Author: Niang, C. I.; Quarles van Ufford, P.
In the context of Sub-Saharan Africa, the case of Senegal is a rather particular one, in that the HIV infection rate is at once low and stable. However, it would be difficult to defend the idea that there are no socio-economic impacts. The truth of the matter is that, so far, no surveys have been carried out. For Senegal, it is important to carry out studies on the socio-economic impacts of HIV/AIDS, together with surveys on response policies. Beyond the understanding of the situation, these surveys could help develop policies and measures meant for alleviating the impacts and the interventions for the preventive policies and the management of cases. These studies would also, no doubt, help learn lessons from the Senegalese experience as to how to struggle against AIDS in the other parts of Africa, for example.
The research methodology is based on a desk review and field surveys carried out in Dakar and in six other localities in Senegal selected for their importance in the ethno-cultural and epidemiological plans: Kaolack, Tambacounda, Thies, Mbour, St- Louis and Ourossogui.
On the whole, a total of 468 people have been interviewed for this field survey. The two interviewing guides have been applied to 42 people (4 or 5 per locality). Medical files have been filled in by 134 people; a children-based questionnaire has been applied to 64 people while the adults-centered questionnaire has been applied to 200 people from the different localities where the study was carried out. Drawings by 14 children aged 4 to 12 from both non-affected by HIV and affected, but unaware of their family member's status, were analyzed.
Findings and Conclusions:
In Senegal, a nationwide assessment of the effects of this pandemic on children's health care is quite difficult, probably because of the low HIV/AIDS prevalence in the country. The main indicators reveal a progressive improvement of children's health care. Thus, the drop in infant mortality has been real in the periods prior to, and subsequent to, the outbreak of HIV/AIDS.
In epidemiological records, notably those from a selected Dakar health center, the most representative age group of children infected with HIV/AIDS is 2 to 5 years. As a result, a high mortality rate may be expected. But, according to attending physicians, even if there is a rise in the number of children who die of AIDS, it would be difficult to conclude that there is a considerable nationwide growth of infant mortality related to AIDS. For interviewed paediatricians, as long as the HIV/AIDS prevalence for children is low and stable, there will likely be a decrease in the mortality of children under 5 in Senegal.
Through medical records, we find that, in most cases, AIDS-infected children live with a parent who has the same serological status. Data analysis has resulted in the following conclusions:
People are often not aware of the existence of AIDS cases within their own families, which is due to the fact that HIV is still considered a taboo. Very often, HIV-infected people strive hard to hide their serological status from members of their families. In the same line of ideas, an analysis of children's drawings reinforces the impression that AIDS, even though people will avoid talking about it, has an impact on the ways in which children reconstruct the image of their families or social environment.
Medical records also show that AIDS orphans are adopted, in most cases, by their grandmothers, the latter being the children's closest relatives, beside their own parents. The maternal side represents the group that provides immediate help, but though we generally have large families, the number of people involved in family solidarity networks is very limited. Uncles, cousins and other relatives tend to sneak away, leaving the rest of the family with the responsibility to cope with AIDS orphans.
The most important support seems to come from projects, associations or NGOs fighting against HIV. According to medical records data, 13% of children with HIV/AIDS have benefited from sponsoring through NGOs. We find the majority of those children in Saint-Louis and Dakar. The data also show that 20% of children with HIV/AIDS (most of them living in Dakar, Kaolock and Tambacounda) have at least had a parent who benefited from income-generating programs.
Other interviews have reported that, in similar cases, some orphans run away and turn into street children. In our survey, we have not recorded any AIDS orphan who has become a street child. But, we collected many qualitative data about psycho-affective frustrations and disturbances of children who were bereaved of their parents by AIDS. People's compassion for them is often short-lived.
Through the analysis of some interviews, we find out that the separation of mother and children can contribute to the creation of conditions that urge women to resort to prostitution. Thus, from the analysis of some texts, it looks as if prostitution is matrilinearily inherited, with the recurrent pattern of young women being separated from their daughters, and grandmothers stepping in to take over and bring up their granddaughters.
The analysis of some variables from the adult-centered questionnaire has highlighted many ways in which interpersonal relationships and social networks are adversely affected. Cases of death or AIDS disease often lead to family reconstruction processes involving parents and children. The death of a head of family often results in the scattering of his family members (wives and children) who go into other homes (remarriages, inheritance of widows and children).
In the survey, people living with HIV/AIDS (PLHIV) as well as people not living with HIV (PNLHIV) were asked whether they went to a doctor, had some medical screening or paid prescriptions. When the answer was yes, people were asked if they received any help. Paradoxically, the percentage of people not living with HIV, who got financial aid to pay for tests and prescribed drugs, is higher than that of PLHIVs who benefited from the same assistance. We also notice some disparities in the origins of this assistance.
For people living with AIDS, assistance is restricted to the circle of husbands and wives, nephews, children, and marabouts whereas for people not living with HIV, others like parents-in-law, friends, former husbands and neighbors also provide assistance. For their consultations, adults with HIV pay almost, on average, twice more than those without AIDS, although in some areas like Saint-Louis, AIDS patients do not pay consultation costs in public hospitals. We also have the same disparities with biomedical screenings. The number and the cost of screenings are much higher with AIDS-infected adults.
Medical records reveal that all children with HIV have been subjected to serological tests. The average cost for the tests is FCFA 11,000. The same records indicate that 68% among them suffer from opportunistic infections (ear infection, diarrhea, mycosis, etc.). The estimate cost is from 5,000 to FCFA 10,000 for each treatment. In an interview, a person who adopted an AIDS-infected child said that he spent FCFA 55,000 in the last 3 months for the treatment of infections caused by the child's HIV. According to the survey, opportunistic infections (in the last 3 months) amount to an average CFA 26,571. We also notice that 8% of children are presently subjected to ARV treatment. All these children reside in Dakar where there exist social programs facilitating access to that kind of treatment.
The time patients spend at hospital is generally between 10 and 15 days. The cost of most admissions was waived, the diseased children being people with social problems whose admission expenses are supported by the health structure. However, for those who paid admission expenses, the average cost is FCFA 16,000. If we refer to the questionnaire data in which adults were asked questions on children, we notice that, compared with children without AIDS, children with HIV/AIDS admitted to hospitals (37% to 11%) or have been consulted in the last 3 months (65% to 37%) is statistically higher.
As for the psychosociological aspect, medical records indicate that 37% of children with AIDS have been attending free counseling sessions provided by PW.AIDS associations or other organizations fighting AIDS. 48% received visits at home, 48% were offered gifts, in kind sometimes (this mainly concerns children from Tambacounda).
Medical records of children with AIDS show that 40% were of school age, 89% of them were actually attending state-owned public schools or private schools, with the rest at Koranic schools. Koranic schools were considered by social workers as substitutes for public education for children with AIDS. It appears that AIDS negatively affects children's school education since the affection discourages parents to enroll their offspring.
Another effect would be the poor results children with AIDS obtain at school because they frequently miss school and, as a consequence, tend to repeat classes. For the school year 1999-2000, 6% of adults with AIDS declared that their disease has resulted in at least one of their children being dismissed from school. Dismissals and poor school results are, according to parents, due to arrears in school registration fees or monthly payments, difficulties in buying school stationery, of parents' failure to look to their children's education, added to absenteeism caused by children's duties at home, as they replace a mother or a father admitted to hospital.
HIV/AIDS has, primarily, a tremendous psychological effect on infected people. Some indicators used in the questionnaire show that half of the HIV-positives acknowledge that they feel angry while with non-infected adults, only a little more than 10% said they had the same feeling. This anger is enhanced by the melancholy mood shown by 60% of people with HIV, while people without AIDS are 19.8%. AIDS's physical symptoms cause patients to remain in bed for hours, which results in the fact that about 50% people with AIDS suffer from depression, while 20% of people without HIV experience the same.
We have recorded only one case of someone who lost his job in the formal sector because of AIDS. But most people with AIDS confessed that their working performance was reduced in various proportions, which, in its turn, can adversely affect the family and children's living conditions.
It also stands to reason that children can be highly affected by adults' social and emotional situations, especially those who suffer from AIDS. In the drawing of an AIDS-infected boy whose father has AIDS too, the latter occupies a tiny space in the background. Psychologists explain that while physically present, the father tends to disappear in the child?s imagination. According to psychologists, children sense that they have AIDS, even if nobody tells them. Psychologists and psychoanalysts realized this phenomenon through HIV-infected children's drawings.
Infected children's feeling of discomfort is clearly represented by some indicators in the children-centered questionnaire. In 35% of all cases, parents of children with AIDS recognize that their children were abandoned by many friends while that phenomenon was mentioned by no parent without AIDS. Parents also said that children lost all appetite and stopped playing because they were rejected by their friends. They were also frustrated by the lack of other forms of socialization like holidays, during which they can get out of their family environment.
On the other hand, no systematic discrimination among children in socialization places, like schools, was pointed out. An informant from Tambacounda explains: In most cases, neither the teacher nor the students know that there is an AIDS patient in the classroom. When the latter misses classes for health care reasons, they just say he/she is sickly, without envisaging the possibility that the pupil has AIDS. If ever the teacher knows that one of his pupil suffers from AIDS, he tries hard to keep it secret. Often, the family concealment of the child's disease is extended to school; sometimes, family members are the last people to know that one of their relatives suffers from AIDS. Thus, conflicts may arise from concealing strategies developed in families, which have considerable
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