The Impact of HIV Combination Prevention on Declining Orphanhood Among Adolescents, Rakai, Uganda, 2001-2018 (Updated 16 April 2021)

Purpose: Orphanhood increased dramatically in the 1980s and 1990s in sub-Saharan Africa (SSA) due to HIV mortality among parents. Little is known about the contribution of HIV interventions such as antiretroviral therapy (ART) and male medical circumcision (MMC) to more recent trends in orphanhood.   Methods: We examined the prevalence of orphanhood among adolescents 15-19 years, before and after roll out of ART beginning in mid 2004 and MMC in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study (RCCS). We used multinomial logistic regression (MLR) with clustered standard errors to estimate adjusted relative risk ratios (adj.RRR) for maternal-only, paternal-only, and double orphanhood compared to non-orphanhood over 11 survey rounds between 2001 and 2018.  Controlling for community HIV prevalence, household socioeconomic status (SES), and adolescent age, we examined the association between community prevalence of ART use among people living with HIV (PLWHIV) and prevalence of male circumcision (MC) including traditional circumcision.     Results: Orphanhood declined from 52% in 2001-2002 to 23% by 2016-2018 (p<0.001), while double orphanhood declined from 20% to 3% (p<0.001).  Community prevalence of ART use rose from 11% in 2005-2006 to 78% in 2016-2018; MC rose from 19% to 65%.  In the MLR model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adj.RRR=0.90, 95% CI=0.85-0.95) and double orphanhood (adj.RRR=0.80, 95% CI=0.75-0.85). Likewise, a 10% increase in the community prevalence of MC was associated with a decrease in paternal orphanhood in the pre-ART (2001-2004, adj.RRR=0.85, 95% CI=0.75-0.97) and the post-ART era (2005-2018, adj.RRR=0.92, 95% CI=0.86-0.97), and double orphanhood in the post-ART era (adj.RRR=0.91, 95% CI=0.85-0.98).  Conclusions: Widespread availability and uptake of HIV combination prevention was associated with dramatic reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people. Funding Information: This work was supported by the U.S. National Institutes of Health (R01HD091003). Declaration of Interests: We declare no conflicts of interest related to this research. Ethics Approval Statement: For unemancipated minors (<18 years), both written minor assent and parental/guardian permission are obtained; 18+ year-olds and emancipated minors provide their own written informed consent. Ethical approvals were obtained from the Research Ethics Committee (REC) of the Uganda Virus Research Institute (UVRI), the Uganda National Council for Science and Technology (UNCST), and Institutional Review Boards at Johns Hopkins and Columbia Universities, and Western IRB Olympia WA.