Expanded HIV treatment dramatically reduced orphanhood rates in Uganda

The scale-up of HIV treatment and prevention programs has led to remarkable declines in orphanhood rates in Rakai, Uganda, according to a new study at Columbia University Mailman School of Public Health. Antiretroviral therapy (ART) availability has been the primary driver of these improvements, underscoring the critical importance of sustained investment in HIV programs. Findings from the study, " Incidence and prevalence of orphanhood in Rakai, Uganda: a population-based cohort study, 1995–2022" are published in The Lancet Global Health.  

Using data from the Rakai Community Cohort Study (RCCS), one of the largest community cohort studies in sub-Saharan Africa, the research tracked 92,441 children and adolescents under age 18 years in 28 continuously surveyed communities from 1995 to 2022 to advance understanding of orphanhood trends in the context of evolving HIV programs.

Between 2003–04 and 2020–22, orphanhood prevalence in Rakai declined dramatically from 21.5 percent to just 6.3 percent -a reduction of approximately 70 percent. Orphanhood incidence (new cases of becoming an orphan) showed an even greater decline.

The steepest declines occurred after ART became fully available (2015–22), compared to periods of partial availability (2004–14) and pre-ART era (1995–2003). The proportion of new orphanhood cases attributed to maternal HIV status plummeted from 67 percent in 2004 to just 11 percent in 2022. For parental HIV status, attribution declined from 71 percent to 12 percent over the same period. 

The scale-up of antiretroviral therapy in Uganda has clearly played a leading role in the observed declines in orphanhood incidence, demonstrating the life-saving impact of comprehensive HIV treatment programs and treatment as prevention." 

Aleya Khalifa, PhD, postdoctoral research scientist in the Department of Population and Family Health, and co-lead author

"Importantly, these programs have not just extended the lives of parents living with HIV but have also protected children from the devastating social and health consequences of losing their parents," added Debbie Malden, DPhil and epidemiologist in the Columbia Population Research Center, and a co-lead author.

These findings provide compelling evidence for the effectiveness of widespread ART availability and the power of treatment as prevention in reducing orphanhood in sub-Saharan Africa, according to the authors. However, they emphasize that despite these gains, a considerable burden of orphanhood persists, particularly among adolescents. The study recommends that public health policies should ensure sustained investment in HIV treatment and prevention programs, improve accessibility of ART services, and adapt programming to address the ongoing vulnerability of children at risk of orphanhood. 

The Rakai Community Cohort Study was a collaborative research project among researchers at Columbia University Mailman School of Public Health, the Rakai Health Sciences Program, Imperial College London, The Alan Turing Institute, Johns Hopkins University, Makerere University, City University of New York, University of Oxford, and the Uganda Virus Research Institute.

Co-authors are John Santelli, Philip Kreniske Columbia University Mailman School of Public Health; Oliver Ratmann, Yu Chen, Imperial College London, London, and Johns Hopkins University; Oliver Ratmann, Susan Hillis, The Alan Turing Institute, London; M. Kate Grabowski, School of Medicine, Johns Hopkins University, College of Health Sciences, Makerere University, Uganda; Larry W. Chang, Rakai Health Sciences Program, Uganda and College of Health Sciences, Makerere University, Uganda; A.F. Nalugoda, G. Kigozi, T. Lutalo, N. K .Sewankambo A Ndyanabo MSc, F Makumbi PhD, D Serwadda, R Ssekubugu, A. Ssettuba, H. Nakawooya, College of Health Sciences, Makerere University, Uganda, N. K. Sewankambo, F. Makumbi, CUNY Graduate School of Public Health and Health Policy; P. Kreniske, Makerere University School of Public Health, Uganda; F. Makumbi, D. Serwadda, The Global Reference Group for Children Affected by Crisis, University of Oxford; and S Hillis, Uganda Virus Research Institute, Entebbe, Uganda.

The study was supported by the National Institute of Allergy and Infectious Diseases, National Institute of Child Health and Development, Gates Foundation, National Institute of Mental Health, and National Institutes of Health Fogarty International Center.