Study Title: School support as structural HIV prevention for adolescent orphans in Western Kenya
Context: The HIV/AIDS pandemic has led to illness and early death for millions of adults, and this, in turn, has left many millions of orphans in sub-Saharan Africa. In Kenya, alone, there are more than 2.4 million orphans who are at great risk for school dropout, early sexual debut, and HIV infection. Approaching the fourth decade of the AIDS epidemic, many in the field have called for a paradigm shift in HIV prevention, to address structural, as well as individual-level, factors.
Study Aims: This study examines the impact of school support as a structural intervention, tested among adolescent Luo orphans in Nyanza Province, Kenya. The Luos have the highest HIV prevalence and largest orphan prevalence of all ethnic groups in the country. The study uses a rigorous randomized controlled trial design to test whether school support can retain adolescent orphans in school through the transition to high school, delay sexual debut, and reduce the likelihood of HIV and herpes simplex virus type 2 (HSV-2) infections. Specific aims for the proposed study are: 1) To experimentally test whether providing comprehensive school support to Luo orphaned boys and girls will reduce school dropout, reduce sexual risk behaviors, and prevent HIV/HSV-2 infection; 2) To conduct a process evaluation of the implementation of the program; and 3) To conduct comparative cost effectiveness analyses, specifying the intervention’s cost and return on investment as evidenced by cost per unit improvement in the primary outcomes of school enrollment, delay of sexual debut and prevention of risk behaviors and HIV/HSV-2 infection, as well as by gains in health- related quality of life.
Methods: The design randomizes 24 primary schools to intervention or control condition. All youth in grades 7 and 8 who have lost one or both parents, regardless of cause of death, will be invited to participate; the total number of participants to be recruited into the study is approximately 840 students, 420 in each condition. Youth in intervention schools will receive five years of school support, including tuition, fees, uniforms, and a school-based adult “helper.” Data will comprise annual ACASI surveys, school data (attendance, grades), and HIV/HSV-2 bio-specimens. Analyses will test posited mediators and gender moderation in causal pathways and program effects. Cost effectiveness analyses will add much needed policy-relevant information.
Public Health Relevance: Although millions of children have been orphaned as a result of the AIDS pandemic, few studies have considered the particular vulnerability of young orphaned adolescents for school dropout, risky sexual behaviors, and HIV infection. The Luo people of Nyanza Province have the highest proportion of orphans, highest HIV prevalence, and earliest sexual debut among all ethnic groups in Kenya. This structural intervention trial uses a strong conceptual framework and rigorous experimental design to test whether school support can keep adolescent Luo orphans in school, reduce sexual risk behaviors, and prevent HIV /HSV-2 infection. Process evaluation and cost effectiveness analyses add further relevance for policy development.
Principal Investigator: Hyunsan Cho (Pacific Institute for Research and Evaluation)
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Study Title: Pathways to health and well-being: social networks of orphans and abandoned youth
Context: Globally, 153 million children are estimated to have been orphaned as defined by the death of one or both parents due to diseases such as malaria, tuberculosis, maternal mortality, unintentional injuries, natural disasters and armed conflict: AIDS accounts for 16.6 million of these children. Little is known, however, about the social networks that have been informally established that may assist orphaned and abandoned children (OAC) as they transition from structured family care or residential facility settings to their adult lives.
Study aims: The primary goal of this study is to determine key factors that may put youth at a disadvantage as they transition from structured care settings into their adult lives and those that support positive transitions. To accomplish this, researchers will study existing education and employment support networks as well as sexual communities. Researchers will then be able to determine how certain characteristics of these networks are associated with OAC health outcomes, including poor education, ability to generate income, and HIV risk-taking behaviors. Based on prior OAC-related research, this study expects to find that OAC networks are small and lack variability, leading to reduced access to education, fewer positive employment opportunities, and increased sexual-risk behavior. Findings will be used to construct potential interventions to promote OAC health and well-being.
Methods: This study will use a “network analysis approach” to identify major characteristics of OAC social and sexual networks. Researchers will then examine the association between network factors and OAC outcomes in two steps: examining the relationships between social network characteristics and education and income-generation outcomes, and between sexual network characteristics and HIV-risk outcomes. Researchers expect to learn which social and sexual network features are associated with poor outcomes, such as educational accomplishment, obtaining employment, and high sexual risk behavior. Such risk behaviors include an early age of sexual debut, a high number of sexual partners, and certain characteristics of the sexual partners themselves. This research will provide the basis for designing interventions to prevent disenfranchisement as OAC enter their adult lives. With this research, we will be able to learn how to effectively design community networks for OAC to prevent poor health and lifestyle outcomes.
- To determine if OAC network features account for success in educational, income generation, and sexual risk-taking behaviors
- To provide the basis for social network and sexual network interventions to reduce damage done to OAC to prevent disenfranchisement as OAC become adults.
Principal Investigator: Lynne Messer (Duke University)
Investigators: Bernard Agala (Duke University), Cyrilla Amanya (ACE Africa, Kenya), Misganaw Eticha (SVO Ethiopia), Amy Hobbie (Duke University) Dafrosa Itemba (TAWREF, Tanzania), Rachel Manongi (KCMC, Tanzania), Jim Moody (Duke University), Vanroth Vann (Homeland, Cambodia), Augustine Wasonga (ACE Africa, Kenya), Kathryn Whetten (Duke University), Rachel Whetten (Duke University)
Contact: [email protected]
Study Title: Randomized Controlled Trial of Ways to Improve OVC HIV Prevention and Well-Being (Zambia CBT)
Context: With millions of youth orphaned by AIDS in sub-Saharan Africa undergoing high levels of stress-related problems—such as interpersonal and problem-solving skills deficits, unhealthy thoughts, and maladaptive behaviors—addressing trauma and stress is a pressing need. Addressing these stressors is especially important in preventing the spread of HIV by reducing stress-induced risky sexual behaviors among orphaned and vulnerable children. Other studies have shown that cognitive behavior therapy interventions, when adapted for local environments, have been effective in addressing such stress-related problems.
Study Aims: This study will focus on comparing the effectiveness of psychosocial counseling (PC) and trauma-focused cognitive behavioral therapy (TF-CBT). The study will primarily compare the effectiveness of psychosocial counseling and trauma-focused cognitive behavioral therapy in addressing the stress-related problems among orphaned and vulnerable children (OVC). In addition, the study will examine the effectiveness of these two major types of treatment in reducing sexual risk behaviors while accounting for factors that mediate and moderate HIV risk behaviors. Finally, this study will compare the cost-effectiveness of the two treatment methods.
Methods: This study, which is being conducted in Zambia, utilizes a randomized controlled trial of psychosocial counseling and trauma-focused cognitive behavioral therapy, which has been utilized in other previous and ongoing studies. The major outcomes that this study will analyze include HIV risk behaviors, emotional and behavioral health, social support, overall well-being and mental health development of OVC. Researchers will recruit adolescents aged 13-17 who report risky sexual behavior, including recent sex without a condom. Adolescent participants and their caregivers will be assessed utilizing a computerized interviewing program that will enhance privacy and honesty of responses.
- This study will provide necessary scientific evidence on the feasibility, effectiveness, and cost effectiveness of interventions for OVC affected by HIV/AIDS.
- Results from this study will help inform efficient program design, policy, and effectiveness of interventions for preventing HIV among OVC living in low-resource settings.
M-Principal Investigators: Laura Murray (Johns Hopkins University) and Paul Bolton (Harvard University)
Investigators: Judith Cohen (University of Pittsburg), Shannon Dorsey (University of Washington), Kathryn Whetten (Duke University),
Contact Information: [email protected]