HIV and AIDS: Orphans and Sexual Vulnerability

Reference: Foster, G. (1998). HIV and AIDS: Orphans and Sexual Vulnerability. Sexually Exploited Children; Working to Protect and Heal. P. K. M. McDermid. Monrovia, CA, MARC: 216-232.
 

Where would you be were it not for your parents? Would you be a different person if you had grown up without your father or mother? In the West it is rare for children to be orphaned. But in many developing countries orphans (defined as children whose father or mother has died) are many. And the number of orphans, especially double orphans (children who have lost both father and mother), is increasing dramatically due to HIV / AIDS. Try putting yourself in an orphan's shoes.
 

You are young. Your father becomes ill. At first his illnesses are not serious; but as time passes by, he gradually becomes weaker. He learns he has AIDS. It is necessary for him to take time off from work; he loses his job. Next he begins to lose weight drastically, becoming dependent, bed-bound and requiring round-the-clock care from your mother. After he dies your life changes dramatically as your family becomes poor. A few years later the same fate befalls your mother. This time you are the one called upon to provide care during her frequent illnesses. At the same time you must look after your younger brothers and sisters. After your mother dies, you drop out of school and try to find work to bring some income into your family. Fearful, vulnerable and open to exploitation, you and your little family try as best you can to cope with your plight.

Most of us have little notion of what it is like for children who have the responsibilities of parenthood thrust upon them. But as a result of the AIDS epidemic, thousands of children are heading families of younger brothers and sisters. Millions more orphaned children are cared for by grandparents. Children are growing up in a world very different from the one in which their parents were raised; they are children living in a world with AIDS. Children bear the brunt of many disasters. The AIDS disaster is no exception.

Let me tell you the story about a girl I'll call Maria. After her mother died from AIDS, Maria (then 16 years old) was left looking after three young brothers and sisters. Her father worked as a gardener in town and visited the family on weekends. But soon he remarried and the visits dropped away. Maria stopped going to school so that she could care for her little family. They were very poor and lived in a mud-and-thatch hut, which was falling apart. At night the boys slept under one blanket while the girls shared the other blanket. In turn, each of the children dropped out of school because they could not find two dollars a year for school fees.

Crises often occurred in the family - hunger, illness, difficulties with the house or problems with the crops in the fields. One day there was an emergency. Tendai, age 8, was sick with malaria. Maria took him to the local clinic where the nurse gave him chloroquine. But Tendai got worse. That evening the children were desperate. Tendai was delirious and looked as if he might die. Maria realized that she must somehow get Tendai to the hospital. She went to a neighbor, the local storekeeper, and begged him to take them in his truck. He said the fare would be five dollars in advance, but he made it clear that if she could not find the money, they could come to some "special" arrangement instead. Maria went home to nurse Tendai, but he was now unconscious.

So Maria made a difficult decision, one that many young girls around the world feel increasingly compelled to make. She decided to trade her body. She went back to her neighbor and agreed to his proposition. He transported Tendai to the hospital. On the way back, he had sex with Maria in the back of the truck. Fortunately, Tendai arrived at the hospital in the nick of time. His cerebral malaria improved, and he was discharged a few days later.

THE IMPACT OF AIDS ON CHILDREN
"It pays to take proper care of your children. When you are old, they will take care of you," goes one Zimbabwean proverb. But in countries with severe HIV epidemics, most young adults living now will not enter old age.
 

According to estimates published by the U.S. Bureau of the Census the HIV epidemic is unfolding in its severest form in countries in east and southern Africa.¹ By 1996, life expectancy had fallen in Zambia from 57 to 36 years, in Zimbabwe from 64 to 42 years, in Uganda from 53 to 40 years and in Kenya from 65 to 56 years. Further falls are anticipated to as low as 29 in Malawi, 30 in Zambia and 33 in Zimbabwe and Botswana as a result of AIDS. One consequence of the fact that most people will die before reaching middle age is a large increase in the number of orphaned children.
 

Projections of the orphan epidemic for Zimbabwe suggest that by 2005, fewer than 20 percent of Zimbabwean women may be expected to live throughout their childbearing years; only one-third of girls aged 15 are estimated to survive to their thirty-fifth birthday; and one-third of children under 15 may have been maternally orphaned.²

Orphanhood has profound implications for child survivors. The traditional method of coping with orphans was the extended family, especially aunts and uncles. But as a result of rapid increases in the number of orphans because of AIDS, the elderly and the young are being recruited for childcare. We interviewed 300 orphan households in Zimbabwe in 1995 and found that nearly one-half of the caregivers were grandmothers.³ Many of the grandparents were elderly (average age 62), and some were sick and infirm. Some orphan households were headed by older sisters or brothers who took over childcare following the death of an elderly grandmother. As the number of orphans increases and the number of young adults in the population falls, we can expect to see more and more grandparent- and child-headed households.

In 1997 we interviewed 43 child-headed households; in almost all the households, the mother or both parents had died; the youngest head of household was an 11 year-old girl.⁴ Older brothers were also heading households and providing childcare. In many cases relatives provided support by regular visits and small amounts of material assistance. Once child-headed households start to occur in countries with severe AIDS epidemics, their numbers will increase and younger children will be recruited into childcare. This is likely to be particularly pronounced in southern Africa, where the epidemic is having its greatest impact and where traditional extended family coping mechanisms are weakened.

Children living in orphan households are at risk in many ways. Most of the problems facing children affected by AIDS can be summarized under the headings of poverty and parenting.

Poverty
AIDS has been described as a poverty-seeking missile. HIV infection not only thrives in impoverished environments -the disease is itself also a potent cause of poverty. Households in which family members have been affected have higher expenditures due to costs of seeking medical care and reduced incomes associated with loss of affected breadwinners' earnings; when the breadwinner dies, the family's resources are further depleted as a result of funeral expenses and property removal by relatives of the deceased. Consequently, the AIDS epidemic is leading to in- creasing poverty among survivors indirectly affected by HIV infection.

We measured the level of poverty of child-headed orphan house-holds in Zimbabwe by comparing them with their neighbors. Orphan households were likely to be poorer, with fewer possessions, blankets, cows, goats and chickens; the number of rooms per household resident was smaller and the monthly income was less for orphan households compared to their neighbors. As might be expected, orphan households had experienced more deaths in the preceding five years, more moves in the preceding two years and more previous caregivers than children in control households.⁵

Figure 1: Comparisons between rural child- or adolescent-headed and control households.

We spoke to groups of orphaned children about their experiences. Here are some of their comments:⁶

"When father was alive, we used to go to school without any problem of school fees; my uncle helped with school fees and now my brother helps." (Girl, 13)

"My father used to buy school uniforms; nowadays it is difficult." (Boy, 13)

"Now that I stay with grandparents, I no longer have new clothes." (Boy, 9)

"We are segregated because we don't have shoes." (Girl, 12)

PARENTING
Orphaned children face many problems because their parents have died. Some children spoke about difficulties they had experienced:

a. Extended family support to orphan households:

"We moved from our original home and built on another spot after my aunts and grandmother refused to take care of us." (Brother-caregiver)

"My uncle used to come when he wanted mother to be his wife but when mother refused, he stopped coming." (Girl, 15)

"Auntie only came when she wanted to take the property." (Girl, 14)

"Mother is in a sewing cooperative so I am left at home looking after the young children." (Girl, 14)

b. Differences from other children:

"We steal and sell to earn a living, which is different from them [non-orphans]." (Girl, 15)

"We want to go to school but I must help uncle in the fields. He said, 'You are not my child so I cannot send you to school.'" (Girl, 16)

"When my ballpoint finishes, I sometimes absent myself from school and sell manure to get money to buy a pen. I am not pleased being absent from school." (Boy, 13)

"Father remarried another woman who mistreats me." (Boy, 11)

"A certain girl assaulted me, saying she did not want to play with those who don't have fathers." (Girl, 13, who then started crying)

"My friends changed after the death of my mother." (Two 10-year-old boys)

c. Psychological problems:

Children suffer anxiety and fear during the years of parental illness, then grief and trauma following the death of a parent. Stigmatization, dropping out of school, changed friends, increased work load, discrimination and social isolation all increase stress for orphans; this makes coping with their situation more difficult and painful. Difficult relationships with new caretakers also contribute to stress; two children said they were "being given a hard time" by a grandparent and a stepmother.

As a result, children may become depressed, reducing their ability to cope with growing pressures. During one focus group discussion the facilitator asked about changes experienced following parental death. One boy stated his stepmother mistreated him, whereon a 12-year-old boy started crying and continued sobbing throughout the rest of the discussion. Psychological problems are often less obvious than material ones and may remain unnoticed by the children themselves. However, they were a major concern to relatives, neighbors and community workers.

"My mother is suffering, unlike when father was alive; she cannot carry the burden alone." (Girl, 12)

"[Because of the situation,] I almost thought of committing suicide." (Brother-caretaker)

AIDS, ORPHANS AND SEXUAL EXPLOITATION
Sexual exploitation during childhood and adolescence is not a new phenomenon. Children who are sexually abused are at high risk of being HIV-infected as a result. But the AIDS epidemic increases the vulnerability of children to sexual exploitation in many different ways:

Children who are orphaned are more vulnerable to HIV infection
By 1996 some nine million children were estimated to have lost their mother due to AIDS.⁷ In Zambia the number of children orphaned by AIDS is expected to increase from 80,000 in 1991 to 600,000 in 2000; currently, more than 70,000 children are living on the streets, and 37 percent of families are caring for at least one child orphaned by AIDS.⁸ Wherever they are living, orphaned children, especially girl children and those whose mothers have died, are vulnerable to sexual exploitation. Children living with relatives are at risk of continuous sexual molestation or incest. They may even be put to work in prostitution in return for room and board.

"This lady likes mistreating me because my mother is dead," said one Ugandan girl "She wants me to sleep with men because I stay at their house. She brings these men into her house and introduces them to me. She often tells me to be good to them and this is the only way I can continue to live in her house."⁹

Children living alone are at risk of rape and sexual exploitation. Children living in orphanages, institutions, remand homes and foster homes are at risk from staff, caregivers and other residents and inmates. These homes, which are supposed to be places of safety for children, are often places of abuse - both heterosexual and homosexual abuse. And increasing numbers of orphaned children, escaping poverty and abuse in their homes, are now living on the streets, where early sexual activity is the norm. Whether forced or as a form of income generation, sex can be relied on to bolster children's emotional insecurity.

Men seek childhood sex partners to reduce their risk
The average age at which people are becoming infected with HIV is falling in countries with severe epidemics; most females are infected before they reach the age of 21. Girls believed to be HIV-negative are being singled out by older men for sexual favors in many countries with severe HIV epidemics. In Zambia the trend is increasing the severity of the HIV-infection rate among Zambian girls aged 15 to 19.¹⁰ The "sugar daddy syndrome," as it is referred to, is blamed for the rise in infection rate among these girls, reportedly six times higher than that of boys the same age. Zambian schools generally do not inform children about sexual issues and approximately 50,000 children in Zambia are HIV-positive, with perinatal transmission accounting for 75 percent of the cases.

AIDS leads to poverty and prostitution
Poverty is associated with increased vulnerability to HIV infection. In countries like Zimbabwe, a large proportion of the next generation of young adults - this generation's children - will be at increased risk of HIV infection as a result of orphanhood and poverty. Orphaned children who are poor are especially vulnerable to sexual exploitation. In some orphan families prostitution is the main source of income. Orphaned girls may become involved in commercial sex to provide basic requirements for themselves or children in their care. And unlike this generation, they will have no mothers available to care for them when they are dying of AIDS. There will be no grandmothers around who can act as caregivers to their orphaned children. Instead of seeing reductions in HIV transmission, the AIDS epidemic may be perpetuated by a vicious cycle of orphanhood, poverty and increased vulnerability.

WHAT CAN CHRISTIANS DO TO HELP?
This chapter has drawn attention to the rapidly increasing numbers of children orphaned as a result of AIDS, children who are at risk of sexual abuse and contracting HIV themselves. What are Christians and local churches doing to protect these children? This final section provides a biblical basis for helping and draws on practical examples of Christian community care in Zimbabwe.

Orphans and the Bible
It is evident from the Bible that the Lord has a special regard for widows and orphans. Over 40 verses in the Bible talk about the ways in which believers are to help widows and orphans:

[A complaint arose] because their widows were being overlooked in the daily distribution of food (Acts 6:1).

Honor widows who are really widows. . . . Let a widow be put on the list if she is not less than sixty years old. . . . If any believing woman has relatives who are really widows, let her assist them; let the church not be burdened, so that it can assist those who are real widows (1 Tim. 5:3, 9, 16, NRSV).

Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress (James 1:27, NRSV).

These verses and other passages elsewhere tell us a great deal about the early church's ministry to support widows and orphans.

The early church established an organization within its body to oversee the work among widows and orphans
When the church in Jerusalem was small, it was easy to make sure that widows and orphans were not overlooked. As the number of disciples grew, some of the poor in the church drew attention to the fact that they were being neglected. The matter was resolved when the church leaders appointed seven men to become responsible for the daily distribution of food and other support to needy families. This allowed the leaders of the church to give time to their own area of gifting of prayer and Bible teaching.

It should be noted that this social ministry of the church was not inferior to the spiritual ministry. Visiting widows and orphans was to become one of the church's main areas of ministry. According to Acts 6 this ministry was not something left to a small group of well-meaning "do-gooders." The main requirement for the leaders of this program was being full of the Holy Spirit and wisdom. Among the seven people chosen were Stephen, the first Christian martyr, and Philip the Evangelist.

These leaders had the responsibility of "serving tables," literally overseeing the daily distribution of food to widows in the church. The requirements for these deacons (literally "servers") are listed in 1 Timothy 3:8-13.

Like elders, deacons were required to be men worthy of respect who did not abuse alcohol. But there were other attributes that were required of prospective deacons. They had to be good managers, not only of their own families but also of domestic affairs. Administrative abilities were necessary for deacons to provide efficient service. They had to have no predisposition toward dishonesty - this would counteract any temptation to skim off the church's material aid for their own ends. And their wife had to be able to keep confidences - gossiping about the goings-on in the lives of beneficiaries could destroy the effectiveness of the program.

Deacons were chosen by the voice of the people (Acts 6:3). Only after the men had been proved by a searching inquiry to see whether they were blameless would they be appointed to the ministry of serving as deacons. Success in a deacon's ministry would lead to their strengthening their faith and increasing their spiritual effectiveness.

By the time Paul wrote his letter to Timothy, another group of people had become active in the ministry of supporting widows in the church. These were older widows who were responsible for carrying out ministry to orphans and other widows. In 1 Timothy 5:9 we read about a list of widows. Widows on this list had to be older women who had been faithful to their husband and had a past record of good works. A woman who had a record of hospitality, helping people in trouble and bringing up children would be well-qualified to provide support to other widows in need.

Younger widows were not to be put on the list of widow-deaconesses. Entering this ministry meant permanent acceptance of the state of widowhood; such a promise should not be recommended to young widows, who should be encouraged to remarry. Therefore, the church's orphan program was to be carried out by an organization made up of older widows. Tertullian, Hermas and Chrysostom wrote about church life in the first three centuries after Christ. They all mention an order of older widows ministering with a sympathizing counsel to other widows and orphans.

The church was selective in whom it helped
Not every widow or orphan in the church was to receive financial help in the church's support program. It is likely that Paul wrote to Timothy because there had been some abuse of the church's orphans-and-widows program. The church was not to assume the role of supporting orphans and widows when there was another family member capable of bearing this burden. Only those who were in need and without other means of support were to receive assistance. Families with members capable of supporting their relatives who were widows and orphans were not to be allowed to escape their responsibilities. In this way the church could concentrate its limited resources upon those who were really in need.

Visiting widows and orphans and distributing food to them were daily activities of the early church
Visiting people in their homes is the only way to assess whether families are really in need. Home visiting for the early church was to be a regular event. During a home visit, material aid could be distributed.

But meeting physical need was not the only purpose of the home-visitation program. Loneliness is a real problem for many widows, and visits to homes can provide friendship. And no doubt such home visits gave opportunities for spiritual ministry and support to widows and orphans.

Orphans, orphanages and the church
For many people the mention of orphans immediately brings to mind the solution of orphanages. Most orphanages have been the result of Christian initiatives. Many people have selflessly dedicated themselves to providing for unaccompanied children by raising resources to construct and run some kind of institution. Some of these orphanages have gone a long way in trying to re-create family caring structures and avoiding problems associated with bringing up children in institutions. But according to experts, orphanages should be considered as a last resort in providing care to those orphaned by AIDS.

Children growing up in orphanages often have difficulty knowing where they belong in society. To which family or tribe do they belong? Who will receive or pay the bride price? In fact, only a tiny proportion of children who have lost one or both parent are being brought up in orphanages. When we conducted a survey in Mancaland in 1991, we found 170 orphans in 19 institutions. However, we estimated that the province held a total of 47,000 orphaned children. Almost all the children were being cared for in a family setting. The number of orphans is rising rapidly as a result of AIDS and will more than double during the next decade.¹¹

What should the church do?
We asked community members living in a rural area in Zimbabwe what they thought should be done to cope with the growing number of orphans. No one suggested that sending orphaned children to an institution was an appropriate response. Many said that though they were poor and could not afford to give much material help, they were trying to help orphans cope with their desperate situation.

"We sometimes think about the problem but come up with no solution - at times, we don't even sleep. We want to help the orphans very much but sometimes our endeavors are limited because of lack of resources." (Caregiver)

"People should come together like this, talk about it [the situation of orphans], form societies, build love and help." (Art cooperative worker)

"I wish there were more people in the area willing to help orphans [besides ourselves]." (Community worker)

"We take care of the children voluntarily; some come to us on their own and others we come across during home visits." (Caregiver-visitor)

"Sometimes we visitors noticed that the children were seriously ill and saved their lives by getting them to the hospital." (Caregiver-visitor)

"The late husband's family takes everything but sometimes the community elders intervene." (Homecare volunteer)

Practical example
Let me give a practical example of what some churches are doing about orphans. In late 1992 a volunteer working with Family AIDS Caring Trust (FACT) in Mutare visited a church in eastern Zimbabwe. The women's group of the church was aware of several needy orphan families in their area and on a number of occasions had provided material support. The volunteer spoke about the important role that Christians and local churches had to play in providing social, emotional, material and spiritual support to orphans and widows.

As a result the women organized themselves into a committee and started visiting orphan households. They identified 55 needy families. A gift of US $1,000 enabled the program to function for a year. Six women, mostly widows, started regularly visiting orphan households and distributing modest amounts of food. In return they received a small gift of maize meal to help them provide for their own orphans.

Since that inauspicious beginning the program has grown. Families, Orphans and Children Under Stress (FOCUS), is a program administered by FACT, supports community-based orphan initiatives in six sites in Zimbabwe. At each site volunteers from different churches are identified. In most cases these are women, many of whom are widows themselves. They are provided with basic training so they can identify and register orphans in the community. The most needy are then visited regularly. Here are some comments by community members in these areas:

"The FOCUS coordinator gave us corn to pop; we sold the popcorn and made almost $500 (US$50); we used the money to buy books and pens for the orphans." (Caregiver-visitor)

"On Saturdays the orphans spend the whole day playing at the center. We teach them knitting, sewing, carving, moulding and gardening. They take part in football, netball and traditional dances." (Caregiver-visitor)

"The church sometimes helps us by donating clothes. FOCUS also helps with food, school fees, and blankets." (Caregiver)

"The church also helps the orphans; sometimes everyone contributes one dollar to help the poor./I (Community worker)

"People are becoming more sympathetic to each other and offer love and comfort to the bereaved." (Community worker)

In the last six months of 1996 the program involved 3,192 orphans from 798 families at four rural sites. The 88 volunteers made a total of 9,634 visits. Families receive an average of 1.5 visits per month; particularly needy families, such as child-headed house- holds, receive weekly or twice-weekly visits. Volunteers made an average of 18.2 visits per month; this is possible since volunteers live in villages and visit only families living nearby.

Some material assistance is provided in the form of food, clothing, blankets and primary school fees. Income-generating projects have been established to encourage self-reliance. The cost of supporting orphans in the community is much less than the cost of supporting them in an institution. The total cost of the FOCUS program in 1996 was US$26,000. Of this amount, most was spent within the communities affected, in the form of material assistance (31 %), volunteer meetings (11 %) and incentives (9%). Indirect costs were staff salaries (27%), transport (13%) and office administration (9%). The cost per month per family was US$2.70 and per orphan child US$0.68. The cost per visit was US$1.55.¹² The community-based model of providing support to orphaned children in their families is not only biblical and culturally sensitive, it is cost-effective as well.

HOW TO START ORPHAN PROGRAMS
Christians have an important role to play in providing support to orphaned children. When the church gets involved in such activities, we act as "salt of the earth" (Matt. 5:13). Instances of sexual abuse and exploitation fall as people realize that children are being watched over, cared for and protected.

It is not difficult for churches to establish support programs. After forming a committee, the next step is to visit families in the neighborhood. During visits the needs of the family should be assessed; sometimes it is possible to persuade relatives to assume their family responsibilities rather than the church taking over a role of material support.

A register of orphan households should be established. This needs to be updated because situations change over time. We have heard of child-headed households that later start being supported by family members. An increasing concern with the AIDS epidemic is for orphans to be taken into a new home only for the new caregiver to become sick and die from AIDS. So it is necessary for committees to update their orphan register regularly. Material support is the most obvious need in many orphan homes: food, clothing and school fees. But when we asked groups of caregivers what they really wanted, many of them said, "Teach us some skills so we can provide for the children ourselves." Similarly, many of the older orphans are also looking for help to earn a living.

In time we hope it may be possible to help orphans and widows be taught a skill by others in their community. In this way our programs may help move people away from handouts and into looking after themselves.

Finally, we need to remember the spiritual needs of orphan children. I was recently with a group of widows. As they described their efforts to bring up their children single handedly, it became obvious that they often felt weary. It was difficult to find time to pray or read the Bible to their families. In administering our material support programs, let's not forget the spiritual needs of orphans and widows.

According to Proverbs 14:31b, "Whoever is kind to the needy honors God." What an amazing statement. Helping a poor person is like helping out the One who created all things! God is concerned about the poor. So it is no surprise that God wants his people to have the same concern. If we are kind to the poor, we are in actual fact giving our lives to our God upon whose heart is the plight of countless numbers of widows and orphans.

Notes

1.  U.S. Bureau of the Census, The Demographic Impacts of HIV/AIDS- Perspectives from the World Population Profile: 1996 (Washington D.C.: International Programs Center, Population Division, U.s. Bureau of the Census, 1997).
2.  S. Gregson, et al., "Determinants of the Demographic Impact of HIV-1 in Sub-Saharan Africa: The Effect of a Shorter Mean Adult Incubation Period on Trends in Orphanhood," Health Transition Review 4, supplement, pp. 65-92.
3.  G. Foster, et al., "Supporting Children in Need Through a Community-based Orphan Visiting programme, AIDS Care 8: 389-403. The re- search reported in this chapter is based on published scientific studies from Family AIDS Caring Trust (FACT), a Christian AIDS service organization founded by Dr. Foster.
4.  G. Foster, et aI., "Factors Leading to the Establishment of Child- headed Households-The Case of Zimbabwe, Health Transitions Review 7, supplement 2, pp. 157-70.
5. Ibid.
6.  G. Foster, et al., "Perceptions of Children and Community Members Concerning the Circumstances of Orphans in Rural Zimbabwe, AIDS Care 9 (1997): 393-407.
7.  Fact sheet titled UNAIDS and UNICEF Launch the "Children in a World with AIDS Initiative," August 28,1996, Stockholm.
8.  Africa News Online, "'Sugar Daddy Syndrome' Blamed for AIDS Infection," July 15, 1997, CDC National Center for HIV, STD, and TB Prevention.
9.  PANOS Media Briefing, "AIDS and Children: A Lifetime of Risk," 20-page mimeograph (London: PANOS Institute), p. 5
10. G. Foster, Orphans in Zimbabwe-A Descriptive and Enumerative Study, abstract POD 5158, VIIIth International Conference on AIDS, Amsterdam, 1992.
11. PANOS Media Briefing, "AIDS and Children: A Lifetime of Risk," n.p.
12. G. Foster, Low Cost Replicable Orphan Support programme in Zimbabwe, abstract submitted to XIIth International Conference on AIDS, Geneva, July 1998.

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© Viv Grigg & Urban Leadership Foundationand other materials © by various contributors & Urban Leadership Foundation,  for The Encarnacao Training Commission.  Last modified: July 2010