**AIDS and Trauma: Adults, Children and Orphans**

Rachel Whetten and Kristen Shirey

*Center for Health Policy & Inequalities Research Duke University USA* 

#### **1. Introduction**

260 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

WHO, 2004. The World Health Report 2004: Changing history. [Online] Available:

http://www.who.int/hiv/pub/prev\_care/en/haiti\_e.pdf.

http://www.who.int/hiv/mediacentre/2006\_GR\_CH02\_en.pdf.

http://whqlibdoc.who.int/icd/hq/2004/a85554.pdf.

WHO, 2006, Overview of the. [Online] Available:

Though HIV/AIDS has become more of a chronically-managed illness in the most well-off of places, it is still a devastating disease that spreads rapidly and silently. Biomedical and behavioral research conducted over the last 25 years has taught us a tremendous amount about HIV: the people it infects, the way it infects and the damage it reaps. While some of this research is headline news, particularly those discoveries that lead us closer to a vaccine or other biomedical prophylaxis like microbicides, and to a lesser extent behavioral research that teaches us about effective prevention efforts, what are infrequently discussed but are no less important are the very substantial effects that trauma has on those infected and affected by HIV. We have found that there are higher rates of past and current trauma in adults infected by HIV than in the general population and subsequently these adults often have higher rates of substance abuse and other high risk activities. In children orphaned and otherwise affected by AIDS, we see they suffer not just the loss of a parent, but also significant emotional wounds that require specific treatments to heal. HIV is more than a virus; it is a disease that exploits already present vulnerabilities like poverty and goes on to wreak havoc on all levels of society. In this chapter, we will talk about trauma and its relationship to HIV in both adults and children. We will use fictitious case studies starting in childhood and moving through adulthood to explicate the complicated life stories, specifically the significant role trauma plays in the lives of people who are affected by HIV.

#### **1.1 Orphans and culture and how AIDS has changed orphanhood**

Orphans have been a part of the fabric of all cultures for time immemorial. Parents die at all times of a child's lifespan, from childbirth through the teenage years. AIDS has not created the experience of orphanhood but it has exacerbated the situation in many countries. Today, one hundred and forty-three million children are estimated to have lost one or both parents, fifteen million of these to AIDS (United Nations Children's Fund [UNICEF], 2009). Millions more have been abandoned by their parents. While Africa is most often referenced when discussing the orphan burden with respect to HIV/AIDS, South and Southeast Asian countries are caring for 67.5 million orphans alone (UNICEF, 2009). In both Africa and Asia, high mortality among young parents from conditions such as malaria, tuberculosis, HIV/AIDS, pregnancy complications, injuries, and natural disasters are responsible for the

AIDS and Trauma: Adults, Children and Orphans 263

order to receive this aid. How does that affect the recipients, particularly in cultures where the word 'orphan' means more than being without parents: it means you are without care or without love, and is necessarily associated with pity? Does this definition bring to the child its own kind of stigma and therefore *more* suffering instead of less? We do not have answers to these questions, but feel they are, at the very least, important to consider in the context of how we understand and digest the world of 'HIV and orphanhood.' In addition, it is important to note that it is those who have lost both parents who are truly the most vulnerable, and according to the Positive Outcomes For Orphans (POFO) data1, children who have lost one parent show similar rates of trauma to those who have lost *neither*. We are not the first to point out that we are not the first to point out, that the very thing that makes children *most* vulnerable is not their orphanhood but poverty, to which children, not just

Regardless of the language of the international community there is no question that any

While the death of a parent at any age is upsetting and painful, even as adults we mourn the loss of a parent in ways specific to the relationship that we do not experience when mourning the death of a friend or even a spouse. For children, the loss of a parent has a particular gravity, by nature definition children do not have the developmental distance from their parents *as their own person* to mourn their passing separate from themselves, since they are by nature dependent on them (Brown et al., 2008). In other words, children are connected to their parents in ways that tie directly to their identification of self; children selfidentify through their parents and only learn to separate their identities in their adolescence. So losing a parent during any developmental stage, but particularly for younger children, has a specific weight that is qualitatively different than any other kind of loss one can

All children naturally grieve the loss of their parent(s), and this is very healthy. However, the profound nature of losing a parent, perhaps in the context of other environments that make a child more vulnerable, can bring about a specific kind of grief called 'Childhood Traumatic Grief (CTG)' that researchers and professionals have only in the last decade or so really started to strongly define and parse out from post-traumatic stress disorder (PTSD) or other symptoms of normal grieving following a traumatic experience such as the death of a loved one. The definition of CTG is distinct from depression and PTSD and understood as occurring following a loved one's death and the subsequent natural/normal grieving of the child is interrupted/disturbed by the development of trauma symptoms, which can include intrusive thoughts, intense and prolonged longing for the deceased, and, in school-aged

Other research suggests that children who have lost a parent to AIDS face increased burdens related to emotional and psychological well-being. In his Ghanaian study (2009), Doku's findings support the mounting evidence which tells us that children orphaned by AIDS show more problems with their peer relationships when compared to other children their age (Ntozi et al., 1999; Nyambehdha et al., 2006; Cluver et al., 2008). Dowdney explains that

1 Positive Outcomes For Orphans is a longitudinal research study following orphaned and abandoned

child who experiences the death of a parent experiences a profound loss.

children, inability to concentrate (J. Cohen et al., 2006).

children in 5 less wealthy nations funded by the NIH.

http://globalhealth.duke.edu/dghi-fieldwork/open-projects/pofo

orphans, are subject.

**1.2 Traumatic grief** 

experience.

large and increasing number of orphans (World Health Organization [WHO], 2007). Most children in less wealthy nations are orphaned not at birth but at older ages (Norwegian UN Association, 2009; UNICEF, 2009; Zuberi et al., 2005); 36% of all orphans and 29% of double orphans are aged 6-11; almost half of single orphans and nearly two-thirds of double orphans are aged 12-17 (UNICEF, 2006).

Traditionally, cultures all over the world have long had their own unique ways to manage their populations of orphans. Eastern Europe is known for its past history of the institutionalization of children; Western Europe after World War I and II also dealt with orphaning through institutionalization; the United States used institutions and then later foster care became more popular. In many parts of Africa, extended family members are expected to absorb their brother or sister's children into their own families; neighbors or even whole villages tacitly and implicitly agree to care communally for the young members of a household that is suddenly parentless. Even today, many non-governmental organizations (NGOs) and other organizations working to care for orphans and vulnerable children (OVCs) use traditional African village culture as a model and point of reference for setting up care systems all over the world, particularly in Sub-Saharan Africa. Indeed, there have always been ways and means to care for orphans in their own societies, by their own societies.

The difference today is the sheer number of orphans that the HIV pandemic has created, with the most dramatic increases in orphaned children occurring in Sub-Saharan Africa and in Southeast Asia. With the virus killing off men and women of reproductive age the fastest – in some countries up to 40% of the men and women in this age group are infected - the number of children with one or both parents dead has increased exponentially in the last 20 years and has thereby overwhelmed these traditional mechanisms (Ntozi et al., 1999; Nyambehdha et al., 2006; Joint United Nations Programme on HIV and AIDS [UNAIDS] et al., 2004). This orphan epidemic of sorts has has left entire communities with sometimes thousands of children they are unable to clothe, educate or even feed. In some cases children are heading up their own households. HIV/AIDS has made desperate a generation of children who were already vulnerable from poverty. This is a crisis by any definition.

However, before we go too much further into the traumatic experiences that concern children infected and affected by HIV/AIDS, it is also important that we recognize how HIV/AIDS has changed the way we *talk* about orphanhood and orphans, perhaps in a way that does not serve them. According to Helen Meintjes and Sonja Giese at the University of Cape Town, from the time the epidemic first started killing off men and women of reproductive age, the NGO and aid community started referring to children who experienced the death of a parent from the disease as 'AIDS orphans.' This change was significant because typically a child was not labeled an 'orphan' in most parts of the world unless he/she lost both of his/her parents. This is still true today when one is *not* speaking in terms of HIV; the loss of one parent is no less a hardship but a child is not called an orphan. Yet, in the context of HIV/AIDS, losing one parent makes you an orphan according to the international aid community. While the attention and subsequent resources the focus on orphans has brought to countries with the most 'orphans' have no doubt been materially and instrumentally helpful to children who are most certainly in need, it is naïve to believe that focusing on what these children have lost, rather than what they still have – which in *many* situations is another biological parent – has some kind of cultural or at the very least semantic repercussion (Meintjes & Giese, 2008). Further, a child must be identified as an orphan – as someone who has lost something vital and makes him/her the target of aid – in order to receive this aid. How does that affect the recipients, particularly in cultures where the word 'orphan' means more than being without parents: it means you are without care or without love, and is necessarily associated with pity? Does this definition bring to the child its own kind of stigma and therefore *more* suffering instead of less? We do not have answers to these questions, but feel they are, at the very least, important to consider in the context of how we understand and digest the world of 'HIV and orphanhood.' In addition, it is important to note that it is those who have lost both parents who are truly the most vulnerable, and according to the Positive Outcomes For Orphans (POFO) data1, children who have lost one parent show similar rates of trauma to those who have lost *neither*. We are not the first to point out that we are not the first to point out, that the very thing that makes children *most* vulnerable is not their orphanhood but poverty, to which children, not just orphans, are subject.

Regardless of the language of the international community there is no question that any child who experiences the death of a parent experiences a profound loss.

#### **1.2 Traumatic grief**

262 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

large and increasing number of orphans (World Health Organization [WHO], 2007). Most children in less wealthy nations are orphaned not at birth but at older ages (Norwegian UN Association, 2009; UNICEF, 2009; Zuberi et al., 2005); 36% of all orphans and 29% of double orphans are aged 6-11; almost half of single orphans and nearly two-thirds of double

Traditionally, cultures all over the world have long had their own unique ways to manage their populations of orphans. Eastern Europe is known for its past history of the institutionalization of children; Western Europe after World War I and II also dealt with orphaning through institutionalization; the United States used institutions and then later foster care became more popular. In many parts of Africa, extended family members are expected to absorb their brother or sister's children into their own families; neighbors or even whole villages tacitly and implicitly agree to care communally for the young members of a household that is suddenly parentless. Even today, many non-governmental organizations (NGOs) and other organizations working to care for orphans and vulnerable children (OVCs) use traditional African village culture as a model and point of reference for setting up care systems all over the world, particularly in Sub-Saharan Africa. Indeed, there have always been ways and means to care for orphans in their own societies, by their own

The difference today is the sheer number of orphans that the HIV pandemic has created, with the most dramatic increases in orphaned children occurring in Sub-Saharan Africa and in Southeast Asia. With the virus killing off men and women of reproductive age the fastest – in some countries up to 40% of the men and women in this age group are infected - the number of children with one or both parents dead has increased exponentially in the last 20 years and has thereby overwhelmed these traditional mechanisms (Ntozi et al., 1999; Nyambehdha et al., 2006; Joint United Nations Programme on HIV and AIDS [UNAIDS] et al., 2004). This orphan epidemic of sorts has has left entire communities with sometimes thousands of children they are unable to clothe, educate or even feed. In some cases children are heading up their own households. HIV/AIDS has made desperate a generation of children who were already vulnerable from poverty. This is a crisis by any definition. However, before we go too much further into the traumatic experiences that concern children infected and affected by HIV/AIDS, it is also important that we recognize how HIV/AIDS has changed the way we *talk* about orphanhood and orphans, perhaps in a way that does not serve them. According to Helen Meintjes and Sonja Giese at the University of Cape Town, from the time the epidemic first started killing off men and women of reproductive age, the NGO and aid community started referring to children who experienced the death of a parent from the disease as 'AIDS orphans.' This change was significant because typically a child was not labeled an 'orphan' in most parts of the world unless he/she lost both of his/her parents. This is still true today when one is *not* speaking in terms of HIV; the loss of one parent is no less a hardship but a child is not called an orphan. Yet, in the context of HIV/AIDS, losing one parent makes you an orphan according to the international aid community. While the attention and subsequent resources the focus on orphans has brought to countries with the most 'orphans' have no doubt been materially and instrumentally helpful to children who are most certainly in need, it is naïve to believe that focusing on what these children have lost, rather than what they still have – which in *many* situations is another biological parent – has some kind of cultural or at the very least semantic repercussion (Meintjes & Giese, 2008). Further, a child must be identified as an orphan – as someone who has lost something vital and makes him/her the target of aid – in

orphans are aged 12-17 (UNICEF, 2006).

societies.

While the death of a parent at any age is upsetting and painful, even as adults we mourn the loss of a parent in ways specific to the relationship that we do not experience when mourning the death of a friend or even a spouse. For children, the loss of a parent has a particular gravity, by nature definition children do not have the developmental distance from their parents *as their own person* to mourn their passing separate from themselves, since they are by nature dependent on them (Brown et al., 2008). In other words, children are connected to their parents in ways that tie directly to their identification of self; children selfidentify through their parents and only learn to separate their identities in their adolescence. So losing a parent during any developmental stage, but particularly for younger children, has a specific weight that is qualitatively different than any other kind of loss one can experience.

All children naturally grieve the loss of their parent(s), and this is very healthy. However, the profound nature of losing a parent, perhaps in the context of other environments that make a child more vulnerable, can bring about a specific kind of grief called 'Childhood Traumatic Grief (CTG)' that researchers and professionals have only in the last decade or so really started to strongly define and parse out from post-traumatic stress disorder (PTSD) or other symptoms of normal grieving following a traumatic experience such as the death of a loved one. The definition of CTG is distinct from depression and PTSD and understood as occurring following a loved one's death and the subsequent natural/normal grieving of the child is interrupted/disturbed by the development of trauma symptoms, which can include intrusive thoughts, intense and prolonged longing for the deceased, and, in school-aged children, inability to concentrate (J. Cohen et al., 2006).

Other research suggests that children who have lost a parent to AIDS face increased burdens related to emotional and psychological well-being. In his Ghanaian study (2009), Doku's findings support the mounting evidence which tells us that children orphaned by AIDS show more problems with their peer relationships when compared to other children their age (Ntozi et al., 1999; Nyambehdha et al., 2006; Cluver et al., 2008). Dowdney explains that

<sup>1</sup> Positive Outcomes For Orphans is a longitudinal research study following orphaned and abandoned children in 5 less wealthy nations funded by the NIH.

http://globalhealth.duke.edu/dghi-fieldwork/open-projects/pofo

AIDS and Trauma: Adults, Children and Orphans 265

are more likely to be biologically predisposed to gravitate to drug and alcohol use and risky sexual activity (Adinoff, 2004; Gordon, 2002). Our team's adult HIV studies have demonstrated strong relationships between childhood trauma and adult drug and alcohol use, as well as high-risk sexual activity (Leserman et al., 2005; Mugavero et al., 2007; Pence et al., 2008; K. Whetten et al., 2005). Baseline data from the POFO study indicate ongoing traumatic experiences of OAC (K. Whetten et al., 2011); in the 36 month follow-up, some

There is ample evidence associating PTSD with trauma exposure in children, with documented and well-researched examples such as bearing witness to neighborhood or familial violence, war, and/or natural disasters. A plethora of research exists examining the effect of all sorts of traumatic events: following the terrorist attack of September 11th in the United States, post-conflict research in Bosnia-Herzegovnia, Croatia, Cambodia, Algeria and Palestine; victims of both community and personal violence (rape or physical assault); and victims of natural disaster, etc. all documenting rates of PTSD and the effects of traumatic events (Calderoni et al., 2006; Dobricki et al., 2010; Hoven et al., 2005; Klaric et al., 2007; Loncar et al., 2006). However, there are remarkably few articles in the literature examining PTSD among orphans, given the sheer number of orphans and the simple vulnerability of the population. There are some studies that have identified trauma and PTSD as significant factors in the life of a child orphaned by HIV. In her South African study of over 1,000 children ages 10-19, Cluver found that AIDS-orphaned children reported high levels of symptoms of PTSD when controlling for age, migration (moving between homes), household size, and gender. This same study revealed higher levels of other psychological distress among children who were orphaned by AIDS, when compared to children orphaned by other causes and non-orphans. The POFO study also found that in addition to losing 1 or both parents, 98% of the sample of 1,258 children experienced at least 1 more traumatic event and more than half (55%) experienced 4 or more traumatic events. While this study did not diagnose PTSD, the sheer fact of having experienced what have been scientifically proven as

What may be even more important, particularly as we try to intervene on the behalf of children who have experienced trauma and those who have been diagnosed with PTSD is that children who have already experienced one trauma are at an increased risk of experiencing more traumas. Simply put, trauma begets trauma; this is terrifying because we do know that children who experience trauma and/or have experienced PTSD are more vulnerable in their adult lives to psychological problems like depression and anxiety, as well as an increased risk for contracting HIV and other STDs (K. Whetten et al., 2008; Whitmire et al., 1999) than children who have not experienced trauma/do not have PTSD. A 2009 review of all published psychosocial interventions for children orphaned by or vulnerable from HIV/AIDS, defined psychosocial intervention as including "…psychological therapy, psychosocial support and/or care, medical interventions and social interventions…" with liberal inclusion criteria "..Randomised controlled trials, crossover trials, cluster-randomised trials and factorial trials were eligible for inclusion. If no controlled trials were found, data from well-designed non-randomised intervention studies (such as before and after studies), cohort, and case-control observational studies were considered for inclusion. Studies which included male and female children under the age of 18 years of age, either orphaned due to AIDS (one or more parents died of HIV related-illness or AIDS), or vulnerable children (one

OAC reported illicit drug use and having been drunk.

**1.4 Post-traumatic stress disorder and trauma in children** 

potentially traumatic events is ominous, never mind *four* such events.

that the death of a parent under any circumstances, regardless of the additional burden of a stigmatizing illness, is grounds for increased risk of depression and anxiety. She further suggests that one in five children who experience parental death will "likely develop a psychological disorder" (Dowdney, 2000). Dysphoria and depression are the most widely reported of psychological problems in children following parental death (Dowdney, 2000). Severe depression is a potential issue, but is infrequently found in the literature on childhood bereavement. However, it is important to remember that depression and anxiety are associated with suicidal ideation. The type of despair that can accompany the loss one feels with the death of a parent, when unchecked and unmonitored, particularly in the wake of a stigmatizing illness where there is little to no community supporting that child, is a sobering picture.

There are other behavioral and emotional issues that are potential risks with parental death such as anxiety, temper tantrums, hyperactivity, withdrawal and other kinds of somatizing disorders (stomachaches) but in the case of children orphaned by AIDS, it is difficult to tease out causal variables (AIDS, AIDS orphanhood, orphanhood alone) due to the complexity of challenges when a parent is lost to a stigmatizing illness. There is varying evidence related to whether expected death (long illness preceding death) further complicates or ameliorates the grieving process. Likely there are many mediating and moderating factors, such as the way death is dealt with in the family, the way the illness/death is viewed in the community (stigma), any planning that is done ahead of time, and how much the child is included in these decisions and discussions. Indeed, these are not symptoms unique to children who have been orphaned, but it is necessary to understand the full complexity these children are facing when they lose their parents to HIV/AIDS and why they may be more vulnerable to trauma and traumatic experience.

#### **1.3 HIV-related risk-taking behaviors as it relates to trauma in children**

Sexual risk behaviors, and other HIV risk behaviours are of particular concern when discussing the health of OVCs. Studies found orphans to be more sexually active than nonorphans (Kang et al., 2008; Nyamukapa et al., 2008; Palermo & Peterman, 2009; Thurman et al., 2006); and to have higher rates of sexual risk-taking and reported forced sex (Birdthistle et al., 2008). Other research, including pilot study research conducted by these authors*,* finds orphaned girls more likely to go into sex work and, conversely, sex workers in low and middle income countries (LMICs) to be highly likely to have been orphaned and abandoned children (OAC) (Mangoma et al., 2008). The small, qualitative pilot study was not meant to demonstrate causality but to explore the relationship between OAC and sex work. Qualitative interviews were conducted with 25 female sex workers in Hyderabad, India. Our research team and outreach workers visited 'hot spots' (railway stations and bus stops known as areas where sex workers find customers) and sex workers' homes. While not part of the inclusion criteria for the study, it was notable that 16 of the 25 women (64%) were found to have been either single or double orphans.

Human and animal studies demonstrate that greater stress results in increased propensity for drug and alcohol use (Gordon, 2002). The biological response to early life stress modifies neurodevelopment in permanent ways; these neuroadaptations occur within the same neuronal systems that comprise the drug, sex and risk-taking/gambling reward circuit (Adinoff, 2004; Gordon, 2002). Children who have experienced trauma and chronic stress

that the death of a parent under any circumstances, regardless of the additional burden of a stigmatizing illness, is grounds for increased risk of depression and anxiety. She further suggests that one in five children who experience parental death will "likely develop a psychological disorder" (Dowdney, 2000). Dysphoria and depression are the most widely reported of psychological problems in children following parental death (Dowdney, 2000). Severe depression is a potential issue, but is infrequently found in the literature on childhood bereavement. However, it is important to remember that depression and anxiety are associated with suicidal ideation. The type of despair that can accompany the loss one feels with the death of a parent, when unchecked and unmonitored, particularly in the wake of a stigmatizing illness where there is little to no community supporting that child, is a

There are other behavioral and emotional issues that are potential risks with parental death such as anxiety, temper tantrums, hyperactivity, withdrawal and other kinds of somatizing disorders (stomachaches) but in the case of children orphaned by AIDS, it is difficult to tease out causal variables (AIDS, AIDS orphanhood, orphanhood alone) due to the complexity of challenges when a parent is lost to a stigmatizing illness. There is varying evidence related to whether expected death (long illness preceding death) further complicates or ameliorates the grieving process. Likely there are many mediating and moderating factors, such as the way death is dealt with in the family, the way the illness/death is viewed in the community (stigma), any planning that is done ahead of time, and how much the child is included in these decisions and discussions. Indeed, these are not symptoms unique to children who have been orphaned, but it is necessary to understand the full complexity these children are facing when they lose their parents to HIV/AIDS and why they may be more vulnerable to

Sexual risk behaviors, and other HIV risk behaviours are of particular concern when discussing the health of OVCs. Studies found orphans to be more sexually active than nonorphans (Kang et al., 2008; Nyamukapa et al., 2008; Palermo & Peterman, 2009; Thurman et al., 2006); and to have higher rates of sexual risk-taking and reported forced sex (Birdthistle et al., 2008). Other research, including pilot study research conducted by these authors*,* finds orphaned girls more likely to go into sex work and, conversely, sex workers in low and middle income countries (LMICs) to be highly likely to have been orphaned and abandoned children (OAC) (Mangoma et al., 2008). The small, qualitative pilot study was not meant to demonstrate causality but to explore the relationship between OAC and sex work. Qualitative interviews were conducted with 25 female sex workers in Hyderabad, India. Our research team and outreach workers visited 'hot spots' (railway stations and bus stops known as areas where sex workers find customers) and sex workers' homes. While not part of the inclusion criteria for the study, it was notable that 16 of the 25 women (64%) were

Human and animal studies demonstrate that greater stress results in increased propensity for drug and alcohol use (Gordon, 2002). The biological response to early life stress modifies neurodevelopment in permanent ways; these neuroadaptations occur within the same neuronal systems that comprise the drug, sex and risk-taking/gambling reward circuit (Adinoff, 2004; Gordon, 2002). Children who have experienced trauma and chronic stress

**1.3 HIV-related risk-taking behaviors as it relates to trauma in children** 

sobering picture.

trauma and traumatic experience.

found to have been either single or double orphans.

are more likely to be biologically predisposed to gravitate to drug and alcohol use and risky sexual activity (Adinoff, 2004; Gordon, 2002). Our team's adult HIV studies have demonstrated strong relationships between childhood trauma and adult drug and alcohol use, as well as high-risk sexual activity (Leserman et al., 2005; Mugavero et al., 2007; Pence et al., 2008; K. Whetten et al., 2005). Baseline data from the POFO study indicate ongoing traumatic experiences of OAC (K. Whetten et al., 2011); in the 36 month follow-up, some OAC reported illicit drug use and having been drunk.

#### **1.4 Post-traumatic stress disorder and trauma in children**

There is ample evidence associating PTSD with trauma exposure in children, with documented and well-researched examples such as bearing witness to neighborhood or familial violence, war, and/or natural disasters. A plethora of research exists examining the effect of all sorts of traumatic events: following the terrorist attack of September 11th in the United States, post-conflict research in Bosnia-Herzegovnia, Croatia, Cambodia, Algeria and Palestine; victims of both community and personal violence (rape or physical assault); and victims of natural disaster, etc. all documenting rates of PTSD and the effects of traumatic events (Calderoni et al., 2006; Dobricki et al., 2010; Hoven et al., 2005; Klaric et al., 2007; Loncar et al., 2006). However, there are remarkably few articles in the literature examining PTSD among orphans, given the sheer number of orphans and the simple vulnerability of the population. There are some studies that have identified trauma and PTSD as significant factors in the life of a child orphaned by HIV. In her South African study of over 1,000 children ages 10-19, Cluver found that AIDS-orphaned children reported high levels of symptoms of PTSD when controlling for age, migration (moving between homes), household size, and gender. This same study revealed higher levels of other psychological distress among children who were orphaned by AIDS, when compared to children orphaned by other causes and non-orphans. The POFO study also found that in addition to losing 1 or both parents, 98% of the sample of 1,258 children experienced at least 1 more traumatic event and more than half (55%) experienced 4 or more traumatic events. While this study did not diagnose PTSD, the sheer fact of having experienced what have been scientifically proven as potentially traumatic events is ominous, never mind *four* such events.

What may be even more important, particularly as we try to intervene on the behalf of children who have experienced trauma and those who have been diagnosed with PTSD is that children who have already experienced one trauma are at an increased risk of experiencing more traumas. Simply put, trauma begets trauma; this is terrifying because we do know that children who experience trauma and/or have experienced PTSD are more vulnerable in their adult lives to psychological problems like depression and anxiety, as well as an increased risk for contracting HIV and other STDs (K. Whetten et al., 2008; Whitmire et al., 1999) than children who have not experienced trauma/do not have PTSD. A 2009 review of all published psychosocial interventions for children orphaned by or vulnerable from HIV/AIDS, defined psychosocial intervention as including "…psychological therapy, psychosocial support and/or care, medical interventions and social interventions…" with liberal inclusion criteria "..Randomised controlled trials, crossover trials, cluster-randomised trials and factorial trials were eligible for inclusion. If no controlled trials were found, data from well-designed non-randomised intervention studies (such as before and after studies), cohort, and case-control observational studies were considered for inclusion. Studies which included male and female children under the age of 18 years of age, either orphaned due to AIDS (one or more parents died of HIV related-illness or AIDS), or vulnerable children (one

AIDS and Trauma: Adults, Children and Orphans 267

*though not everyone in the village attended, as was the tradition. He wanted to ask his mother about* 

Stigma is a formidable presence in the lives of children affected by HIV but one that is difficult to measure. Stigma can be witnessed in the form of outright discrimination – not allowing children who are infected or those associated with people infected (like children of infected parents) to play or associate with uninfected children is one of the major ways that children experience stigma. The POFO study sought to measure stigma by asking people employed as caregivers in orphanages and people who took care of children who were not biologically their own if they would hypothetically allow their children to play with a child who was known to be infected by HIV. The research team also asked the participants if they would care for a relative who was sickened by the virus. The results showed that individuals associated with institutions were more accepting of those infected with HIV (willing to care for relatives and/or letting their children play with an infected child) and more knowledgeable about the virus (Messer et al., 2010). Unpublished qualitative data from the same study asked about stigma experienced by both children orphaned by HIV and those who were orphaned by other causes. The participants reported that children orphaned by HIV were sometimes stigmatized and shunned by other children and even their caretakers treated them poorly. A few children reported that they felt that being an orphan 'marked' them either through the simple fact of being parentless or by the poverty that often befell them as a result of losing an adult breadwinner in their family. There have been numerous interventions and attempts at reducing stigma targeted in the areas hardest hit by the epidemic. However, as a global society we have yet to evolve enough to where being HIV+ is not a mark of shame for individuals

*Joshua's younger brothers continued to go to school and he continued to work the fields with his mother while his elder sister worked at home and took the vegetables they could afford to sell into town. He missed his father and he had less to time play with his friends. When he did have a little spare time, he had less in common with them because he felt older and more mature than them. He was not sure, but he thought that some of his friend's parents didn't look at him directly anymore, like his friend Michael. His mother used to invite him inside every time he would play football with Michael, but since his father died, she had not invited him in the house. Michael and he used to talk about the other kids in their class a lot. Michael kept him updated on the school gossip, but it just made Joshua sad because he realized while it felt important to be taking care of the family and to be the 'man' of the household, he missed his old life; he missed his friends and he even missed school. He started making up excuses to not play football when Michael came around to spend time with him. It wasn't difficult to come up with reasons to not go, because truthfully there were always more chores, more things to be done for the household – animals to tend to, water to be fetched, children to be* 

Another stress that is not measured or noted much in the literature but is a very real and concerning issue is how children in families affected by AIDS find themselves cut off from their former social networks and from their friends. Most importantly, they are often cut off from their natural emotional outlets for sharing and working through problems with their friends. Whether this is done through sitting down and talking under the acacia tree or on the football field with nine other boys, the outlet is crucial and when these begin to crumble

*Things were different at Joshua's house now. Paul, the seven year old, was getting in trouble in school not infrequently; he was bringing home letters from the teacher detailing his poor behavior during lessons and sometimes discussing fights he instigated with others. When questioned, he claimed he is* 

through stigma and through new responsibilities to the family, these children suffer.

*this, but he was afraid he knew the answer. People were afraid of how his father died.* 

and/or their families.

*bathed. And his mother seemed more tired than usual lately.* 

or more parents living with HIV or AIDS)…", turned up exactly ZERO tested, evidencedbased interventions available to these children who are in such desperate need and in a clear and present danger (King et al., 2002). In other words, it is documented that there are children in need of help, yet there is little evidence that the 'help' on the ground is based on empirical research.

Currently, these authors are aware of a few pilot studies that are using Judith Cohen's manualized Cognitive-Based Therapy (CBT) to address traumatic grief in children who have been orphaned and early analysis is showing real promise.
