Non-enrollment in School and drop-out in the Era of

HIV care &Treatment, Rakai South-Western Uganda

Presenter Fredrick Makumbi, PhD Makerere University School of Public Health, & The Rakai Health Sciences Program

A Wednesday Noon Seminar, at JHBSPH Department of PFRH September 25th 2013

Background • HIV care and treatment has improved Survival of HIV infected adults and children

Quality of life of the HIV+, and many have rejoined the active work force

• Significant declines in the incidence of orphanhood,

and increased proportion of children born without HIV-infection

Background

• However, data on the indirect benefits of HIV care and treatment intervention are still limited

• For example, the effects of HIV care services on the rate of school enrollment or school drop-out rates among children of school going age

Background • Uganda’s Universal Primary (1996) and secondary

(2007) education Policy was introduced

• Not all children of school going age enroll in school, or maintain their enrolment

• Although UPE policy provides free tuition to the pupils, a number of other requirements that enable pupils to be in school are still borne by parents/caretakers

Background • Factors such as household SES, parental/care takers’

health status (especially HIV/AIDS related), can lead to non-enrollment or drop-out due to lack of some basic school requirements or care for the sick parents

• HIV+ children may also be less likely to enroll in school

• Availability and quality of schools, as well as community attitudes towards schooling may affect enrolment

Conceptual Framework for School enrolment, drop-out and HIV-care

Objective

• To determine the effect of parental receipt

of HIV-care services on children’s school

non-enrollment and drop-out in a rural

resource limited setting

Rakai Community Cohort study

• Population aged 15-49 years • 56 communities grouped into 11 clusters • Total population: 13,000 • Composition: Rural, semi-urban, urban • Population-based surveys of the Rakai cohort have

been conducted every 12-15 months since 1994 .

Rakai

Entebbe Airport

Rakai District

Why rural Rakai?

An HIV epicenter

D Serwadda, N Sewankambo et al first identified “slim disease” patients in Rakai in

1982.

Chronology of RCCS activities

1. Community Mobilization

Health Education and Community Mobilization

Survey team in the field, end of day

Field-based collection of biological samples for HIV, STD and infectious disease surveillance

Methods

• Annual household enumeration conducted in the Rakai community cohort surveillance

• Data include age, sex, relationship to house

head, schooling status for the 5-22 year olds, survival of biological and dwelling structure to construct house-hold SES

Methods

• Adult (15-49 years) HIV status from

consenting adults

• Free HIV care and treatment services to HIV+

provide by Rakai program

Statistical analysis

• Descriptive analysis with outcome as non-

enrollment in school, and drop-out

• Survey rounds R11 (Jan 2005/May 2006) to R14

(Dec 2009/May 2011) with data on outcome

• Eligible School ages 6-12 years (Primary) and

13-16 years (Secondary)

Statistical analysis

• Binary outcome thus use of logistic regression

model

• Xtlogit model with robust variance and

unstructured covariance structure to account for

repeated measures

• Adjusted for SES, Parent’s HIV, age, HIV-care,

time(survey rounds)

FINDINGS

R011 R012 R013 R014 N % N % N % N % Overall 16,065 100 17,402 100 17,203 100.0 17,025 100.0

Sex Female 51.3 51.8 51.6 51.6

Male 48.7 48.2 48.4 48.4

Age(years)

6-12 66.0 67.5 67.1 67.1

13-16 34.0 32.5 32.9 32.9 School Enrolment

Enrolled 93.0 92.8 97.7 94.4 Non-enrolled 7.0 7.2 6.0 5.6

Characteristics of Children of school going age 6-16 years

R011

R012

R013

R014

% % % % SES High 40.3 42.6 44.8 49.3 Middle 30.6 30.2 31.8 31.5 Low 29.1 27.1 23.4 19.1 Orphanhood Non-orphans 73.8 77.2 79.6 82.2 Double 7.3 6.3 4.9 3.6 Maternal-alone 5.6 4.9 4.4 4.0 Paternal-alone 13.3 11.7 11.1 10.2

Characteristics of Children of school going age 6-16 years

R011

R012

R013

R014

% % % %

Parental HIV-status

Both-missing 39.5 38.1 39.3 38.1

HIV-both/one missing 50.8 51.8 50.6 51.0

At least one HIV+ 9.7 10.2 10.1 10.9

HIV care enrolment

Not in Care 63.4 51.2 43.6 40.0

In Care 36.6 48.8 56.4 60.0

Characteristics of Children of school going age 6-16 years

Summary of characteristics of Children, 6-16 years

• ~ 2/3 were primary school going age (6-12 years)

• Nearly universal enrolment, only 7% not enrolled and declines overtime

• Over 40% in high SES and has increased to 50% in last survey

• Orphanhood been decreasing over time, most significantly double orphans

• Proportion with at least one HIV+ parent has been stable over time, ~10%

• Parent’s enrolment in HIV care& treatment been increasing

0 .1

.2

.3

.4

.5

.6

.7

.8

.9

1

Prop

ortio

n no

t enr

olle

d Trends in School non-enrollment by age eligibility

17-22 yrs

13-16 yrs 6-12 yrs

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

0 .0

2 .0

4 .0

6 .0

8 .1

.12

.14

.16

.18

.2

Prop

ortio

n no

t enr

olle

d Trends in School non-enrollment by sex

13-16 year olds

6-12 year olds

Females

Males

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

0 .0

5 .1

.1

5 .2

Pr

opor

tion

not e

nrol

led

Trends in school non-enrolment by Parental HIV+ status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

13-16 year olds

6-12 year olds HIV-negative

At least one HIV+

Both unknown HIV

0 .0

5 .1

.1

5 .2

.2

5 Pr

opor

tion

not e

nrol

led

Trends in School non-enrollment by Orphanhood status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

Non-orphans

Double-orphans

Maternal

Paternal

13-16 year olds

6-12 year olds

Trends in non-enrollment in school by children characteristics

• Non-enrollment in school is higher among older (13-16 years) than younger (6-12 years) children

• Overall, observed declines in non-enrollment in school over time

• Non-enrollment is significantly higher • among males compared to girls • Children with parents of unknown HIV status • among orphans, in older children (13-16 years)

0 .0

5 .1

.1

5 .2

Pr

opor

tion

not e

nrol

led

Trends in School non-enrolment by Parental HIV care

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

None in HIV-care

At least one in HIV-care

13-16 year olds

6-12 year olds

0 .0

5 .1

.1

5 .2

.2

5

Prop

ortio

n no

t enr

olle

d Trends in School non-enrollment by SES

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Dec 2009/ May 2011

Low

Medium

High

13-16 year olds

6-12 year olds

Trends in non-enrollment in school by children characteristics

• No clear association of Parental receipt of HIV care

and non-enrollment in school

• Lower SES is a significant determinant of non-

enrolment in both young and older children

6-12 year olds 13-16 year olds Parent HIV status Adj.OR 95% CI Adj.OR 95% CI HIV-Neg 1.0 1.0

At least 1 HIV+ 0.98 0.81 1.17 1.12 0.93 1.35

Both unknown 1.28 1.13 1.45 2.22 1.99 2.47

Orphaned 1.15 0.98 1.34 1.31 1.18 1.45

Sex

Male (vs female) 1.43 1.28 1.59 1.18 1.07 1.29

Age (years) 0.62 0.59 0.64 2.17 2.08 2.26

SES (High=ref)

Medium 1.95 1.70 2.23 1.42 1.28 1.57

Low 3.25 2.84 3.72 1.97 1.76 2.20

Adjusted OR for non-enrollment in School; All children Combined

Adjusted OR for non-enrollment in School among children with HIV+ parent

6-12 year olds 13-16 year olds

HIV care Adj.OR 95% CI Adj.OR 95% CI Not in care 1.0 1.0

In care 0.77 0.55 1.09 0.94 0.67 1.32

Orphaned 0.87 0.57 1.34 1.12 0.80 1.58

Sex

Male (vs female) 1.57 1.12 2.21 1.70 1.21 2.41

Age (years) 0.53 0.45 0.62 2.61 2.22 3.06

SES (High=ref)

Medium 2.56 1.61 4.07 1.62 1.11 2.37

Low 3.21 2.05 5.05 2.56 1.72 3.80

0 .0

5 .1

.1

5 .2

Pr

opor

tion

drop

-out

Trends in primary school dropout by gender, 6-12 years

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Females

Males

13-16 year olds

6-12 year olds

0 .0

5 .1

.1

5 .2

Pr

opor

tion

drop

-out

Trends in primary school dropout by Parental HIV-status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

13-16 year olds

6-12 year olds

No known HIV Status

At least one HIV+

Only known HIV-

0 .0

5 .1

.1

5 .2

Pr

opor

tion

drop

-out

Trends in School dropout by Parent’s HIV care status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

Parent not in care

Parent in care

13-16 year olds

6-12 year olds

6-12 year olds 13-16 year olds Parent HIV status Adj.OR 95% CI Adj.OR 95% CI

HIV-Neg

At least 1 HIV+ 1.03 0.66 1.60 1.05 0.86 1.29 Both unknown 2.46 1.92 3.16 1.27 1.12 1.44 Orphaned 1.17 0.91 1.52 1.24 1.09 1.41 Sex

Male (vs female) 1.76 1.40 2.22 1.51 1.35 1.69 Age (years) 1.42 1.33 1.53 1.48 1.41 1.56

SES (High=ref)

Medium 1.49 1.11 2.00 1.86 1.62 2.14 Low 2.45 1.88 3.20 2.84 2.47 3.26

Adjusted OR for School drop-out; All children Combined

Adjusted OR for School drop-out among children with HIV+ parent

6-12 year olds 13-16 year olds HIV care Adj.OR 95% CI Adj.OR 95% CI Not in care 1.0 1.0 In care 0.50 0.21 1.18 1.41 0.98 2.04 Orphaned 1.08 0.43 2.71 0.88 0.61 1.27 Sex

Male (vs female) 3.45 1.37 8.67 1.67 1.16 2.40 Age (years) 1.14 0.92 1.43 1.51 1.29 1.76 SES (High=ref)

Medium 2.18 0.73 6.51 1.27 0.83 1.96 Low 3.43 1.23 9.53 2.06 1.31 3.24

When outmigration and deaths compete with known drop-out as an outcome

6-12 year olds 13-16 year olds

Study visit Total out-

migrated (%) Died (%) Total

out-migrated (%)

Died (%)

Jan 2005/ May 2006 10952 - - 5582 - -

Aug 2006/ Apr 2008 13750 1879(13.7) 29(0.2) 7125 1426(20.0) 9 (0.1)

May 2008/ Sept 2009 13541 1904(14.1) 21(0.2) 7021 1328 (18.9) 14 (0.2)

Dec 2009/ May 2011 13498 1966(14.6) 25(0.2) 6838 1198(17.5) 11(0.2)

0 .0

5 .1

.1

5 .2

.2

5 .3

.3

5 .4

.4

5 .5

Prop

ortio

n dr

opou

t/dea

th/o

utm

igra

tion

Trends in School dropout/death/outmigration by gender

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

13-16 year olds

Male

6-12 year olds Female

0 .0

5 .1

.1

5 .2

.2

5 .3

.3

5 .4

.4

5 .5

Pr

opor

tion

drop

out/d

eath

/out

mig

ratio

n Trends in School dropout/death/outmigration by orphan-status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

13-16 year olds

6-12 year olds

Orphans

Non-orphans

0 .0

5 .1

.1

5 .2

.2

5 .3

.3

5 .4

.45

.5

Pr

opor

tion

drop

out/d

eath

/out

mig

ratio

n Trends in School dropout/death/outmigration

by parent HIV care-status

Jan 2005/ May 2006

Aug 2006/ Apr 2008

May 2008/ Sept 2009

13-16 year olds

6-12 year olds

In care

Not in care

Adjusted OR for School drop-out among 6-12 year olds children with HIV+ parent

Drop-out, only Composite drop-out HIV care Adj.OR 95% CI Adj.OR 95% CI Not in care 1.0 1.0 In care 0.50 0.21 1.18 0.72 0.60 0.87 Orphaned 1.08 0.43 2.71 1.14 0.92 1.42 Sex

Male (vs female) 3.45 1.37 8.67 1.12 0.94 1.35 Age (years) 1.14 0.92 1.43 0.95 0.91 1.00 SES (High=ref)

Medium 2.18 0.73 6.51 0.87 0.70 1.08 Low 3.43 1.23 9.53 0.91 0.73 1.13

Adjusted OR for School drop-out among 13-16 year olds children with HIV+ parent

Drop-out, only Composite drop-out HIV care Adj.OR 95% CI Adj.OR 95% CI Not in care 1.0 1.0 In care 1.41 0.98 2.04 1.12 0.87 1.43 Orphaned 0.88 0.61 1.27 1.00 0.78 1.28 Sex

Male (vs female) 1.67 1.16 2.40 0.92 0.72 1.18 Age (years) 1.51 1.29 1.76 1.23 1.11 1.37 SES (High=ref)

Medium 1.27 0.83 1.96 1.12 0.83 1.52 Low 2.06 1.31 3.24 1.99 1.48 2.69

Key summary findings

• Parental receipt of HIV care & treatment

services tends to be associated with lower

drop-out among younger children (6-12 years)

but not older children

Key summary findings

• School non-enrolment and drop-out are

decreasing over time

• Orphanhood, lower SES, and higher age, and

male gender are determinants of drop-out,

especially among older children

Conclusion

• In Universal Primary and Secondary education

environment, with increasing availability of HIV

care and treatment services, children’s non-

enrollment and drop-out are lower when parent(s)

is in HIV care

• However, drop-out and non-enrollment are

significantly higher among boys or older children