Association of care environment with HIV incidence and death among Orphaned, Separated, and Street-Connected children and adolescents in Western Kenya

Abstract

In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced Question What is the association of care environment with incident HIV and death among orphaned, separated, and street-connected children and adolescents in western Kenya? a proliferation of institutional care. Few studies have investigated the association between care Findings In this cohort study of 2551 environment and physical health among orphaned and separated youths in sub-Saharan Africa. orphaned, separated, and street-connected youths in western Kenya, OBJECTIVE To examine the association of care environment with incident HIV and death among living in an institutional environment orphaned and separated children and adolescents who were living in charitable children’s was not associated with either death or institutions, family-based settings, and street settings in western Kenya over almost 10 years. incident HIV compared with living in a family-based setting. However, living in DESIGN, SETTING, AND PARTICIPANTS The Orphaned and Separated Children’s Assessments a street setting was associated with a Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort higher rate of incident HIV and death study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and compared with living in a family-street-connected children from communities within 8 administrative locations, which included 300 based setting. randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children’s institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019. Meaning This study’s findings suggest that alternatives for orphaned, separated, and street-connected youths in low-income regions are needed when designing public policies for the care of EXPOSURES Care environment (family-based, institutional, or street setting). vulnerable children, includingdeinstitutionalization, to ensure that the MAIN OUTCOMES AND MEASURES Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death. RESULTS Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during rights and well-being of children and adolescents are upheld. + Invited Commentary + Supplemental content

listed at the end of this article. the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children’s institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55).