LAUSR

Parents and children from lowand middle-income countries (LMIC) may have a myriad of health and social challenges that increase the risk of parental death, chronic conditions, or acute serious illnesses in parents or children, or family economic hardships that can result in child abandonment or orphanhood. Such conditions can include HIV/AIDS, COVID-19, physical or mental trauma, undermanaged chronic diseases, mental health disabilities,1 civil strife, extreme poverty with food and housing insecurities, and many others. The intergenerational consequence of such parental death or family disruption is that vulnerable children can be orphaned, abandoned, or separated because of war, civil strife, or related to immigration policy, such as at the US-Mexico border. Varying estimates from UNICEF and other sources suggest between 140 million to 153 million children are orphaned worldwide; orphaned and separated children and adolescents represent at least 7% of the world’s 2.2 billion children under the age of 18 years. In the article by Braitstein et al,2 a research team from Canada, Kenya, and the US reports results of their 10-year cohort study of 2551 orphaned and separated children and adolescents in Uasin Gishu County in northwest Kenya. The Orphaned and Separated Children's Assessments Related to their Health and Well-Being (OSCAR) Project enrolled children who lived in a variety of housing settings and living circumstances: 1230 children lived in charitable children’s institutions (CCI), 1230 children lived in family-based settings, and 91 children were deemed street-connected youth. The median follow-up time was 6.2 years (interquartile range, 2.0-7.4 years) and differed by venue: 3.1 years (1.0-7.0 years) for participants in CCI institutional care; 6.9 years (2.3-7.4 years) for participants in family-based care; and 6.5 years (2.0-8.1 years) for street-connected youth. Outcomes included death, incident HIV in children who were not infected perinatally, and survival for those children living with HIV. Many factors can influence whether orphaned and separated children and adolescents are placed in residential or family-based care or must provide for themselves on the street. Random allocation was not possible, so the OSCAR Project investigators used survival regression models to assess associations of care environment with the outcomes. After adjusting for baseline HIV status, age, and sex, youth who lived in a residential CCI setting had a lower adjusted hazard ratio for mortality (AHR, 0.26; 95% CI, 0.07-1.02) compared with youth living in family-based care, but CIs indicated that differences may have been because of chance. Incident HIV was similar for youth living in CCI and youth living in family-based care (AHR, 1.49; 95% CI, 0.46-4.83) with 59 incident HIV infections among the 2551 participants. The HIV incidence rate was 2.06 per 1000 person-years (95% CI, 1.1-3.0 per 1000 person-years) overall, differing by venue (CCI dwellers: 2.2 per 1000 person-years [95% CI, 0.5-3.8 per 1000 person-years]; orphaned and separated children and adolescents living with families: 1.2 per 1000 person-years [95% CI, 0.2-2.1 per 1000 person-years]; and children living on the streets: 15.5 per 1000 person-years [95% CI, 3.1-27.1 per 1000 person-years]). The findings that street-connected youth were far more likely to die or acquire HIV were expected. A conservative conclusion is that the institutionalized CCI youth in Kenya did no worse than youth in family-based settings; the evidence trend suggested that CCI youth may have done better in terms of mortality risk. Given resource constraints and the number of children requiring care in LMICs, orphaned and separated children and adolescents typically have worse health outcomes than children growing up + Related article