**6. Discussion and implications**

This chapter examined the schooling experiences of HIV-positive adolescent boys and girls in Uganda from the viewpoints of not only perinatally infected in-school young people but also school officials, teachers, and the general student body. As expected, most of the adolescents living with HIV are vulnerable on account of both their young age and the fact that the majority had lost one or both parents. Thus, although nearly all of them had ever attended school and most of them were still in school at the time of the survey, issues of absenteeism, class repetition, stigma and discrimination (by others or self-imposed) remain a challenge. These challenges cut across adolescents of various groups, that is, age, sex and whether they live with a biological parent. Moreover, the most commonly cited reasons for missing school and repeating a class are lack of fees or education materials, illness, going for treatment, and poor performance. Those who are in boarding institutions face additional challenges including poor diet, cold showers, and adherence to treatment for fear of being stigmatised.

The above challenges have implications for the academic performance and educational attainment of HIV-positive young people. Schools, however, lack formally established mechanisms for addressing these needs. Formal access to treatment, counselling, care and

reminded them to take medicine in cases where they were aware that the children were on antiretroviral drugs (ARVs). Nonetheless, the interviews revealed that the support was mainly non-formal and a lot seemed to depend on the goodwill of particular head teachers, other teachers, and school nurses who sometimes use their own resources. In one school, for example, a teacher reportedly helped HIV-positive students to pick their monthly refill of ARVs so that they did not miss lessons while in another, the head teacher invited the guardian of one of the students to the school, counselled them, and connected them to a treatment centre. As one senior female teacher in one of the primary schools

"Sometimes their guardians do not genuinely have the money but others [guardians] are just negligent they feel that 'after all the child may not have long to live'. In cases where the child knows that they are HIV positive this adds to their psychological stress. At school we ask them 'where are the materials we sent you for'; at home they are being told 'we do not have money'. When we do not know their special circumstances we think they are just being stubborn and not informing their parents. But when we find out, we try as a school to see how best to help them. Some teachers even buy them the materials using their own money

Findings from the in-depth interviews further show that HIV-positive young people in boarding institutions face additional challenges such as poor diet, adherence to ARVs, and taking cold showers. Whereas these have implications for their academic performance, schools lack formally established mechanisms for meeting these needs. For instance, sickbays—where they exist in schools—are ill-equipped; they do not commonly stock antibiotics, have no full-time nurses while the available staff members are equipped to provide First Aid treatment only. Moreover, school-based caregivers (school nurses, guidance and counselling teachers, and senior teachers) are inadequately trained to handle

This chapter examined the schooling experiences of HIV-positive adolescent boys and girls in Uganda from the viewpoints of not only perinatally infected in-school young people but also school officials, teachers, and the general student body. As expected, most of the adolescents living with HIV are vulnerable on account of both their young age and the fact that the majority had lost one or both parents. Thus, although nearly all of them had ever attended school and most of them were still in school at the time of the survey, issues of absenteeism, class repetition, stigma and discrimination (by others or self-imposed) remain a challenge. These challenges cut across adolescents of various groups, that is, age, sex and whether they live with a biological parent. Moreover, the most commonly cited reasons for missing school and repeating a class are lack of fees or education materials, illness, going for treatment, and poor performance. Those who are in boarding institutions face additional challenges including poor diet, cold showers, and adherence to treatment for fear of being

The above challenges have implications for the academic performance and educational attainment of HIV-positive young people. Schools, however, lack formally established mechanisms for addressing these needs. Formal access to treatment, counselling, care and

but this is after they have found out the circumstances."

the healthcare needs of HIV-positive students.

**6. Discussion and implications** 

stigmatised.

explained:

support at school or through school is almost non-existent. Sick-bays—where they exist in schools—are not equipped with essential medicines while school-based caregivers (school nurses, guidance and counselling teachers, and senior teachers) are inadequately trained to handle the healthcare needs of HIV-positive students. Existing attempts at addressing the needs of in-school HIV-positive young people are ad hoc, at individual level, and crisisdriven. The absence of formally established mechanisms could also partly be due to nondisclosure of students' sero-status by parents/guardians during admission given that in certain cases, school authorities often discovered when the student became symptomatic while at school or because of continued absenteeism or seeking permission to go for treatment on specific days.1

These findings have important programmatic implications for the education sector not only in Uganda but other SSA countries affected by HIV/AIDS. Specifically, they suggest the need for: (1) school-based programs to assist orphans and other vulnerable children, including those living with HIV, so that they do not miss attending school for lack of essential materials; (2) strengthening the school-based healthcare program including treatment, care and support for HIV-positive students, encouraging in-school young people to undergo testing and counselling for HIV, and equipping sick-bays—where these exist with essential medicines; (3) pre- or in-service training for school-based caregivers (school nurses, guidance and counselling teachers, and senior teachers) on HIV counselling, care and support; (4) putting in place psychosocial support mechanisms for HIV-positive young people, orphans and other vulnerable children in schools, which should be expanded to incorporate all students irrespective of their HIV status in order to reduce stigma and discrimination through innovative ways such as child-to-child communication; and (5) putting in place measures to discourage stigma and discrimination against HIV-positive students through sensitizing school officials and students on the consequences of the same on those who are exposed to them.

Although this chapter identifies possible responses by the education sector to the needs of in-school HIV-positive young people, its major limitation is that it does not consider acceptable, feasible and effective strategies for addressing these needs. This is largely because it relies on data from an exploratory study whose aim was to provide a better understanding of the schooling experiences of this subset of the population. Operations research is best suited for providing answers regarding acceptable, feasible and effective strategies for responding to these needs. Operations research can, for instance, provide answers to the following questions: What school-based support programs are appropriate and effective in meeting the education needs of orphaned and vulnerable children, including those living with HIV? How can school-based health care programs be strengthened to better meet the needs of in-school HIV-positive young people? Does training of school-based caregivers improve the provision and quality of care and support for HIV-positive learners? What strategies and psychosocial support mechanisms can

<sup>1</sup>In Uganda, parents/guardians complete medical forms upon student admission so that the information can be used to identify those with needs that might require special attention. However, most parents/guardians tend to conceal certain ailments including HIV, perhaps, for fear that their children might not be admitted if their conditions are known or to protect them from stigma and discrimination.

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effectively reduce stigma and discrimination in schools? These are questions which are beyond the scope of the present chapter.

### **7. Conclusion**

In-school HIV-positive young people in Uganda face a number of challenges including: (1) high rates of absenteeism and class repetition because of illness, having to go for drug refills regularly for those on ART, or socio-economic hardships at home; (2) stigma and discrimination from fellow students, teachers or self-imposed; and (3) poor diet, cold showers, and non-adherence to ART because of fear of stigma and discrimination from fellow students among those in boarding institutions. At the same time, schools are not adequately prepared to respond to their special needs. Key actors in the education sector (government, private sector, non-governmental organizations, and donors) should therefore consider appropriate interventions aimed at enhancing the capacity of schools to respond to the unique needs of HIV-positive learners.

### **8. Acknowledgement**

The study that provided the data for this chapter was funded by the Ford Foundation and implemented by the Population Council in collaboration with the Child Health and Development Centre- Makerere University, The AIDS Support Organization (TASO)- Uganda, and the HIV/AIDS Unit in the Ministry of Education and Sports- Uganda. Florence Baingana of the Institute of Public Health- Makerere University conducted the in-depth interviews with school officials. The TASO Internal Review Board, the Uganda National Council for Science and Technology (UNCST), and the Population Council's Institutional Review Board granted ethical clearance for the study. The views expressed in this chapter are, however, those of the authors.

#### **9. References**


effectively reduce stigma and discrimination in schools? These are questions which are

In-school HIV-positive young people in Uganda face a number of challenges including: (1) high rates of absenteeism and class repetition because of illness, having to go for drug refills regularly for those on ART, or socio-economic hardships at home; (2) stigma and discrimination from fellow students, teachers or self-imposed; and (3) poor diet, cold showers, and non-adherence to ART because of fear of stigma and discrimination from fellow students among those in boarding institutions. At the same time, schools are not adequately prepared to respond to their special needs. Key actors in the education sector (government, private sector, non-governmental organizations, and donors) should therefore consider appropriate interventions aimed at enhancing the capacity of schools to respond to

The study that provided the data for this chapter was funded by the Ford Foundation and implemented by the Population Council in collaboration with the Child Health and Development Centre- Makerere University, The AIDS Support Organization (TASO)- Uganda, and the HIV/AIDS Unit in the Ministry of Education and Sports- Uganda. Florence Baingana of the Institute of Public Health- Makerere University conducted the in-depth interviews with school officials. The TASO Internal Review Board, the Uganda National Council for Science and Technology (UNCST), and the Population Council's Institutional Review Board granted ethical clearance for the study. The views expressed in this chapter

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beyond the scope of the present chapter.

the unique needs of HIV-positive learners.

**8. Acknowledgement** 

are, however, those of the authors.

Education.

30(1):77-82.

**9. References** 

**7. Conclusion** 


**5** 

*Queen's University,* 

*Canada*

**An Institutional Analysis of Access to GBV/HIV** 

**Services in Rural KwaZulu-Natal, South Africa** 

The health systems context in rural South Africa presents significant challenges for addressing the intersecting problems of HIV/AIDS and Gender Based Violence (GBV). In KwaZulu-Natal Province, district level government responses to these issues are principally focused in urban, higher population areas. Rural health systems rely more heavily on nongovernmental organizations (NGOs), which have serious time limitations and insecure external funding. Weak management skills, and insufficient capacity to design and monitor services, are key problems. There is also a shortage of health personnel in rural areas, and high attrition rates due to poor work conditions, substandard accommodation environments, inadequate pay and benefits, and illness and stress resulting from to the high demands posed by the HIV/AIDS epidemic and other primary health care issues. Overall, the rural health structure is very under-developed, under-staffed, under-resourced and

There is a pressing need for rural health services to focus on health promotion and prevention - including violence prevention - and to develop new strategies for coordinating the activities of health professionals with voluntary associations and NGOs. This paper presents an institutional analysis of why access to GBV and HIV/AIDS services is low in rural KwaZulu-Natal, with a focus on understanding existing professional structures and community beliefs that act as barriers to health system development. Such an understanding can also reveal how existing strengths and resources may be harnessed to encourage changes in the cultural attitudes and structures that support the gender violence-HIV/AIDS

It is well recognized that the health sector faces certain institutional characteristics that distinguish it from other sectors of society [Jan et al., 2008; Mooney, 1994]. Specifically, these characteristics include the role of institutions in providing access to health benefits, or more exactly, preservation from ill health or health losses. In this view, institutions are not organizations per se, but are the 'rules' that govern the conduct of players, whether individuals or organizations, within society [North, 1993]. Thus, institutions include formal rules such as legislation concerning resource allocation to health and the regulation of professionals, and informal rules such as social customs and community norms that shape

nexus, and identify salient points of entry at which interventions can be designed.

**1. Introduction** 

under-trained around issues of GBV and HIV/AIDS.

**1.1 An institutional perspective on "Access" 1.1.1 The health system as "Institution"** 

William Boyce, Sarita Verma, Nomusa Mngoma and Emily Boyce

