The number of children who have lost a parent in southern Uganda significantly declined from nearly 25% in the early 2000s to 6% in 2022. New research indicates this reduction in orphanhood, defined as the loss of at least one parent, was largely driven by foreign aid programs targeting HIV.
Background
In the mid-1990s, Uganda experienced a severe HIV pandemic, resulting in over 100,000 deaths annually. Children whose mothers had HIV were approximately 20 times more likely to become orphaned than those with HIV-negative mothers. Orphaned children often faced increased stigma, school dropout rates, and poverty, contributing to a cycle of vulnerability.
Impact of Aid Programs
U.S.-funded initiatives, primarily the President's Emergency Plan for AIDS Relief (PEPFAR), contributed to mitigating these challenges. According to a study by Aleya Khalifa and Dr. David Serwadda published in The Lancet Global Health, children with HIV-positive mothers are now only twice as likely to be orphaned, a substantial decrease from the previous 20-fold likelihood. Rachel Kidman, a social epidemiologist not involved in the research, noted that this decline in HIV-related orphanhood is attributable to adults gaining access to life-saving antiretroviral drugs (ART).
Research Findings
Khalifa and colleagues utilized data from a long-running study in Rakai District, southern Uganda, tracking over 90,000 children from 1995 to 2022. Before 2004, when ART was unavailable, orphanhood was high. The availability of these drugs initially targeted only the very sick. Following the World Health Organization's expansion of eligibility to all individuals living with HIV in 2014, a significant decline in orphanhood was observed. Prior to 2004, about 70% of new orphans had HIV-positive parents; this figure dropped to approximately 11% after 2015. Lucie Cluver, a social scientist, described the paper as a testament to the impacts of PEPFAR and the global HIV response, which has invested over $100 billion worldwide, including $3 billion in Uganda.
Future Concerns and Transitions
The future of PEPFAR faces uncertainty due to changes in U.S. foreign aid policy. Dr. Serwadda reported that significant reductions in foreign aid last year disrupted HIV treatment programs in Africa, including Uganda, leading to instances where healthcare workers could not deliver drugs due to unpaid wages, despite drug availability. While many programs eventually resumed with reduced budgets, some were terminated. Dr. Serwadda expressed concern about potential increases in HIV transmission and deaths if patients lose treatment.
The U.S. State Department stated that PEPFAR continues to provide HIV testing, care, and treatment services, emphasizing that "the most effective way to prevent HIV-related orphanhood is to keep parents alive." The department also noted that new global health agreements prioritize life-saving HIV medicines and the frontline workers who deliver them. The U.S. is currently negotiating health agreements that aim to transition funding responsibility for HIV programs to national governments. An agreement with Uganda was signed in December to invest up to $1.7 billion over five years to combat infectious diseases, representing a 25-30% reduction compared to previous PEPFAR funding levels. Dr. Serwadda views country-level ownership as potentially more sustainable, but expressed apprehension about the transition phase, highlighting the numerous factors that must align for its success.