Planta baja

HIV infection not only affects the person concerned but also their family and household and the community as a whole. The impact of a case of HIV infection on a person’s family and household unfolds gradually, from the point at which they first become sick or discover their HIV status until many years after they have died (Timæus, 2006a). In other words, HIV infection is usually characterised by a prolonged illness leading to death, thus having many short- and long-term consequences for households and their surviving members, for example, increased household mobility (Urassa et al., 2001), household dissolution (Mushati et al., 2003) and the role reversal within households (Mathambo and Gibbs, 2008) The role reversal includes:

• grandparents taking on the role of primary caregivers to their grandchildren instead of being cared for themselves,

• healthy family members having to shoulder an increasing number of responsibilities, • wives taking up paid employment to secure a household income (in a community

where a wife’s responsibility is care for the home and the children),

• children having to assume adult roles, for example, seeking employment in an attempt to bring an income into the household.

HIV infection, especially among productive adults, is associated with household disruption, as illustrated in the FLC model by Hosegood et al. (2008) (shown in Figure 34) which includes:

• widowhood and the creation of one-parent households or households with no middle-aged members as children relocate to live with their grandparents on the death of one or both parents;

• divorce and separation due to direct and indirect stresses associated with HIV infection and AIDS such as suspicion and accusations of infidelity (Porter et al., 2004).

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• a barrier to forming a new household through marriage or remarriage after divorce or widowhood due to suspicions that the former partner was HIV-positive (Oleke et al., 2005);

• a barrier to reproduction due to fertility decisions not to have children or widowhood;

• the increased risk of household dissolution as the remaining partner chooses to join another household after divorce or the death of a partner, or children join other households or create new households after the death of both parents;

• barrier in the growth of nuclear households with young adult parents to those with older parents attributed to the death of adults or a barrier to the exit of adult children mainly staying home to be cared for by their parents (if the adult children are HIV infected) or alternatively to care for their HIV infected parents.

Household dissolution is also argued to be dependent on the structure of the household before infection, the position of the infected in the household and whether the infected has developed AIDS. For example Figure 34 illustrates:

• the risk of household dissolution was lower among extended larger households than in smaller ones such as nuclear households,

• widowed and divorced male partners remarrying or continuing as single-person households, sending the children to be cared for by grandparents,

• co-residence of older household members or their presence in the neighbourhood reducing the risk of household dissolution by offering support to households that have experienced an adult AIDS death, for example, an aunt living in close proximity supporting her nieces and nephews after the loss of their parents to AIDS. (Hosegood, 2008).

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Studies of the impacts of adult mortality have found no association with whole household migration (Monasch and Boerma, 2004, Heuveline, 2004, Hosegood et al., 2004a, Hosegood, 2006b). In fact the migration of some rather than all the household members is more common as a coping mechanism. The household member migration could be attributed to: dependants being sent to be cared for by others, as evidenced by an increase in child migration (Heuveline, 2004, Monasch and Boerma, 2004); adult residents relocating elsewhere to find work, mainly to boost a household income depleted by the expenses associated with HIV infection and loss of income due to the adult’s death (Hosegood et al., 2004a); and the HIV-positive resident relocating to get terminal care (Yamano and Jayne, 2004) or to a preferred place to die (Urassa et al., 2001). The risk of individual migration rises in households that experience multiple deaths although such households are not common (Urassa et al., 2001). Households that are unable to cope dissolve (Hosegood et al., 2004a).

Adult death has been found to be associated with household dissolution, with higher dissolution rates in households where:

• the deceased was the head of the household or his or her spouse, especially if the household head was under 60 years old or female (Urassa et al., 2001, Yamano and Jayne, 2004);

• multiple deaths have occurred (Urassa et al., 2001, Hosegood et al., 2004a, Hosegood, 2006b, Hosegood et al., 2007, Hosegood, 2008);

• the household is small (Yamano and Jayne, 2004).

Households that do not dissolve after the death of the male household head experience an increase in the out-migration of female residents, while if the deceased adult is not the household head or his or her spouse the household tends to experience an increase in the in- migration of new adult residents (Heuveline, 2004, Yamano and Jayne, 2004). No difference has been observed in the rates of dissolution between households that have experienced AIDS-related and non-AIDS-related deaths (Urassa et al., 2001, Mushati et al., 2003, Hosegood et al., 2004a, Hosegood, 2006b).

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Researchers predict an increased emergence of:

• households of children living without adults (child-only or child-headed households; sibling-only households);

• single-person and single-parent households with a widowed or divorced head, commonly female;

• households of children and older adults but no younger adults (‘skip-generation’ households) as more older adults assume a greater role in caring for children (grandparent headed) (Heuveline, 2004, Hosegood, 2008, Mathambo and Gibbs, 2008, CHGA, 2011).

5.2.1 Widowhood and couple separation during the HIV era in Uganda

In the early 1900s, researchers reported that after a death, most of the property of the deceased person in Ugandan societies was inherited by the deceased’s heir who could not be the widow. This was usually the deceased’s oldest son, brother or close male relative who would also inherit the widow (Ntozi, 1997). The situation was different for widowers. As a result of the high prevalence of polygamy in Ugandan societies, many widowers had other wives to continue marital life with when one wife died. However, for monogamous men, parents of the dead wife replaced her with her sister to be the new wife and look after the children of her deceased sister. This was reported common among the Basoga (Roscoe, 1924), the Baganda (Roscoe, 1911), the Banyankore (Roscoe, 1923), the Bakiga (Edel, 1957) and Basebei (Roscoe 1924). In regards to the children to the deceased, the customs discouraged a widow leaving her children behind and marrying elsewhere. This forced her to stay and marry one of her late husband’s agnatic relatives as a means of survival for both her and her children.

However, during the HIV/AIDS epidemic, investigations in the 1990s reported that despite the knowledge that a man had died of AIDS, his widows were inherited and sexual intercourse undertaken/practised between the widows and the inheritor (Bantebya and Konings, 1994). Non-AIDS widows who refused to be inherited by men they suspected to be HIV-infected were left to fend for themselves and their children, which was difficult. The

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situation was even worse with AIDS widows who were shunned by in-laws who refused to assist them and their children because they would not inherit them. Obbo (1993) found that widowhood in Uganda results in poverty, worsened by the requirement for the widow to pay off the debts incurred while caring for her sick husband.

In an investigation of the HIV/AIDS epidemic in Uganda, Ntozi (1997) found 43.2% of widowhood in Masaka district (ranking high in AIDS prevalence in Uganda) attributed to AIDS, with the widows and widowers dying off rapidly (Wagner et al., 1993). A look at a sample of 1,797 households covering east, south and western Uganda, Ntozi (1997) observed 65.1% of the widowers remarried compared to a significantly low percentage of 27.3 for the widows. The higher percentages of widowers than widows remarrying were mainly attributed to some men already having other wives and because in Ugandan societies it is easier for men than women to remarry. However, the fear of AIDS discouraged some men from inheriting widows (Berger, 1994). A remarriage could however, be attributed to:

• The custom requirements for widows to be inherited by their late husband’s male relatives despite the AIDS epidemic and the awareness of its dangers through educational campaigns (Wawer et al., 1994);

• Widows’ desperation for assistance for themselves and their children as this is withheld by the in-laws unless the widowed remarried. The in-laws could even go as far as to evict a widow from her late husband’s property. In addition to survival, a widow would need an income or assistance in paying off debts incurred in the treatment of the late husband (Obbo, 1993)

• The fear of an AIDS widow or widower to die alone lead to an attainment of a partner for comfort and support.

Ntozi (1997) further observed migration of a widow and widower less likely if the spouse died of AIDS in comparison to non-AIDS deaths, and even less likely if the widow or widower had a children before the death of the spouse. In addition men were more likely to move than women. Migration of widows was attributed to:

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• stigma against widows and widowers forcing them to migrate to escape discrimination for themselves and their children especially if the spouse had an AIDS death,

• the desire to escape a customary forced remarriage,

• a widow’s migrating to seek alternative means of survival for herself and her children resulting from the in-laws seizing her properties or refusing to support the her and her children.

Interviews from a community-based randomized clinical trial in Rakai, Uganda showed a strong association between HIV infection among women and divorce or separation and widowhood with the relative odds of widowhood being much larger than those of a divorce or separation (Porter et al., 2004). Separation or divorce after HIV infection could mainly be attributed to: the health effect of the infection limiting the performance of the expected sex roles; or the stigmatization due to sickness or suspicion of the infection being due to infidelity. Separation was more common if the infected person was the woman (in which case the woman was sent away), and higher in discordant (woman positive, man negative: F+ M-) than in concordant (woman and man HIV-positive: F+ M+) unions (Bledsoe, 1990). The husband tended not to send the spouse away if he were HIV-positive mainly due to the woman’s caretaking roles. However, the women were unlikely to initiate separation or divorce even in discordant (woman negative and man positive: F- M+) unions due to their limited access to paid employment or inability to return to their parental home.