December 2007 Vol 8 After Meeting.indd From HIV Abandonment to Adoption Case study of New Life Home for abandoned babies, Kenya *Abdul Majid Wangai Jr, Maryam Wangai, Mary Beckenham, Clive Beckenham SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL DECEMBER 2007 VOL 7, NO. 3, P. 239-246 SULTAN QABOOS UNIVERSITY© SUBMITTED - 23TH MAY 2007 ACCEPTED - 12TH SEPTEMBER 2007 C L I N I C A L A N D B A S I C R E S E A R C H التبني إلى البشري املناعة نقص فيروس إهمال عالج من املهملني الرضع لألطفال جديد بيت في حياة حالة دراسة بيكنهام كليف واجنبي، ميري بيكنهمام، مرمي آر، جي وجني ايد عبد الرضع اجلديد لرعاية األطفال البيت مهام من . البشري اجلائِحَ املناعة نقص فيروس نتيجة وباء في العالم واملعرضون اليتامى األطفال عدد زاد امللخص: هذا البحث يتحرى عن . للتبني ــة بحاج مما يجعلهم املذكور، للفيروس تعرضهم ــبب بس الغالب في كذلك أصبحوا الذين أو املهملني ، ــى ــن اليتام م رضيعا 490 طفال عن منط التحري في االستعادي التحليل بني . املذكور البيت من إنشاء ونصف سنوات ــع تس ألول ــتنبطة املس الدروس بتوثيق ويقوم ، املنظمة/ للفيروس التعرض ، ــوزن ال البيولوجية ، ، وحتليل املعطيات ــال األطف هؤالء إقامة ونتائج صفات مراجعة حيث متت ــت، البي ــي هذا ف ــوا ادخل الذين ، أو البيت ذلك خارج يتم تبنيه رضيع/رضيعة أي تتابع ال ــة الدراس هذه البيت. في التداخل ونتيجة الطفل ومصير ، احلالة حولت الوكالة التي من (15%) الصحية ، املراكز طريق عن األطفال من (58%) حتويل مت . األصلية باألسر إحلاقهم اعيد الذين أكبر عمرا أو ألطفال بيت إلى نقلوا أو ماتوا يزالون ال رضيعا (92%) 425 هناك كان ــة الدراس في نهاية األخرى. األطفال بيوت من و(25%) ، اليهودية من اجلمعيات (2%) ، احمللية ــلطات الس 45%)) وكان ، - <0.003) (احتمالية واضح إحصائي فرق مع - ــهر أش ــتة الس ــن س ((%80 منهم دون هناك فكان ماتوا الذين .أما احلياة قيد على والوزن ،<000) (احتمالية للفيروس التعرض إليه: أدت العوامل التي ومن ،1000-/77.6 األطفال وفيات معدل كان للفيروس. بالنسبة موجبا منهم 6 عمر 1.6 – 2في ــبة املعرضني بنس غير أكبر من للفيروس املعرضني األطفال وفيات كان معدل . =0.002) (احتمالية البيت في ــجيل التس عند 12 عمر 1000/94.7 في ، 6 أشهر عمر 1000/71 في املعرضني للفيروس وفيات األطفال معدل كان 18شهرا. و التوالي على ــهرا 12ش و ــهر أش شهرا. عشر اثنا عمر و1000/46.7 في ــهر أش ــتة س 1000/43.3 في عمر املعرضني بينما كان لغير ، ــهرا 18 ش عمر 1000/100.6 في و ــهرا ش تبنيهم مت الرضع األطفال معظم . (22%) وِيّ مَ واإلِنْتانٌ الدَ (56%) االلتهاب الرئوي هو العرضني للفيروس األطفال عند ــي الرئيس الوفاة ــبب س كان حياة . سنا أطفاال أكبر ترعى اخرى بيوت الى حولوا (1.4%) 7 الباقي والقليل األصلية عوائلهم الى 32 منهم أعيد(6.3%) بينما ،(67%) 323 جديدة والبدء بحياة التبني احلصول على ميكنهم املعرضني األطفال ألن غالبية ، األطفال اليتامى واملعرضني لرعاية محتمال مثاال توضح اجلديد البيت نقص فيروس ــار انتش التي يكون األفريقية الصحراء جنوب في دول األطفال مثل هؤالء معضلة لتخفيف وتطبيقها ــتها دراس ميكن الطريقة هذه . . كبيرا املكتسب املناعة ، كينيا. اليتامى املناعة البشري ، نقص : فيروس الكلمات مفتاح New Life Home, P. O. Box 62610, City Square, Nairobi 00200, Kenya, East Africa * To whom correspondence should be addressed. Email: drmajidwangai@yahoo.co.uk Objective: The number of orphaned and vulnerable children (OVC) worldwide has increased as a result of the Human Immunodefi- ciency Virus (HIV) pandemic. New Life Home (NLH) specialises in the care of infants who have been orphaned or abandoned, often because of their exposure to HIV and places them for adoption. This paper documents the lessons learnt from the Home’s first 8.5 years of existence. Methods: This retrospective study analyses the pattern of the 490 infants admitted at NLH. The characteristics of the infants’ stay are analysed: bio-data, weight, HIV exposure, referring organisation/agent and outcome. This study ceased to follow infants after adoption, death, transferral to other homes, or reunion with own family. The infants came via health facilities (58%), local authorities (5%), good Samaritans (2%), and other children’s homes (25%). Results: At the end of the study period, 425 (92%) of babies were still alive. Of those who died, 80% were less than 6 months old (p<0.003) and 45% were HIV positive. A child mortality rate of 77.6/000 was demonstrated with the key associated factors being HIV exposure (p <000), and weight at admission (p=0.002). The mortality rate for the HIV exposed was 7/000 at 6 months, 94.7/000 at 2 months and 00.6/000 at 8 months, while for those not exposed to the virus it was 43.3/000 at 6 months and 46.7/000 at 2 months. The major cause of death in the HIV exposed was pneumonia (56%) and septicaemia (22%). The majority of infants, 323 (67%) were adopted, some were reabsorbed into their biologi- cal families 3(6.3%) and a minority 7(.4%) transferred to other children’s homes which cater for older children. Conclusion: NLH demonstrates a possible model of care for OVC as majority of vulnerable child can have the opportunity to be adopted and thereby a ‘second lease’ of life. This strategy is worth studying and duplicating in the mitigation of the OVC dilemma in HIV high prevalence countries in sub-Saharan Africa. Keywords: HIV; AIDS; Care, orphans, Kenya. A B D U L M A J I D WA N G A I J R , M A R YA M WA N G A I , M A R Y B E C K E N H A M A N D C L I V E B E C K E N H A M 240 IN THE LAST TWO DECADES, KENYA HAS SEEN AN unprecedented increase in the number of orphans. In 2001, it was estimated that there were about 1 million orphans countrywide. This number was pro- jected to rise to 1.8 million by 2005 and 2.2 million by 2010. The majority (90%) of these orphans are as a re- sult of the HIV/AIDS epidemic.1, 2, 3 This problem is not unique to Kenya. Worldwide, 13.2 million children are orphaned as a result of AIDS.4 By the year 2010, this number is expected to rise to more than 25 million.4 In 12 African countries, projec- tions show that orphans, who constituted 12% of all children under 15 years of age in 2001, will increase to 15% by 2010.5, 6 To compound this scenario further, orphaned chil- dren living in areas with a high HIV prevalence are es- pecially vulnerable to a myriad of problems, including HIV infection, malnutrition, high morbidity and mor- tality, physical and social abuse, exploitation, illiteracy, fear, isolation and loss of inheritance.7, 8, 9 Households headed by orphans are also becoming increasingly common in these areas.10 The HIV/AIDS epidemic is having a devastating im- pact on children in Sub-Saharan Africa. Regardless of whether a baby is infected or not, the mortality in chil- dren born to HIV positive mothers is higher than those born into non-HIV affected households.7, 10, 11 The past decade alone has seen an increasing disparity in infant mortality rates between the least developed countries (LCD) and other developing countries. The difference in the rates between these countries is widening from 2.1 to 2.3 fold.12 This disparity has been attributed to three key factors: HIV/AIDS epidemic, underinvest- ment in children, instability and conflict. Secondly, there has been a steady increase in the under-5 child mortality rate. In Kenya, under-5 mortality has risen from 87 per 1000 live births in 1986 to 115 per 1000 live births in 2003.13 This denotes a reversal of health gains made over the previous three decades.14 However, there are some valiant efforts being made on behalf of young children. Individuals, communities and governments as a whole are responding in vari- ous ways to stem the negative effects of the epidemic.3 Orphanages and other formal institutions have proved to be an inadequate part of the response to orphaned and vulnerable children. The financial costs to maintain each child outstrips that of other forms of care. Fur- thermore, the children are left without the psychologi- cal, social and cultural skills which they need to func- tion successfully as adults. Orphanages are therefore seen as a last or temporary resort.14 The government of Kenya has shown commitment to mitigating the effect of the HIV/AIDS pandemic on children by developing policies and guidelines to give strategic direction in the care of orphaned and vulnera- ble children, for example: National Programme Guide- lines on Orphans and Other Children Made Vulnerable by HIV/AIDS.1 This has been done as part of the wider multisectoral approach to controlling HIV/AIDS in the country. This has resulted in close collaboration be- tween government and various organisations in order to implement effective programmes which meet the needs of vulnerable children. To be part of the mitigation efforts, while recog- nising the importance of the first months and years of a child’s life, New Life Home (NLH) in Nairobi, has sought to provide a home for orphaned, abandoned and HIV positive babies. The children receive food, shelter, clothing, free medical care, love and caring sup- port within the environment of an actual home, and are eventually put up for adoption. The purpose of this study is to examine the charac- teristics of the children admitted into this Home and their exposure to HIV and the lessons learned therein. M E T H O D S A N D M A T E R I A L S ST UDY SI TE This is a case study based on data compiled from records of all infant admissions into the NLH for aban- doned and HIV babies in Nairobi, Kenya. The Home is Advances in Knowledge This article highlights one of the social impacts of the HIV/AIDS pandemic with reference to orphaned and vulner- able children. Application to Patient Care The article demonstrate a pioneering model and concerted effort to rehabilitate orphaned and vulnerable children in a region gripped by the HIV/AIDS pandemic and hampered by limited resources. F R O M H I V A B A N D O N M E N T T O A D O P T I O N 241 situated in a residential area within the city’s environs. The building in which the Home is located was reno- vated to incorporate an acute medical care unit and a well-baby residential portion. The administrators are a live-in couple. The Home is registered with the Min- istry of Home Affairs and National Heritage as a chil- dren’s home, while the medical care unit is registered by the Ministry of Health as a private medical centre and nursing home. In a bid to sensitise the public about the Home and encourage adoptions, targeted promotions were held in collaboration with opinion leaders at religious meet- ings, and in the print and electronic media. The procedures used for adoption were adapted from laws of England by the Home’s Board of Manage- ment with the support of the Children’s Department in the Ministry of Home Affairs. This was necessary because at the time the national guidelines were still under development. The adoption procedure used in- volved assessments of interested families for the stabil- ity of their homes and their socioeconomic base. This was done by a social worker in collaboration with the Directors of the Home. When the interested families met the criteria a lawyer was contracted to process the adoption through the High Court of Kenya for expatri- ate families or through the local Magistrates courts for Kenyan citizens. The adoption process took four to six months to complete. ST UDY P O P UL ATI O N A N D PE R I O D The study examines data from 490 infants’ records over a period of 8.5 years from June 1994 to Decem- ber 2002. Within this period, the Home admitted 490 infants from various sources: hospitals, police, good Samaritans, other children’s homes, including an infant rescue centre and the Kenya Red Cross. The infant res- cue centre is located in Kisumu, a high HIV prevalence region, 350 km from Nairobi. Infants were admitted from all over the country within the age group of 0 to 6 months. Upon admission, the infants underwent a medical examination and a rapid HIV test. For the initial two years of the Home, ELISA tests were used to determine possible exposure to the virus. Subsequently, rapid test kits were used: Determine® and Unigold®. The testing al- gorithm involved the use of the two different rapid test kits simultaneously (parallel testing). Due to the high costs, Polymerase Chain Reaction (PCR), using Roche RNA amplification assay, was only conducted for the babies who demonstrated that they had been exposed to HIV and were candidates for adoption. The data extracted from the children records in- clude the infant’s bio-data, weight, HIV exposure, re- ferring organisation/agent, and outcome. The infants were referred for admission from private and public hospitals, local government administration (e.g. police and chiefs), other children’s homes, a NLH rescue cen- tre based in Kisumu (350 km away) and the Kenya Red Cross. Figure 1: Organisations that refer infants to New Life Home in Nairobi A B D U L M A J I D WA N G A I J R , M A R YA M WA N G A I , M A R Y B E C K E N H A M A N D C L I V E B E C K E N H A M 242 This study ceased to follow each infant once he/she was adoption out, died, transferred to other homes for older children or reunited with the biological family. A future study in progress traces adopted babies after they leave NLH. DATA M A N A GE ME N T The data tabulation and cleaning was done using Sta- tistical Package for Social Sciences (SPSS) version 12. Analysis and mining was done using frequency distri- bution and cross tabulation. Frequency distribution was used for data cleaning. Analysis began by examin- ing frequency distribution of each variable. Also statis- tical analysis was done using frequency and cross tabu- lation to characterize the HIV exposure and referring organisations/agencies, gender and infant mortality. The predictive value for statistical significance was 0.05 (p < 0.05). R E S U L T S Between June 1994 and December 2004, 490 infants were admitted into NLH. The female infants (245) were equal in number to the male babies. The infants were admitted from various organisations: 129 (26.3%) from Kenyatta National Hospital, 59 (12%) non-governmen- tal health facilities, 96 (19.6%) other public health fa- cilities and 107 (2.8%) from the New Life Home Rescue Centre in Kisumu. The local police were also involved in bringing in 73 (15%) of the abandoned infants to the Home. These babies were entrusted to NLH by the rel- evant government agencies with legal mandates to take care of them for life, until adoption or upon their un- fortunate demise. NLH is therefore the custodian of all infants brought under its care. The Home is not an orphanage. It is a home. The live-in couple are the parents of all babies, who mix with the couple’s own children, eat with them, play with them and are basically taken care of as the couple’s own children. All children get the same treatment. Ex- tra hands by many staff assist the couple to provide the extra help needed to take care of all these babies. In es- sence, it is an enlarged home environment, rather than an impersonal orphanage. The age of the infants at admission ranged from one day to 320 days (11 months) with a mean of 53 days (7.5 months). However, of those admitted 186 (38%) were neonates and 476 (97%) were below 6 months. Once admitted the average length of stay was 150 days (5 months; interquartile range (IQR) 1.5-6 months) and a maximum of 3 years. The longest staying chil- dren were those infected with the HIV virus (X2 = 381; p<000). The age at which the children are discharged ranged from 2 days to 785 days (2.2 yrs) with a mean of 203 days (6 months) and IQR of 3-9months. C H I L D MO RTA L I T Y A N D H I V E X P O SUR E At the close of the study period, a total of 452 (92%) out of 490 infants were still alive denoting a child mortality Figure 2: Comparison of adoption between Kenyan and expatriate parents over time F R O M H I V A B A N D O N M E N T T O A D O P T I O N 243 rate of 77.6 per 1000 live births. Of the infants who died 22 (58%) were female and 16 (42%) were male. Eight- een (47%) of the infants who died had been exposed to HIV. Of all the children who died, 32(84%) were 198 days old (6.5 months) and below. Twenty two (58%) of the infants who died were referred from the various health facilities, 7 (18%) from police and 8 (21%) from children’s homes. The factors associated with infant mortality weight at admission (p=0.002), HIV exposure (p<0001) and length of stay (p=0.16). On admission, 177 (36%) infants tested positive for antibodies to the HIV virus. Of all the children, eight- een (3.7%) were HIV exposed children who died. One hundred and thirteen (35%) of the children adopted demonstrated evidence of having been exposed to HIV before their admission into the Home. The mortality rate of children exposed to HIV was 1.6 and 2 times higher at 6 and 12 months respectively than that of non-exposed children. The mortality rate for the HIV exposed was 71/1000 at 6 months, 94.7/ 1000 at 12 months and 100.6/1000 at 18 months while for those not exposed to the virus it was 43.3/1000 at 6 months and 46.7/1000 at 12 months. In the age bracket 6 to 12 months, the mortality rate was 23.7/1000 in HIV exposed infants and 3.3/1000 in the non-exposed infants, while in the age bracket 12-18 months mortal- ity in the HIV exposed children was 100.6/1000 live births. There were no deaths recorded in the Home in chil- dren older than 18 months. C H A R A C TE R I STI C S O F TH E A D O P TI O N S The majority of infants, 323 (67%), left the Home to join adoptive parents/families. At the end of the study period, 160 (32.7%) of the children had been adopted by expatriate families, 166 (34%) adopted by Kenyan citizens, while only 87 (18%) were still resident in the Home. Over the years, adoption by Kenyan citizens has increased nine-fold. In 1996 only 6% of adoptions were to Kenyan families while in 1999 this had changed to 56%. The average age at which the infants were adopted was 181 days (6 months) (IQR 4 to 7.7 months). These infants had an average weight of 6.2kg (IQR 4.8-7.6kg). Over the latter two years the rate of adoption de- clined from 85% in 2001 to 30% in 2003. This denotes nearly a three-fold decline. The expatriate families were three times less likely to adopt than Kenyan families. Seven (1.4%) of the transfers to other children’s homes have been of HIV positive children. A few children 31 (6.3%) were reabsorbed back into their biological fami- lies. D I S C U S S I O N This study of NLH seeks to demonstrate that irrespec- tive of the referring agent or HIV exposure the outcome of a well managed abandoned or orphaned baby can be Figure 3: Profile of infants’ discharge destinations A B D U L M A J I D WA N G A I J R , M A R YA M WA N G A I , M A R Y B E C K E N H A M A N D C L I V E B E C K E N H A M 244 good. Nearly 40% of admitted infants demonstrated expo- sure to the HIV virus. This is in contrast to the general Kenyan HIV prevalence at antenatal surveillance clin- ics, which ranged between 9 and 13% over the study period.2 This implies that abandoned children are pos- sibly more likely to have been exposed to HIV from their mothers. Accommodating the HIV exposed infants at the Home where they are fed on breast milk reduces the risk of transmission of the virus. Meta-analytical stud- ies have shown that frequency of breast milk transmis- sion is 14% for women with established infection and 29% during acute maternal illness.15 It has also been demonstrated that the use of breast milk substitutes prevents 44% of infections.16 The Home’s infant mortality rate was estimated at 78 per 1000 live births. Mortality was noted to be sub- stantially higher in the children previously exposed to HIV. This was especially evident in the age group be- tween 6 to 12 months where a seven-fold difference was seen. The fact that HIV exposure and infection is a con- tributing factor to mortality has been demonstrated in various studies.11, 17, 18 However, the mortality rate of infants at 12 months for both HIV exposed and non- exposed infants is considerably lower at the Home than is documented in a study conducted in urban Malawi on the effect of HIV on birth weight, infant and child mortality.18 The Malawi study reported a mortality rate that was 2.3 times higher for HIV exposed children at 223/1000 and 1.5 times higher in the non-exposed at 68/1000. However, further study into the Home’s model of care, support and treatment is needed for it to dem- onstrate fully its successes. The commonest causes of death, regardless of the exposure to HIV, were septicaemia (39%) pneumonia (26%) and cardiac conditions (10.5%) in all the chil- dren; however, in the HIV exposed children, pneu- monia was the commonest cause of death followed by septicaemia(56% and 22%, respectively). The cause of death in the HIV exposed children seen in this study is in line with other studies done in Malawi, where one of the frequent causes of death was pneumonia.19 The majority of surviving infants (67%) were adopt- ed into both expatriate families and indigenous Kenyan families. Adoptive parents seemed to prefer to adopt younger children aged about 6 months and weighing about 6kg. Initially, in the early years of the Home, the adop- tions were by expatriate families; Kenyan families were slow to adopt. This may be a result of cultural percep- tions on adoptions among other reasons. However, once opinion leaders adopted children there was a notable increase in young Kenyan couples adopting. The trend noted in this study represents a twelve fold Table 1: Characteristics of infants admitted into New Life Home HIV not exposed HIV Exposed Not tested Total Gender No. (% within gender) No.(% within gender) No. Female 155 (63.3) 83 (33.9) 7(2.9) 245 Male 145 (59.2) 94 (38.4) 6(2.4) 245 Referring Agent No. (% within the referring agent) No.(% within the referring agent) Not tested No. Kenyatta National Hosp. 73 (56.6) 65 (42.6) 1(0.8) 139 Other Public Health Facilities 41 (42.7) 55 (57.3) 0 96 Good Samaritans 9(75) 3(25) 0 12 NGO Health Facilities 38 (64.4) 20 (33.9) 1(1.7) 59 Police/Local Administration 50 (68.5) 13 (17.8) 10(13.7) 73 Other Children Homes 1 (7.1) 12 (85.7) 1(7.1) 14 NLH Rescue Centre- Kisumu 53 (21.6) 54 (22) 0 107 Infant Mortality No. (% within HIV exposure) No. (% within HIV exposure) Not tested No. Alive 286 (95.3) 159 (89.8) 7 452 Dead 14 (4.7) 18 (10.2) 6 38 Fate of children No. (% within HIV exposure) No. (% within HIV exposure) Not tested No. Kenyan Adoptions 115 (38.3) 51 (28.8) 0 166 Expatriate Adoptions 97 (32.3) 62 (35) 1(7.7) 160 Transfers to Children Homes 3 (1) 4 (4.3) 0 7 Transfer to Biological Family 14 (4.7) 12 (6.8) 5 (38.5) 32 Resident at New Life Home 57 (19) 29 (6.4) 1(7.7) 87 F R O M H I V A B A N D O N M E N T T O A D O P T I O N 245 increase over a 9 year period. Expatriate families who were equally willing to participate in adoption supple- mented this trend. In countries hardest hit by HIV/AIDS, care for or- phans and children affected by HIV/AIDS lies prima- rily with their families and communities. This places a heavy burden on the extended family system, which is the backbone of African societies. In response to this, the Malawian and Namibian governments in conjunc- tion with UNICEF provide equipment, supplies and materials to day-care centres that provide free services to orphans.6 Other countries such as Botswana provide support to NGOs, extended and foster families. The support ranges from family counselling to meeting physical basic needs such as food, clothing and education.20 Ex- perience shows that successful programmes are those that are child-centred, family and community focused, and where the rights of the child are respected and protected.21 NLH participates actively in facilitating adoption procedures of the infants into Kenyan or expatriate families. Adoption is encouraged because it allows the infants to transit into homes where there is greater per- sonalised attention. Child socialization can thus be ef- fected while also seeking to secure their future. Within the country, this strategy is deemed one of the avenues for effectively caring for orphans and children affect- ed by HIV/AIDS (OVC’s). In the absence of adoption, AIDS orphans contribute substantially to the number of street children. The study had various limitations as it was de- pendent on extracting previously recorded data from children’s records and gaps in the records existed. First, the completeness of the records was dependent on the thoroughness of the nursing and managerial staff who had previously attended the children. For example, large number of records did not contain the birth weight and heights of the infants therefore analysis was not pos- sible. Second, the retrospective nature of the study (as opposed to prospective) precluded the collection and analysis of other important variables and associations that would affect outcomes such as the nutritional sta- tus of the infants, and the HIV/AIDS and health status of birth mothers. Third, being in a resource constrained setting the Home can only provide for minimal labora- tory and radiologic tests. The cost of PCR (RNA) was US$114-157 for each specimen; hence it was not be possible to determine rates of HIV infection in admit- ted infants at less than 18 months of age, as PCR (ri- bonucleic acid RNA) was not universally done. PCR (DNA), being the better diagnostic test for infant diag- nosis, was not done because it was not readily available in the country during the study period. C O N C L U S I O N The strategy used by the NLH for addressing the Vacs’ situation, with particular reference to abandoned in- fants, is reproducible. Its strength lies in the rescuing of abandoned infants, who are vulnerable to HIV infec- tion, morbidity, mortality or dysfunctional livelihood. These infants are cared for, while community members are encouraged to participate in their adoption. In ef- fect, the Home serves as a transition for OVCs in their infancy. All in all, the mitigation of the HIV impact on chil- dren of all ages is a challenge that demands a multisec- toral response and needs to be dealt with as priority for HIV Positive No. (% in group) HIV Negative No. (% within Group) Total (%) Pneumonia 10 (56) 2 (10) 12 (26) Heart defects and Congestive Cardiac Failure 2 (11) 2 (10) 4 (10.5) Strangulated Hernia 2 (10) 2 (5) Meningitis 1 (13) 1 (5) 2 (5) Septicaemia 4 (22) 11 (52) 15 (38) Cot Death 1(13) 0 1 (3) Malnutrition 2 (10) 2 (5) Aspiration Pneumonia 1 (5) 1 (3) Total 18 (46) 21 (54) 39 (100) Table 2: Cause of infant deaths A B D U L M A J I D WA N G A I J R , M A R YA M WA N G A I , M A R Y B E C K E N H A M A N D C L I V E B E C K E N H A M 246 the sake of securing our next generation, our future. R E F E R E N C E S 1. Republic of Kenya, Department of Children’s Services, Ministry of Home Affairs (MOHA) and National AIDS Control Council. National Programme Guidelines on Orphans and Other Children Made Vulnerable by HIV/ AIDS. Nairobi, 2003. 2. Republic of Kenya, Ministry of Health, National AIDS and STD Control Programme. AIDS in Kenya: Back- ground projections, impact, interventions and policy. 6th ed. Nairobi: NASCOP, 2001. 3. Joint United Nations Programme on HIV/AIDS. Report on the Global HIV/AIDS Epidemic: 4th Report. UN- AIDS, 2004. p. 65 4. Joint United Nations Programme on HIV/AIDS and United Nations Children’s Fund (UNICEF) US Agency for International Development (USAID). Children on the Brink 2002: A joint report on orphan estimates and program strategies. Geneva: UNAIDS, 2002. 5. UNAIDS. Report on the global HIV/AIDS Epidemic. UNAIDS, July 2002. 6. Bellamy C. State of the World’s Children 2001: Early childhood. UNICEF, 2000. 7. Abrams EJ, Matheson PB, Thomas PA, Thea DM, Krasin- ski K, Lambert G, et al. Neonatal predictors of infection status and early death among 332 infants at risk of HIV-1 infection monitored prospectively from birth. New York City Perinatal HIV Transmission Collaborative Study Group. Pediatrics 1995; 96:451-458. 8. Barnett T and Blake P. AIDS in Africa. It’s present and future impact. London: The Bellhaven Press, 1992 9. World Bank, AIDS and Development: Moving Beyond the Partial Paradigm. New York: Oxford Press, 1995. 10. Mukoyogo M C, Williams G. AIDS Orphans: A Com- munity perspective from Tanzania strategies for hope. London: Action Aid, 1992. 11. Newell ML, Coovadia H, Cortina-Borja M, Rollins NC, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet 2004; 364:1236-1243. 12. United Nations Children’s Fund. Poverty and Chil- dren: Lessons of the 90’s for least developed countries. UNICEF, 2002. p. 9. 13. Republic of Kenya, Central Bureau of Statistics, Ministry of Health. Kenya Demographic Health Survey 2003. Cal- verton, Maryland: DHS, MOH and ORC Macro, 2004. 14. UNAIDS. Report on the Global HIV/AIDS epidemic. UNAIDS, 2000. 15. Dunn DT. Newell ML, Ades AE, Peckham CS. Risk of Human Immunodeficiency virus type and transmission through Breastfeeding. Lancet 1992; 340:585 -588. 16. Nduati R, John G, Mbori-Ngacha D, Richardson B, Over- baugh J, Mwatha A, et al. Effect of breastfeeding and for- mula feeding on transmission of HIV-1: A randomised clinical trial. JAMA 2000; 283:1167-1174. 17. Zijenah L, Mbizvo MT, Kasule J, Nathoo K, Munjoma M, Mahomed K, Maldonado Y, et al. Mortality in the first 2 years among infants born to human immunodeficiency virus-infected women in Harare, Zimbabwe. J Infect Dis 1998; 178:109-113. 18. Taha TE, Dallabetta GA, Canner JK, Chiphangwi JD, Liomba NG, Hoover DR, et al. The effect of human im- munodeficiency virus infection on birthweight, and in- fant and child mortality in urban Malawi. Int J Epidemiol 1995; 24:1022-1029. 19. Sherry B, Embree JE, Mei Z, Ndinya-Achola JO, Njenga S, Muchunga ER, et al. Sociodemographic characteris- tics, care, feeding practices, and growth of cohorts of children born to HIV-1 seropositive and seronegative mothers in Nairobi, Kenya. Trop Med Int Health 2000; 5:678-686. 20. UNAIDS/UNICEF. Children Orphaned by AIDS: Front- line responses from Easter and Southern Africa. UN- AIDS/UNICEF, 1999. 21. UNICEF. Poverty Reduction Begins with Children. UNICEF, 2000.