Thesis submitted in fulfillment of the requirements for the degree of Doctor of Philosophy in Psychology, School of Human and Community Development University of the Witwatersrand, May 2017 / Psychosocial support and wellbeing of orphans and vulnerable children (OVC) in sub-Saharan Africa receive a lot of attention globally. However, great concerns still persist due to a multiplicity of factors that affect the children’s quality of life. This study examines experiences of psychosocial support and wellbeing of these children in Nairobi, Kenya. While there are few existing studies on the effects of HIV and AIDS on OVC in Kenya, most focus on OVC in primary schools and high schools leaving out infants and preschool aged OVC, as is the case in sub-Saharan Africa. Thus, information that details psychosocial experiences and wellbeing of OVC in preschools in Kenya is lacking. This study focused on OVC aged between 5 and 7 years old within a resilience theoretical perspective; investigated their lived experiences, risk exposure, support structures and other adaptive experiences. A total of 57 participants (45 were children and 12 teachers) from ECDE centres in Nairobi County were purposively sampled for the study. Multiple methods utilised included: visual stimulus illustrations, face-to-face and conversational interviews, thematic drawings, focus group discussions questionnaires and infrastructural and supportive resource assessment. Thematic content analysis (TCA) which was informed by phenomenological hermeneutic approach was used to analyse data. Findings consistently showed that, OVC were not only susceptible to numerous risk experiences due to environmental and care factors at home, but also on their way to and from school, and within ECDE centres. Nonetheless, ECDE centres exposed them to cognitive skills, social networks, safety, alternative care, primary health services, nutrition and resilience nurturance. These findings indicate the crucial role of having a collective action in reduction of adverse experiences and improving resources to empower the OVC in urban ECDE centres. Directions for further research could focus on expanded population-based studies examining poverty, malnutrition, resilience and coping resources among preschool children living with, and affected by HIV and AIDS, using creative multiple qualitative approaches. A more critical understanding on variations in sexes is equally important in intervention strategies for this group of OVC. / MT2018

A thesis submitted to the Faculty of Commerce, Law and Management, University of the Witwatersrand, in fulfillment of the requirements for the degree of Doctor of Philosophy Final Submission June, 2015. / The HIV and AIDS pandemic has increased the numbers of orphans globally. The severity of the problem is greater in developing countries, especially in Sub Saharan Africa. In Malawi, as in many other developing countries, grandparents have stepped in and have embraced the role left by the deceased parents, seeing the orphans through school, providing food, clothing and shelter for them, even where the grandparents themselves have no steady source of income. Despite the heavy burden placed on grandparents as a result of HIV and AIDS, limited attention has been given by governments, scholars and researchers to documenting in detail the challenges faced by the elderly who look after orphaned children. This study examined the challenges faced by elderly people looking after children orphaned by HIV and AIDS in Malawi using the Sustainable Livelihoods Framework (SLF). This framework looks at household needs and holistically categorises them in terms of social, financial, physical, natural health, and government policies. Following a qualitative approach, this study used a phenomenology approach in documenting the challenges facing the elderly in Malawi, with a special focus on the Rumphi and Zomba districts. The livelihood approach is part of rural development theories that has moved away from the conventional approaches towards development to holistic understanding of the relationship between poverty and economic development. The study also provided a case study on the role of social pensions in Lesotho. Social protection, which is part of social development, focuses on local community development with the emphasis not only on economic development, but also on improvement of health, education, environment and standard of living as critical contributors to sustainable development. This is seen as a medium that discourages dependency and promotes the participation of people in their own development. The aim was to profile social protection benefits for the elderly in Lesotho as an example so that insights could be drawn from the experience. The study used structured and semi-structured interviews and focus group discussions as tools to elicit information from grandparents, orphans, community leaders, teachers, local leaders and policy makers. The findings of the study indicate that the level of rural poverty in elderly headed households has increased due to the challenges resulting from the HIV and AIDS pandemic. The Sustainable Livelihoods Approach presented in this paper advocates that sustained development is only successful if it is based on evidence and understanding of household or community needs holistically and systematically. This study has highlighted five key elements required to understand the elderly households through the Sustainable Livelihoods Framework. Firstly, the evidence from this research challenges the SLF in that it does not take into account all key factors necessary to understanding the elderly households’ needs, As a result, this study proposes other necessary enhancements to the SLF, such as the role of cultural practices as part of social capital in supporting elderly livelihoods, especially where patrilineal and matrilineal family systems exist. Secondly, evidence from this study indicates that the notion of social capital that includes dependency on community networks as key in improving the general livelihood of societies has completely diminished due to community fatigue in relation to offering care and support. The study further reveals enhancements in the forms of social capital like belonging to “secret friendships” or being a member of the village banking scheme. However these social networks have limited elderly membership because of community perceptions that elderly members may not contribute much, be it financially or otherwise, hence the elderly are excluded from social networks. Thirdly, as a result of the many challenges faced by the elderly, this research has highlighted an increase in negative coping strategies in elderly households due to limited support from government and other stakeholders. Negative coping strategies in this regard include engaging in activities like casual labour (ganyu), selling alcohol, school dropouts, selling green maize and begging. The more the elderly adopt negative coping strategies, the more vulnerable they become over time. Fourthly, the livelihoods framework has been used in this study to provide a full understanding of situation of the elderly headed households. This approach provides a new dimension to this body of knowledge as it is used for the first time on elderly households. The research presents a foundation that will require future researchers to look at elderly households holistically and systematically within their context using this research as a guideline or as a point of reference. Finally, this research suggests a possible framework that would address the needs of the elderly, with a combination of the livelihoods framework as the analysis tool and the social pensions as the response mechanism for alleviating the burden on elderly headed households. Social pensions will act as a poverty cushion to the elderly members of the society to meet their needs in raising orphaned children. This research conclusively reinforces the role of social protection for supporting the elderly livelihoods. The researcher’s contribution to theory is embedded in the premises of integration of livelihoods frameworks as an analysis tool that provides an holistic picture of understanding elderly household challenges and needs. Social protection through social pensions can be an intervention for supporting the household challenges of the elderly. The combination of these two frameworks results in an holistic and systematic analysis of elderly livelihoods and subsequent support necessary to respond to their challenges. / MT2016

Orientador: Rejane Maria Tommasini Grotto / Banca: Jaime Olbrich Neto / Banca: Paulo Inácio da Costa / Resumo: Apesar dos grandes avanços que conduziram a um declínio da infecção pelo HIV em crianças, a terapêutica antirretroviral vem sendo limitada pela emergência de resistência. Neste contexto, a finalidade deste estudo foi avaliar o perfil de mutações e resistência aos inibidores de transcriptase reversa análogos de nucleosídeos (ITRN) e não análogos de nucleosídeos (ITRNN) protease (IP) das variantes virais circulantes em pacientes pediátricos atendidos no Ambulatório de Imunologia Pediátrica da Faculdade de Medicina de Botucatu, UNESP. Foram avaliados dezenove pacientes, sendo dezesseis com falha terapêutica e, três virgens de tratamento. RNA viral plasmático foi utilizado como fonte para genotipagem das regiões genômicas da transcriptase reversa (TR) e protease (PR) do HIV. Os resultados demonstraram prevalência do subtipo B (78,95%). As mutações de resistência aos ITRNs encontradas em maior frequência foram L214F (73,7%), M184V (42,1%), R211K (42,1%), M41L (31,5%), T215Y (31,5%), L210W (21%), V118I (21%). As mutações K103N e Y188L encontradas em 26,3% e 10,5% dos pacientes foram as mais freqüentes entre as mutações associadas ao uso dos ITRNNs. Quanto aos IPs as mutações mais frequentes foram M36I (63,1%), L63P (52,6%), E35D (47,3%), R41K (31,5%), I13V (31,5%), M46V (26,3%), L90M (26,3%), I93L (26,3%), V77I (26,3%), V82A (21,1%), I54V (21,1%). No que se relaciona ao perfil de resistência, 3TC, AZT, EFV e NVP foram os ITR com menor potencial de uso devido à resistência. Já os IPs apresentam grande potencial de utilização na população estudada, o que se justifica pela alta barreira genética destes medicamentos. Dos três pacientes não tratados, um apresentava resistência a EFV e NVP, sugerindo ocorrência de resistência transmitida. Novos estudos devem ser conduzidos a fim de avaliar o real significado destes achados / Abstract: Although great progresses lead a decline of the HIV infection in children, the antiretroviral therapy has found obstacles as the resistance emergency. In this context the goal of this study was evaluate to the profile of mutations and genotypic resistance to the Nucleoside Reverse Transcriptase Inhibitors (NRTI), Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI) and Protease Inhibitors (PI) in children assisted in the Pediatric Immunology Ambulatory, Botucatu School of Medicine. Patients (19) were evaluated (16 with therapeutic failure and 3 naïve). Viral RNA was used as source to RT and PR genomic regions genotyping. Subtype B was the most frequent (78.95%) in thi study. The NRTI resistance mutations found were L214F (73.7%), M184V (42.1%), R211K (42.1%), M41L (31.5%), T215Y (31.5%), L210W (21%), V118I (21%). K103N and Y188L were found in 26.3% e 10.5% and we are associated with NNRTI use. About the PI the mutations most frequent were M36I (63.1%), L63P (52.6%), E35D (47.3%), R41K (31.5%), I13V (31.5%), M46V (26.3%), L90M (26.3%), I93L (26.3%), V77I (26.3%), V82A (21.1%), I54V (21.1%). The ARVs resistance analysis showed that 3TC, AZT, EFV and NVP have the lower potential for use due to resistance. PI presented great potential for use due to high genetic barrier. From three naïve patients one presented resistant viral variants to EFV and NVP, suggesting transmitted resistance. New studies should be performed to evaluate these findings / Mestre

Thesis (M.A. (Psychology)) --University of Limpopo, 2013 / HIV/AIDS is devastating and fatal to working adults in the prime of their lives, thus leaving the responsibility of caring for the orphans to their grandparents. This study explored the experiences of grandparents assuming the role of parenting their AIDSorphaned grandchildren in Lephalale, South Africa. Phenomenological face-face interviews were conducted with ten elderly, black African grandmothers between the ages of 55 and 71. The participating women were self-identified as carers for their AIDS-orphaned grandchildren. The challenges the participant grandmothers faced in caring for their grandchildren were identified as the following: recurrent experiences of loss and grief, lack of social support, fear of stigmatization, financial constraints, mental health and physical strain, difficulty in acquiring state social grants, emotional distress, the caring role being divinely ordained and the rejection of orphans by their biological fathers. Recommendations are advanced on the basis of the findings.

The present study aims to explore the experiences of caregivers working with children living with HIV/AIDS in the context of a children's home. While there has been research conducted on family members as well as community based caregivers of people living with HIV/AIDS, there has been a paucity of research on caregivers of children living with HIV/AIDS in Children's homes. There is a strong need to address this area of deficit in order to identify and tackle areas of difficulty as well as rewarding aspects to enhance the caregiving experience This pilot study adopted the interpretive research paradigm, is qualitative in nature and utilized in depth interviews as a means of data collection. Four women working as caregivers at the children's home were interviewed and the data obtained was analysed using thematic content analysis. The present study highlights the positive as well as the negative aspects of caregiving from the perspective of the caregivers. While caregivers identify the difficulties that they face as a result of caregiving, they also acknowledge the rewards that they attain from their line of work. Furthermore the present study emphasises the coping strategies employed by the caregivers on a personal and an organisational level as well as the resources that aid coping and the constraints against utilising the coping resources. In addition issues of attachment and detachment associated with caring for children, that are particularly pertinent to these non -familial caregivers have been explored. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2005.

Background: in 1987, the first child with HIV-1 infection was identified in the paediatric wards at King Edward VIII Hospital in Durban. This made paediatricians aware that the epidemic had spread to the children of KwaZulu/Natal. Although information on transmission and natural history was becoming available from developed countries, little was known about the disease in developing countries. It was important to determine transmission rates and disease patterns in the local population, in order to appropriately counsel women, and for management of infected infants. In addition, with resources for laboratory diagnoses being limited in developing countries, much emphasis had to be placed on clinical findings for identification of infected children. In 1989, a retrospective analysis was made of the HIV-infected children seen over a 2-year period, between 1987 and 1989. Nine such children were identified and their clinical and biochemical features were described. It was concluded that HIV infected children presented with an identifiable pattern of signs, fairly similar to that described for children in industrialised countries. With these findings, a prospective study was undertaken, to determine the vertical transmission rate, the factors affecting this rate, and natural history of vertically transmitted I-IIV-1 infection. ix KwaZulu/Natal, being at the epicentre of the epidemic in South Africa, was a natural site for the study. Patients and Methods: a trained research worker was placed in the antenatal clinic at King Edward VIII Hospital for the specific purpose of educating, counselling, and testing of all women attending the clinic. Women attending the clinic for the first time in the index pregnancy were offered HIV testing if informed consent was obtained. Blood for HIV serology was drawn at the same time as sampling for the obligatory syphilis serology. The acceptance rate for sampling was > 95%. The majority of the women attending the clinic were black, and first attendance was generally late, into the third trimester. The same research worker was responsible for post-test counselling which was offered to all the women, not only those who tested positive. This research worker was also responsible for obtaining maternal consent for entering the newborn infant into the study. All newborn infants were seen within 48 hours of birth. At this time they were examined, growth parameters were recorded, and initial blood samples taken. These infants were then followed-up at 1 month, 2 months, 3 months, then at 3-month intervals up to 18 months, then at 6-month intervals. At each visit, a thorough clinical examination was performed, growth measurements taken, and development assessed. Record was made of any interim illness and visits to health centres, and of hospital admissions. Method of feeding was note& and details on immunisation obtained from the child's immunisation card. The children received all the x routine childhood immunisations according to the national regimen, based on WHO recommendations. Mothers were asked to bring the child to the follow up clinic for any problem, so that episodes of illness would not be missed. The women were reimbursed for transport costs to encourage follow up visits. Calculation of transmission rate and classification of infection status were made according to the recommendations of the Ghent workshop. Children were regarded as infected if they were antibody positive at 18 months or had an HIV related death. They were classified as uninfectd if the antibody test was negative at 9 months of age. Those infants who were lost to follow up before the age of nine months whilst still antibody positive and those whose cause of death could not be determined, were classified as indeterminate. The diagnosis of AIDS was based on the WHO criteria. Blood samples were taken at birth, at age one and three months, then at three month intervals to 18 months; thereafter at six month intervals. Sera were tested for HIV1 antibodies by a commercial enzyme-linked immunosorbent assay,ELISA. Samples that tested positive were confirmed by two tests, a Roche Elisa and by an immunoflourescent assay (IFA). A sample was regarded as being positive if both the second ELISA as well as the IFA or the Western Blot tested positive. xi Results: between October 1990 and March 1993, 234 infants and their 229 mothers were entered into the study. Those who did not attend a single follow up after birth were excluded from the study. The final cohort comprised 181 infants, of whom 48 were classified as infected ( including 17 deaths); 93 not infected, and 40 as indeterminate ( including 8 deaths). Maternal Data: about 60% of the mothers were under 30 years of age and were multiparous; 18% tested positive for syphilis serology; 22.9% were anaemic during pregnancy, and 37% were delivered by caesarean section. Most women lived in urban areas, and 16% chose to bottle-feed exclusively. Vertical Transmission Rate and Factors affecting this Rate: the median vertical transmission rate was 34%, (95% confidence intervals, CI 26%-42%). This figure is similar to that found in most parts of Africa, but much higher than those for Europe and USA. The maternal factors found to be associated with an increased risk of transmission were vaginal deliveries and a low haemoglobin level during pregnancy. Breastfeeding, Transmission, and Outcome: breastfeeding was found to have an increased risk of transmission, by 15 % (CI 1.8-31.8). On assessing growth and morbidity, it was noted that breastfed infants were not protected against such common childhood infections as pneumonia and diarrhoea, and that failure to thrive occurred with equal frequency in both those breastfed as well as those receiving artificial feeds. Newborn Data: when comparing newborn data between those infants who were subsequently found to be infected with those who were uninfected, it was found that there were no major differences between these groups with regard to growth parameters and neonatal complications. However, those infants with rapidly progressive disease (those who died within 24 months), were noted to have lower mean birth weights and lengths, a higher frequency of low birth weights, and tended to have more neonatal problems. Clinical Manifestations: the first differences between the infected and the uninfected infants generally manifested from about 3 months of age. HIV infected children were identifiable by higher frequencies of thrush, lymphadenopathy, skin rash, and hepatosplenomegaly in the early stages, and later on with a higher tendency to neurological and developmental abnormalities, as well as of diarrhoea. Pneumonia was found with equal frequencies in both the infected and uninfected children. The HIV infected child could be distinguished fairly early in life by the combination of the manifestations described above. Progression to AIDS: AIDS was diagnosed in 44% of all the infected children during the study period. Ninety five percent of these children were identified by 12 months of life, showing a rapid progression of the disease Longitudinal Growth: when longitudinal growth parameters were analysed in this cohort, it was found that HIV infected children were stunted from as early as 3 months of age, and remained below the international standards into early childhood. Infected children were also found to be malnourished (i.e. weight for age below international means), from an early age, and this persisted throughout early childhood. Of note, the uninfected childrens' weights, although comparable to international means initially, dropped after the first year of life. However, both groups did not have significant wasting, when compared to international means. Mortality: there were 25 known deaths during the study period. Of these, 17 were classified as HIV-related, and 8 as indeterminate. The mean age at death was 10.1 months, with 83% of all the HIV-related deaths occurring within the first year of life. The commonest diagnoses at the ti me of death were diarrhoea, pneumonia, and failure to thrive; also, thrush was common, as were neurological abnormalities. / Thesis (MD)-University of Natal, Durban, 1999.

In the next few years South Africa with be faced with immense socio-economic problems created by the HIV/AIDS epidemic, not least of which will be the impact on children and their families. Evidence from other African countries shows that the presence oflarge numbers of AIDS orphans has major implications for the societies in which they live. Reports from these countries suggest that, even in the midst of high rates of HIV/AIDS, the African extended family system is remarkably persistent. However there is also evidence"that HIV/AIDS affected children face an increased risk of poor health care, of dropping out of school, of abuse and exploitation. The majority of communities affected by HIV/AIDS in South Africa are already poor, yet HIV/AIDS will place a huge strain on available resources. As the epidemic develops, an increasing number of children are likely to fall through the extended family safetynet and pressure will rise on welfare organisations to provide alternative forms of care. The welfare sector must therefore urgently find innovative ways both to support traditional forms of child care, and to develop new models of care. Welfare organisations are being faced with the challenges presented by HIV/AIDS at a time when national welfare policy is in a process of change. The White Paper for Social Welfare (Department ofWelfare, 1997), promotes a major shift of approach to welfare provision. The new approach is based on the principle wof'developmental social elfare'. This is a broad concept incorporating ideas such as 'building human capacity', 'promoting self-reliance', creating 'appropriate' services through 'community development' and the promotion ofincome generating activities. Organisations are encouraged to move away from a concentration on rehabilitative services and institutional care and to develop a preventative approach which relies more on community-based services and 'community' care. This important shift in welfare policy is being introduced within the constraints of the government's macro-economic strategy GEAR (Growth Employment and Redistribution). GEAR aims to create jobs and to link growth to redistribution. This is to be achieved through a tight monetary policy in which reduction of the budget deficit and 'fiscal restraint' are major emphases. Spending on welfare, along with the rest ofthe public sector is thus constrained within tight budgets. This thesis looks at a changing welfare policy in relation to the development of strategies to support children affected by HIV/AIDs. It explores themes contained in the 'developmental social welfare' paradigm and considers the impact ofthe HIV/AIDS epidemic through an examination of the literature and through empirical research. It focuses on the implementation of macro policy change at an organisational level. The following broad questions formed the basis for this research. 1. Given the growing HIV/AIDS epidemic in KwaZulu-Natal, what is being done by welfare organisations, and by whom, to provide care and support for children affected by HIV/AIDS? 2. Are welfare organisations in KwaZulu-Natal devising 'developmental social welfare' approaches to respond to the challenge of HIV/AIDS? If so, how is this approach being developed to assist children affected by the epidemic? What issues are being encountered? 3. In view of the fact that the AIDS epidemic in South Africa is several years behind other sub-Saharan African countries, are there any lessons that can be learned from other African countries about alternative models of care for affected children which have been developed? The research uses a case study approach within a qualitative research methodology. Research methods used were participant observation, interviews, questionnaires and collection of documentary sources. Three case studies are presented which look at different models of care and support for children affected by HIV/AIDS in the Pietermaritzburg district ofKwaZulu-Natal. Each ofthe case studies focuses on themes contained in the 'developmental social welfare' approach. The first case study looks at a community-based project for the support of HIV/AIDS affected children. It focuses on concepts such as community development and community action and at ideas of 'building human capacity' and 'self reliance'. The second case study considers the theme of,appropriateness' through the development an 'appropriate' adoption service for African children. The third case study, considers the issue of maximising resources through a study of a 'cluster' foster care scheme for HIV positive children. This study paints a picture both of potential disaster and of some possible ways forward. It highlights the achievements of the case study organisations. These include the promotion of awareness about the needs of vulnerable children through a community-based approach, as well as the development of new models of adoption for abandoned children and fostering for mv positive children. However, it also highlights the difficulties which faced these organisations, in particular budgetary constraints and the context of poverty within which they were operating. Tensions were found between the slow progress of community development' and the immediate needs of poor children and their carers in a rapidly progressing HIV/AIDS epidemic. The study points to the important role played by state social grants and the need to protect these . benefits. The study provides examples of the gendered nature of 'developmental social welfare' policies, specifically with regard to notions of 'self reliance' and community care. It proposes the need for a better analysis of the concepts contained within the 'developmental social welfare approach'. The need for a closer collaboration between the state and the non governmental sector is seen as critical to the development of a 'holistic' approach to the support of HIV/AIDS affected children. / Thesis (M.Dev. Studies)-University of Natal, Durban, 1998.

This study explores the ways in which Grade Two boys and girls (aged 7-9) in a predominantly Black school construct their knowledge of HIV and AIDS. The study also seeks to explore how young children, in giving meaning to HIV and AIDS, position themselves as gendered beings in the context of HIV and AIDS. By focussing on the construction of young children’s identities in response to AIDS, this study demonstrates how children, in responding to AIDS, do gender and sexuality. There is very little work around gender and young children, let alone gender, HIV and AIDS, and sexuality. This is because of the ways in which children are perceived to be nonsexual, degendered and without the capacity to think beyond a certain stage of development (See Bhana, 2006; 2007a; 2007b; 2008; Silin, 1995; MacNaughton, 2000 as exceptions). By drawing upon qualitative and feminist methodological approaches, this study positions young children as having their own identities, as active participants who are capable of making meaning. This study shows that AIDS is embedded within social, economic, cultural, political and ideological contexts and that the ways in which these children give meanings to HIV and AIDS are embedded within these contexts. In responding to AIDS, the children in this study inform us of their relationship to AIDS within social processes including sexuality, gender, race and class, and they show us how these are actively acted upon. This study also shows the children positioning themselves as gendered beings with the capacity to think, feel and enact their sexuality. In doing so, they dispel many notions which position young children as unknowing, asexual beings. / Thesis (M.Ed.) - University of KwaZulu-Natal, Durban, 2008.

This study examines the use of participatory methodology with primary school children in mapping HIV/AIDS as a barrier to learning in KwaZulu-Natal. The study draws on a larger National Research Funded (NRF) Project1 undertaken in the Richmond area of KwaZulu-Natal. Data was produced through semi-structured interviews of six researchers involved in the NRF project; through document analysis of the data sets involving the learners and facilitators, the NRF project report and the related journal articles based on the project; and through field observation conducted by me. The findings of the study suggest that in research on HIV/AIDS it is essential to seek participatory ways of enabling children’s voices on the pandemic as it unfolds in their context. High researcher reflexivity is necessary in order to become sensitive and responsive to the challenges of including children’s voices in vulnerable circumstances. Findings also suggest the importance of viewing ethics as situated practice. The study ends with implications for research methodology courses, researcher training and evidence from children for policy on HIV/AIDS. / Thesis (M.Ed.)-University of KwaZulu-Natal, 2008.

Thesis (Ph.D.)--University of California, San Francisco, 2004. / Includes bibliographical references. Also available online.