any measures taken to reduce the effects of HI V/AIDS on early childhood in Uganda? Yes~~ No~__

2. If Yes What are the measures taken to reduce the effects of HIV/AIDS on early childhood in l~lome care?

3. Which of the mentioned measures above have been adopted in Home care Nsambya

57 APPENJ)JX B: BUDGET

58 APPENDIX C: THE PROPOSED TIME FRAME JUNE —OCTOBER 2016

59 ~I A l.A ru A A Ggaba Road, Kansanga* P0 BOX 20000 Kampala, Uganda Tel: +256 (0) 382 277 030 * Fax: +256 (0) 41 - 501 974

INTERNATIONAL E-mail: admin®kiu.ac.ug * Website: http://www.kiu.ac.ug ~UNWERSITY~ IJ

Office of the Head of Department

October11, 2016

Dear Sir/Madam.

RE: INTRODUCTION LETTER FOR MS. NAIGA HELLEN REG. NO.BSW41504/133/DU

The above mentioned candidate is a bonafide student of Kampala International University pursuing a Bachelor’s Degree in Social Work and Social Administration.

She is currently conducting a field research for her dissertation entitled, THE IMPACT OF HIV/AIDS ON EARLY CHILDHOOD. ACASE STUDY OF HOME CARE NSAMBYA HOSPITAL, MAKIDYE MUNICIPALITY,

Your organisation has been identified as a valuable source of information pertaining to her research project. The purpose of this letter then is to request you to accept and avail her with the pertinent information she may need.

Any data shared with her will be used for academic purposes only and shall be kept with utmost confidentiality.

Any assistance rendered to her will be highly appreciated.

Yours faithfully,

Assoc. Prof. Imbuki Kennedy HOD-Applied Psychology

the Heights”