SOCIAL PROTECTION IN THE CONTEXT OF HIV AND AIDS 13
encounter (Gillespie, Kadiyala, and Greener 2007). Poor maternal nutritional status can increase the risk of vertical transmission of HIV from mother to infant (during pregnancy or delivery or via breastfeeding). HIV can suppress the immune system and increase oxidative stress, which lead to nutritional defi- ciencies, which in turn allow for increased HIV replication and accelerated disease progression (Haddad and Gillespie 2001). HIV can lead to insufficient dietary intake, altered metabolism, and malabsorption of nutrients—because opportunistic infections associated with HIV, which cause diarrhea, vomiting, and damaged intestinal cells, among other effects, can inhibit the absorption of nutrients that are consumed—accelerating the onset of AIDS (Semba and Tang 1999, as cited in Gillespie and Kadiyala 2005, 24). Weight loss resulting from the deleterious interactions between HIV and food intake and absorp- tion has been shown to be a strong predictor of morbidity and mortality for HIV-positive individuals. As opposed to experiencing no weight loss, losing 5–10 percent of one’s body weight increases the risk of infection by 61–176 percent, and losing more than 10 percent of one’s body weight is associated with more than double the likelihood of death (Tabi and Vogel 2006). All of these processes severely affect children, from their own risks of
infection (for example, from mother-to-child transmission or risk-taking by adolescents) to the interactions of malnutrition with infection to the eco- nomic and psychosocial impacts of parents’ and other relatives’ illness and death. Children, before and following the death of parents, suffer from trauma, new workloads and responsibilities, abandonment, migration, fear, and stigma (Adato et al. 2005). Children living with ill parents may be more food insecure, or their foster families may not be able to afford, or may not prioritize, spending on them. There is evidence from some countries that orphans are more food insecure and malnourished, are less healthy (Ains- worth and Semali 2000; Lundberg and Over 2000; Gilborn et al. 2001; Dein- inger, Garcia, and Subbarao 2003; Rivers, Silvestre, and Mason 2004), and have lower school enrollment and attendance rates (Case, Paxson, and Ableidinger 2003; Case and Ardington 2006; Evans and Miguel 2007). But there is also evidence that orphans do the same or occasionally better on these indicators and do not always live with poorer families than nonorphans, because wealthier families may be better positioned to take them in (Ains- worth and Filmer 2006). The relationships between child and caregivers, eco- nomic status, household structure, and especially wealth can have more bearing on these indicators than orphan status alone (see Case, Paxson, and Ableidinger 2003 on education; Ainsworth and Filmer 2006 on education; Stewart 2007 on nutrition). In Chapter 3 we review this literature and debate further in discussing how best to target benefits—that is, how to reach people affected by AIDS while remaining fair to others with similar needs.
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