HEALTH STATUS AND NEEDS OF CHILDREN AFFECTED BY HIV

& AIDS (CABA) IN MORGANG DISTRICT, NEPAL

SUMITTED BY:

XXXXXXXXXXXXX
MPH (22-Batch)
PG04-22-10-014

SUMITTED To:

Department of Public Health

State University of Bangadesh

Submission date: 4 October 2010

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 Table of Contents
ABBREVIATION:
SUMMARY OF PROPOSAL

CHAPTER I- INTRODUCTION
1.1. Introduction
1.2. Justification of the study
1.3. Research Question:

1.4. Study Objectives:

1.5. Operational Definition:
1.6. Conceptual Frameworks:

CHAPTER II- LITERATURE REVIEW

2.1. Literature of Review

CHAPTER III- RESEARCH DESIGN AND METHODOLOGY

3.1. Study design:

3.2. Study area:
3.3. Study Duration:
3.4. Study population
3.5. Sample size
3.6. Sampling technique:
3.7. Research tools:
3.8. Method of data collection:
3.9. Methods of data processing:
3.10. Data presentation:
3.11. Quality control and quality assurance:
3.12. Ethical considerations:
3.12 Work Plan:
Reference:

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ABBREVIATION:

AIDS Acquired Immune Deficiency Syndrome

ART Anti-retroviral Therapy
CABA Children Affected and Infected by HIV&AIDS
CD4 Cluster of differentiation
CHBC Community Home Based Care
DACC District AIDS Coordination Committee
DDC District Development Committee
DPHO District Public Health Office
HIV Human Immune-deficiency virus
IDU Injecting Drug Use
MARP Most at Risk Population
MDG Millennium Development Goals
NCASC National Centre for AIDS and STI Control
OI Opportunistic Infections
OVC Orphan Vulnerable Children
PLHA People Living With HIV and AIDS
PMTCT Prevention of Mother to Child Transmission
PRSP Poverty Reduction Strategy Paper
UCAAN Universal Access for Children Affected by AIDS in Nepal
UNAIDS Joint United Nations Programme on HIV/AIDS
UNGASS United Nations General Assembly Special Session on HIV and AIDS
VCT Voluntary Counseling and Testing
VDC Village Development Committee
WHO World Health Organization

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 SUMMARY OF PROPOSAL

The cross-sectional descriptive study will be carried out to determine the health problems and
identify needs of children affected by HIV and AIDS (CABA) under 18 aged in Morang
district, Nepal. And, purposive sampling method will be applied for this study with face to
face interview, observational process using required measurement tools. Because of
premature death of parents due to AIDS and transmitted HIV infection from mother,
Children infected and affected by HIV&AIDS is increasing day by days. The growing
scenario of CABA showing that they are facing vital problems and poses many challenges to
fulfill health and basic needs which is fundamental rights of them. Due to low income level,
poverty of family and helpless, they are not only struggling to maintain quality health and
fulfill the basic needs but also experiencing immense stigma and discrimination from
community. In the context of proposed study area, DACC along with some I/NGO are
intervening support package for them, but still there are many gaps to improve quality life of
CABA, therefore this proposed study will be emphasized to find out the gaps of basic needs
such as educational, nutritional, social supports, pediatric care, treatment and support as well
as to assess the current personal health situation, psychosocial conditions, health seeking
behaviors and coping mechanism against unexpected stigma and discrimination of CABA.
The result of the study will give an idea as baseline, roadmap of real present health situation
and needs of CABA to make further course of actions for concerned stakeholders, policy
makers with creating favorable environment in line of CABA in order to ensure their health
and basic needs.

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CHAPTER I- INTRODUCTION

1.1 Introduction:

HIV&AIDS is recognized as public health issues. Social problems, unemployment, migration

and mobility, cultural taboos, poverty and social violence and discrimination are key factors
of spreading HIV&AIDS at globally, nationally and locally. The consequences of
HIV&AIDS are becoming challenges to achieve development goals. HIV&AIDS is
becoming major causes of premature death in many countries such as Sub-Saharan Africa
countries (UNAIDS, 2008 Global Summary of AIDS Epidemic) 1.

Because of premature death of parents, children affected by HIV&AIDS are increasing day
by day. Children under 15 account for one in six AIDS-related deaths worldwide and one in
seven new HIV infections – the vast majority through mother-to-child transmission, which
can occur in the womb, during birth or through breastfeeding. Ninety percent of the more
than 5 million children who have been infected were born in Africa.

Globally, over than 7400 people per day became HIV infection in 2008 among them 1200
(16%) are children under 15 years aged and more than 97% are in low- and middle-income
countries of these more than two thirds will die as a result of AIDS because of a lack of
access to HIV treatment, care and support. According to UNAIDS at end of 2008, there were
estimated 33.4 million number of people living with HIV amongst 2.1 million were children
under 15 years aged around the world.

Similarly, an estimated 430,000 children became newly infected with HIV in 2008 and of the
2 million people who died of AIDS during 2008 more than one in seven were children
(UNAIDS, 2008). Every hour, around 31 children die as a result of AIDS. Consequences of
these deaths there are more 15 million children under the age of 18 who have lost one or both
parents due to AIDS. In countries with an HIV prevalence of above 5%, child mortality rates
have not fallen in line with global trends.

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Globally Situation of HIV infected children
Region Estimated HIV infected Children under 15 years, 2008
Sub-Saharan Africa 1.8 million
South & South-East Asia 140 000
Eastern Europe & Central Asia 20 000
Latin America 31 000
East Asia 16 000
Middle East & North Africa 15 000
Caribbean 11 000
North America 4500
Oceania 1500
Western & Central Europe 1400
Source: UNAIDS, Global summary of the AIDS epidemic, 2008

The HIV&AIDS is not only threatening the physical health and survival of millions of
children around the world, it is destroying their families and depriving them of parental love,
care and protection. Stigma and discrimination often associated with HIV infection which
can lead to exclusion and isolation and ruin their chances to receive quality health services,
education, other fundamental needs and rights. Children whose families are affected by
HIV&AIDS experience severe emotional and psychological stress.

Likewise, economic hardship resulting from their parents' inability to work may cause
children to become child labour despite continuing education and other child development
activities. Inadequately caring and protection of parents, children affected and infected by
HIV&AIDS are more exposed to exploitation, violence, abuse, and trafficking. As a result of
these consequences it may directly effects on their health conditions and fulfillment of basic
needs. Without addressing children infected and affected these problems, the target of MDG
goals 6 as well as goals no. 4 will not be achieved by 2015. Therefore, identification of
actual health problems and needs of the CABA shows the ways of effective program
intervention.

HIV&AIDS is becoming one of the development agendas in Nepal and also has recognized
as a cross cutting issues. The overall HIV prevalence in Nepal has 0.49 percent in 2007 and

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the estimated number of HIV infected people were 69,790 among them estimated 1,857 were
children living with HIV and AIDS (NCASC, 2007). In fact figure is that there were 15945
number of people living with HIV and AIDS identified at end of 15 July 2010 (NCASC)
among them 1005 (6%) identified HIV infected children in Nepal2. The growing scenario of
Nepali children affected by the HIV infections and deaths of their parents (HIV affected
children) who are facing crucial problems and poses a challenge to child labor, malnutrition
and other public health complications.

There are numerous social, economic and cultural factors that drive sexual and injecting
behaviors among various MARP. Some most at risk population such as IDU has more than
5% prevalence therefore, Nepal has known as concentrated epidemic stage with threatening
of HIV and AIDS being a number one killer in the country. The highest burden of the
epidemic rests on seasonal labor migrants followed by the clients of sex workers and rural
female low risk.

It is estimated that 19,600 children are currently orphaned in Nepal due to AIDS (UNICEF,
2010). The orphan children are facing malnutrition drop out from school, compelling to
involve in child labor and other vulnerabilities3. There were estimated 48,000 children
affected with HIV in Nepal (UN/AIDS, 2006).
According to presentation of Universal Access for children affected by AIDS in Nepal
(UCAAN) on public-private partnership indicated following concerned as below;
• Children living in households with HIV positive parents and/or caregivers are still not
visible
• Children who have lost one parent or both to AIDS are still not visible
• Stigma and discrimination is still common
• Significant needs for protection, education, nutrition, healthcare
• Numbers are low enough in Nepal where we can reach all children through
galvanized efforts

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 • The numbers are high enough that if we do not do something, we will be held
accountable

National strategy plan 2006-2011 has been also spoken to orphan and vulnerable children in
accessing treatment, care and support. In order to address CABA issues nationally UCCAN
network has been formed and starting to respond the issues through public private
partnership initiation. There are still required prompt respond CABA issues from locally.

Morang district is situated in the eastern part of Nepal. The total population of Morang is
843,207 among them 80% are living in village area. It has a sub-metropolitan city (called
Biratnagar) and sixty-five village development committees (VDC). Morang district is …
ranked in human development index out of seventy-five district of Nepal. Even though most
of the people are from indigenous group, HIV&AIDS infected and affected people that are
mostly marginalized and underprivileged.

This district is connected with open border with India which has also led to high mobility of
people for seeking jobs opportunities and trade. Injecting drug use and engaging in unsafe
sex behaviour are main transmission route of HIV among general population is found in the
district4. Open boarder with India, human trafficking, open sex trade near boarder in India,
migration for seasonal labour works, increasing drug abuse, unemployment, increasing high
risk behaviour in cabin restaurant and social violence are mainly underlying causes of
spreading HIV&AIDS among general population by MARP. Women and children affected
and infected by HIV and AIDS are facing crucial problems. Gradually it is becoming priority
issues for development.

In Morang district, there are 884 found out people living with HIV (including AIDS) among
them 624 were female and 260 male respectively (source: DACC, report till July,16,2010).
Client of female sex worker and injecting drug users were contributed 26% and 34%
respectively among sub groups of found out HIV cases. According to DACC report till July

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2010 mentioned that 142 people were died due to AIDS which is also one of higher incidence
death rate in the district. There were 40 children found out as HIV positive in Morang
district5. It has found very difficult to get actual no. of children affected and infected by
HIV&AIDS in the district because of not accessed in VCT, fear of stigma and social
discrimination, lack of awareness and not familiar about HIV status oneself.

In regards children affected and infected by HIV&AIDS (CABA) issues are becoming
priority issue of the district. DACC along with concerned stakeholders are addressing CABA
issues through providing educational support, treatment, care and support even though there
are many gaps which should be fulfilled to improve quality of life of CABA is significant
challenges and opportunities too. They are facing health, basic materials, educational and
other social problems. CABA is being national priorities and program (National strategy plan
2006-2011) although less than 2 percent (1.6%) budget had been allocated for national
HIV&AIDS plan 2006-2008 where more than 72 percent were budget gaps to intervene
program for children affected and infected by HIV&AIDS (UNGASS progress country
report, January 2008). Because children are foundation for the nation but ironically they are
facing unexpected stigma and discrimination, far from fundamental rights such as health and
other basic needs.

Therefore, this study will contribute to find out health status (malnutrition/underweight
prevalence, personal hygiene and sanitation, psychological health, opportunities infections to
HIV infected children etc), social stigma and discrimination and explore the basic needs
(food security, educational, treatment, care and support, social support) of CABA in Morang
district.

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1.2 Justification of the study:

Health and fulfillment of basic needs is fundamental rights of children affected and infected
by HIV and AIDS (CABA). They are facing many challenges to get quality health,
education, social supports and basic materials need because of existing social stigma and
discrimination, not being able to access in treatment, care and support. Resulting of parent's
premature death, separate from family members and having HIV infection, the children are
bearing of burden which directly affecting in psychosocial, socio-economic and health
problems to them.

Family background of CABA is found very poor and marginalized; therefore they have not
afforded healthy food and nutrition, pediatric care, proper treatment and care in need. The
holistic development of CABA children is far from satisfactory level in Nepal as well as
Morang district context too because of HIV&AIDS consequences.

There has been very limited study has been done which was mostly based on identifying
situation of Nepal. This purposed study will be significantly important to find out gaps of
needs as well as present health condition which findings will be very useful for concerned
stakeholders as baseline for their intervention.

The purposed study will be emphasized to describe health status such as personal hygiene
and sanitation, nutritional status, OI management, psychological health and primary physical
as well as the proposed study will be explored educational; social support; combating stigma
and discrimination; basic material needs; essential pediatric care and treatment, CHBC and
support; family support and cohesiveness and mitigation of consequences. The findings of
the study will be used as baseline purpose for I/NGO, GoN and other stakeholders for their
programme intervention. Therefore, this proposed study will help to improve quality life of
CABA in Morang district in Nepal.

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1.4 Research Question:

What are the current health problems and essential needs of children affected by HIV and
AIDS (CABA) in Morang district, Nepal?

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1.5 Study Objectives:

General Objective:

To determine the health problems and identify needs of children affected by HIV and AIDS
(CABA) in Morang district, Nepal

Specific Objectives:

• To identify health problems concerning CABA and health seeking behavior of

children affected by HIV and AIDS in Morang district, Nepal.
• To explore essential health care, educational, nutritional, psycho-social and social
supports needs of children affected by HIV and AIDS in the study area.
• To find out socio-demographic characteristics of children affected by HIV and AIDS
• To assess the availability and accessibility of services for children affected by HIV
and AIDS in the stusy area.

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1.6 Operational Definition:

A. Children Affected by HIV and AIDS (CABA): The terms refer to: (as per definition of
taskforce committee of CABA concept paper presentation in Nepal)
• Children living in or coming from a family where one or more parents or
caregivers are HIV positive;
• Children who have lost one or both parents or primary caregiver/s due to AIDS;
• Children and young people under 18 years of age who are HIV positive.

B. Concerned stakeholder: The organizations which are working in field of HIV&AIDS in

Morang district.

C. Health status: Defined as following rating and indicators

Health Status Indicators Rating
1. Physical check up (fever, illness) 1. Very good – if
2. Eye/ear found at least 9
3. Weight/height measurement indicators are okay
4. Nutritional status (Food consumption) Satisfactory - if
5. Psychosocial (stress, fear, angriness, mental disorder) found at least 7
6. Any kinds of disability indicators are okay
7. History of previous illness during 3 months and types 2. Week - if found at
8. CD4 count/Viral load (If HIV positive and tested least 5 indicators
conditions) are okay
9. Sign and symptoms OI and treatment 3. Very weak - if
10. Adherence ART (Applicable If under ART children) found below 5
11. TB and HIV co-infection indicators okay

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D. Discrimination: means behaving differently toward CABA because of assumptions about
them usually negative sense. Excluding, ignoring, mistreating or exploiting to CABA as a
result they have fear of disclosing ones status to think being rejected or mistreated.

E. Level of nutritional status: Nutritional status will be measured by food habit and
weight/height measurement. It defines current participant's nutritional status by rating as
following;
1. Very good
2. Satisfactory
3. Week
4. Very weak

F. Needs of CABA: Basic requirement to survive and maintain a quality life. Basic needs of
CABA will be defined as following rating indicators if found satisfactory level at least.
• Sufficient food consumption regularly
• Regular school attendance and performance without fear and discrimination
(Applicable only for student)
• Consumption balance diet (nutritional balance food-Carbohydrate, protein and
vitamin)
• Social Support (love, play together with friend, sharing happiness and sorrow ness
with out fear and discrimination, stigma and discrimination coping mechanism)
• Timely treatment of PHC
• Adequate treatment of OI and adherence ARV taking (Applicable for HIV positive
children and ART taking children)
• Coping mechanism against stigma and discrimination

G. Opportunistic Infection: When the body's immune system becomes weakened by HIV
infection then opportunistic infections (such as pneumonia, TB etc) occurs. Almost OIs will
be cured after proper treatment.

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H. Orphan vulnerable children: An orphan is a child who has lost one or both parents or
guardians to HIV AIDS before reaching the age of 18 and who is dependent.

I. Self Support group of PLHA: Formally or informally a formed group and has been
running as organization by HIV infected and affected people in order to advocate their rights
and needs fulfillment at local or district level.

J. Social Support: The individual belief that one is cared for and loved, esteemed and
valued, and belongs to a network of communication and mutual obligations. It is support
systems that provide assistance and encouragement to children affected and infected children
in order to build on self coping capacity by friends, relatives and peer formally or informally
setting.

K. Stigma: In the context of HIV&AIDS, it refers to a negative attitude towards CABA who
are (or are believed to be) HIV positive. Stigma is believed to originate in part of fear or
infection, and in part through moral judgment.

L. Comprehensive care and support: Provide psycho-social, clinical, social and economic,
legal and human rights as well as family and community support with integrate way to
CABA.

M. Low epidemic: Low prevalence is defined as countries with HIV prevalence consistently
<5% (UNAIDS, 2006)

N. Concentrated epidemic Concentrated epidemics is defined as countries with HIV

prevalence consistently >5% in one or more sub-populations but not established in the
general population (UNAIDS, 2006)

O. Mother-to-Child Transmission (MTCT): The passage of HIV from an HIV-infected

mother to her infant. The infant may become infected while in the womb, during labor and
delivery, or through breastfeeding.

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P. Malnutrition: Generally, under-nutrition and over-nutrition, but for the purpose of this
study the term will be sued to describer only under-malnutrition

Q. Counseling: Define providing information and advice to help CABA make informed
decisions or helping them to deal with emotional situation and psycho-social stress.

R. Psycho-social support: Define the support a CABA needs for effective socialization and
psychological wellbeing including counseling, emotional support, spiritual support, reduction
of stigma and discrimination and positive living. In practice, this support comes from a
parents/care takers and community people.

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1.7 Conceptual Frameworks:

Socio-Demographic Factors:
Age, Sex, Ethnicity, Religion, Family Size,
Family Income, Parent occupation, Address,
situation of food security

Health problems related factors:

HIV status, Malnutrition, Food practices,
Ear/Eye problems, Skin disease, Tuberculosis
problems, Sign and symptoms of OI, Status of
having disability, status of getting sickness,
Psycho-social problems Assess health problems,
health care seeking behavior

Essential needs related factors: and needs of children affected

Educational, nutritional, health care, treatment, by HIV and AIDS (CABA) in

comprehensive care and support, CHBC, Morang district, Nepal

psycho-social support, IGA opportunities,

social support

Services Seeking behavior factors:

Participant history of previous illness during 3
months and types, Treatment care and support
services seeking place, type of treatment
received, result of accessed services, reason
for not accessing and availability of services,
practices of high risk behavior (smoking, drug
use (O/I), unsafe sex)

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CHAPTER II- LITERATURE REVIEW

2.1.1 Literature of Review

The statistics show that because of premature death due to AIDS increasing orphan
vulnerable children over the world mostly Sub-Saharan African country. Report of UNAIDS,
2008 revealed that there were estimated 2.1 million to be living with HIV infected children
under 15 years amongst them Sub-Saharan Africa were contributed highest numbers of
infection that were 1.8 million children. In this way, in South and South-East Asia there were
140,000 children infected by HIV contributed second highest infection rate over the country.
The infection of HIV is covered more than 97% are in low-and middle income countries6.

Progress report for children affected by HIV and AIDS, December 2009 of UNICEF
mentioned that orphans and vulnerable children relative to that of non-orphans and non-
vulnerable children. The report finds that OVCs are less likely to have all three minimum
basic material needs for personal care than non-OVCs. The prevalence of malnutrition
among OVCs is in general greater than among non-OVCs7. Measuring progress and
identifying critical gaps of OVCs, the report has been used following indicators;
1. Basic material needs
2. Malnutrition/underweight prevalence
3. Sex before age 15 (women), (men)
4. Food security
5. Psychological health
6. Connection with an adult caregiver
7. Succession planning
8. Children outside family care
9. External Support for OVC
10. Orphans living with siblings
11. Orphan school attendance ratio

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 12. Birth registration
13. Orphaned and vulnerable children policy and planning effort index (OPPEI)
14. Property dispossession
15. Percentage of children who are orphans
16. Percentage of children who are vulnerable
17. Stigma and discrimination (women), (men)
In conclusion, this progress report explained that most of indicators far in seeking equity in
outcomes for children affected by HIV&AIDS, both in terms of programmes and policies as
well as in terms of the data-collection efforts necessary to track children's outcomes over
time. The mentioned indicators are very useful for accessing problems, gaps and needs of
children affected and infected by HIV&AIDS.

Children and AIDS fourth stocktaking report, 2009 published by UNICEF, UNAIDS, WHO
and UNFPA said the progress and challenges that coverage of services for PMTCT has
increased steadily. In 2008, 19 countries had reached coverage rates of 80 percent for HIV
testing and counseling among pregnant women in need of services to prevent transmission of
HIV to their infants. Overall, in 2008, 21 percent of the estimated numbers of pregnant
women living in low-and middle-income countries were tested for HIV. Some 45% of
pregnant women living with HIV in these countries received antiretroviral (ARV) to prevent
the transmission of the virus to their infants, compared with 24 percent in 2006 showed that
the proportion of infants receiving ARVs for PMTCT increased between 2006 to 2008 in
many countries with very high levels of HIV infection particularly the Central African
Republic, Mozambique, Swaziland and the United Republic of Tanzania and in some low-
prevalence countries particularly China, Indonesia and Senegal.

Similarly, on average in 2008 in low and middle-income countries, 32 percent of infants born
to HIV positive mothers were given ARV prophylaxis for PMTCT at birth up from 20
percent in 2007 and 18 percents in 2006. Despite strong global progress and many successful
local and national initiatives, many developing countries are still not track to reach UN

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General Assembly Special Session on HIV AIDS (UNGASS) target8. The majority of women
and children do not yet have access to basic PMTCT services, ART services, pediatric care,
support and treatment. PMTCT along with comprehensive treatment, care and support are
needed to scale up in order to improve health conditions of children infected and affected by
HIV&AIDS in developing countries such as Nepal, India and Bangladesh so on.

Study on Orphans and vulnerable children affected by HIV AIDS in Brazil: where do we
stand and where are we heading in topic was conducted to aim at identifying human
rights status and situation as expressed in the UNGASS of children and adolescents
living with HIV AIDS, non-orphans and orphans affected by AIDS, based on local
and international literature reviews. The study revealed that several rights such as
health, education, housing, nutrition and non-discrimination, physical and mental
integrity are far from satisfactory level among HIV infected and affected children.
The study recommended that Brazil still needs to advance to meet further needs of
those orphaned and vulnerable children and developed actions to ensure supportive
environment for HIV infected and affected children9.

The mixed method combining qualitative and quantitative approaches was conducted in
Anhui, China to understand needs of families and children affected by HIV&AIDS found
that 54% of participants' caregivers related quality of life as poor and 85% reported frequent
negative feelings. The annual income per person HIV&AIDS affected families was much
lower than the provincial average. The impacts of HIV on children were reflected in
children's school performance. Children's nutrition and health were also compromised. The
conclusion of the study was HIV&AIDS directly affect health, nutrition, educational and
other social support aspects of children affected by HIV and AIDS10.

The progress report 2009, Towards Universal Access Scaling up HIV services for women
and children in the health sector was mentioned in key findings that the number of health
facilities providing pediatric antiretroviral therapy in low and middle income countries
increased by around 80% from 2007 to 2008. The number of children receiving antiretroviral

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therapy increased from 198000 in 2007 to about 275700 in 2008, reaching 37% of the
730000 children estimated to be in need of ART in low-and middle-income countries11.The
conclusion of the statement is that increased efforts are needed to expand access to HIV care
and treatment services for children who are infected and including other social support,
materials needs, health improvements are needs if HIV infected and affected children.

According to UNICEF Nepal article 'protection and care for children affected by
HIV&AIDS, it is estimated that 19,600 children are currently orphaned in Nepal due to
AIDS. Consequently, the children are facing malnutrition, inadequate to continue education,
compel to do child labor and other vulnerabilities12.

The study on "Evidence base for children affected by HIV&AIDS in low prevalence and
concentrated epidemic countries: applicability to programming guidance from high
prevalence countries" revealed the eight types of challenges concerned with children affected
and infected by HIV and AIDS as following;

1. Health and health care

2. Nutrition and food security
3. Education
4. Protection
5. Placement
6. Psychosocial development
7. Socioeconomic status
8. Stigma/discrimination

The study findings also were evidence on health and nutrition disparities between affected
and unaffected children was mixed. The study indicates that the CABA are less likely to seek
health care. The children and their families experience a range of socioeconomic
vulnerabilities in low prevalence settings. As well much of the strong evidence on
psychosocial vulnerabilities the affected children face comes from low prevalence13.

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A Situation Assessment of Children Affected by AIDS (CABA) in Nepal conducted in Jhapa,
Parsa, Tanahun, Kanchanpur and Doti district of Nepal on by Jointly HIV&AIDS and STIs
control board-NCASC, CREHPA and Save the Children Save the Children. The purpose of
the study was to assess extend, availability of and accessibility to health care, education,
economic and psycho-social support services among these vulnerable children. The study has
shown that over half of the CABA were orphans (either single or double orphaned); majority
being paternally orphaned. There were few (7%) Children affected by HIV&AIDS in the
sampled who had lost both of the parents. Every seventh child was HIV positive. Families
who fell under “poor” category in fact suffer from extreme poverty and hardship. Field
observation showed that the majority of the CABA were found to be malnourished and their
caregivers were not in a position to provide two meals a day to the family. Whatever income
earned for the family was spent on health care of sick family members.

In the same way, the study states the fact that CABA were discriminated in all the places,
mostly within the community, from peers, at schools and on few situations, within the family
and at health facility. More girls (39%) reported about facing discrimination than boys
(34%). Awareness level on HIV&AIDS was found low. It concluded that their health status,
educational, nutritional status and psycho-social supports is comparatively poor and even
basic materials needs are not addressed properly14.

According to WHO, HIV infection follows a more aggressive course among infants and
children than among adults. One third of children living with HIV die before the age of one
year and almost 50% by the second year. World Health Organization recommends that
antiretroviral therapy be initiated in all infants diagnosed with HIV in their first year of life15.

International Labour Office in Nepal, report on HIV&AIDS and working children in Nepal,
2004 concluded that children orphaned by AIDS are at greater risk of malnutrition, illness,
abuse, child labor, sexual exploitation than children orphaned by other causes and these factors

23
increase their vulnerability to HIV infection16. (Literature review will be continuing until
completion of the research work and will be added with the present ones)

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 CHAPTER III- RESEARCH DESIGN AND METHODOLOGY

3.1 Study design:

The cross-sectional descriptive type of study will be conducted.

3.2 Study area:

Study area will be different VDCs and Biratnagar Sub metropolitan city of Morang district,
Nepal.

3.3 Study Duration:

The duration of the study will start from January 2010 to April 2011

3.4 Study population

Children infected and affected by HIV and AIDS aged below 18 years will be my study
population of Morang district, Nepal. In case of below than 12 years children parent of
participant will be taken interview after verbal consent with the participant children.

3.4.1 Inclusion criteria:

• All children affected by HIV and AIDS aged below 18 years will be equally chance
to participate in the study.
• Children as well as parent whom aged under 12 will be participated the study

3.4.2 Exclusion criteria:

• The parent and children if both of any will refuse to participate in the study
• The children who are unable to provide information due to physically or mentally
illness

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3.5 Sample size

Sample size for the study will be decided by following equation:

We know,
Z2 x pq
n=
d2

Where,

n= Desired sample size

z= Value of standard normal distribution as given level of significant (confidence level),

usually considered 1.96 at 95% confidence interval (CI)

p = Proportion of level of health status and needs among children affected by HIV and AIDS,
which is not known, therefore, it is regarded 50% (0.5)

q = 1-p therefore, 1-0.5= (0.5)

d = Allowable error in the study 5% (0.05)

By using this equation,

Sample size (n) = (1.96)2 x 0.5 x 0.5/ (0.05)2 = 384.16

Because of time constraint and identification difficulty of un-disclosed HIV infected and
affected children in selected the district the estimated sample size will be 200.

3.6 Sampling technique:

Purposive sampling method will be applied for this study. The participants are scatter and we
can find most of them through stakeholders' relationship. Confidentiality of children affected
by HIV and AIDS is a major concerned.

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Stage 1: Relationship building and study's objective sharing with DACC, DPHO and
concerned organizations of the district.

Stage 2: Mapping major concentration sites such as VCT centre, self support group of PLHA
organizations and other concerned organizations among key stakeholders in order to
determine the approximate disclose families/persons.

Stage 3: Rapport building and objective sharing with concerned self support group of PLHA
and VCT centre to outreach children affected by HIV and AIDS.

Stage 4: Determine sample numbers of participant as per inclusion criteria in the concerned
organization.

Stage 5: If number of participant is competitively more than other selected cluster (services
areas) for ensuring equally representation of the study, simple random sampling (SRS) will
be applied to select appropriate and sufficient numbers of participants.

3.7 Research tools:

For collection of primary data to determine health status and needs of children affected by
HIV and AIDS, a structured and open ended questionnaire will be developed based on the
research objectives and the research question. Pre-testing of the questionnaire will be done in
similar types of children affected by HIV and AIDS at other places in the help of self support
group of PLHA or concerned organizations. After the pre-testing, revision of the items and
questions will be finalized based on the findings and observation experiences. The final
questionnaire both structured and open questions will be kept.
Observational checklist (including in questionnaire) …………(If you want to use this tool,
please write in detail)

3.7.1 Instrument of data collection:

• Semi-structured and open ended questionnaire
• Observational checklist (including in questionnaire)

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 • Weight and Height measurement instrument
• Involving Paramedical person to examine physical health status of the participants
3.8 Method of data collection:

Data will be collected by face to face interview with children affected by HIV and AIDS (If
children under 12, parents will be responded of the interview) by the researcher at self
support group of PLHA organization, crisis care centre, related organization and at
their home through field visit where appropriated to maintain confidentiality. Before
taking face to face interview, their consent and convenience will be ensured. Socio
demographic and other personal information will be also recorded from a semi
structured pre-tested questionnaire. The appropriate measurement instruments will be
used during interview period.

Observational checklist (including in questionnaire) …………(If you want to use this tool,
please write in detail)
3.9 Methods of data processing:

3.9.1 Data management plan:

The complete questionnaires will be collected, checked for completeness and clarity then
compiled it. The data from the complete questionnaires will be analyzed by means of
SPSS (statistical packages for social sciences) software.

3.9.2 Data analysis plan:

The descriptive statistics will include the frequencies, percentages, mean, median, standard
deviation of the findings. Cross tabulation along with association among the socio-
demographic characteristic such as educational, ethnicity, religion and level of current health
problems, health seeking behavior, level of accessed in services and needs of participant will
be analyzed using frequencies, mean, median and standard deviation. Other all variables such
as nutritional status, hygiene and level of social supports will be analyzed using frequencies.

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3.10 Data presentation:
Data will be presented in the form of tables and graphs. Descriptive statistics will be
presented with frequencies table. Association will be demonstrated with cross tables. Bar, pie
charts and line charts will be generated to illustrate descriptive statistics.
3.11 Quality control and quality assurance:

Following indicators will be based for quality control and quality assurance
• Careful design the study
• Translation of the questionnaire in local language (English to Nepali)
• Pre-testing of data collection tools will be used for face to face interview
• Re-tested, re-measured and accuracy result given instrument such as height/weight
measurement will be operated
• The involvement of the researcher will be ensured during data collection in field
level.
• Ensure meaningful participation of participant during the study period.

3.12 Ethical considerations:

• All ethical issues related to research will be addressed according to the guidelines of
the research ethical review of State University of Bangladesh and Nepal Health
Research Council.
• Permission from State University of Bangladesh, District AIDS Coordination
Committee, Morang and District Public Health Office Morang, Nepal will be
obtained as pre requisite.
• Inform decision making consent with participant will be taken before the interview.
Consent form will be translation into local languages.
• Confidentiality of participant and will be primed and maintained.
• Participant will have rights to refuse and withdraw from the study, any time will be
accepted.

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• During entire study social and cultural belief will be respected as well as will be used
HIV&AIDS friendly language (non-discriminatory words).
• Before face to face interview informed consent in written form will be taken with
parent/care taker of the participant and in case of under 12 years aged CABA, verbal
consent will be ensured with participant.

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3.12 Work Plan:

Tentative work schedule of the study 2010 November to 2011 April

Activity Month November December January February March April 2011
2010 2010 2011 2011 2011
Week 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

1. Proposal
Writing
2. Literature
Review
3. Develop
questionnaire
4. Proposal
defense
4. Pre-test of
questionnaire
5. Data
collection
6. Data Entry
7. Data analysis
8. Report
writing
9. Draft
submission
10. Defense
11. Final
Submission

Reference:

1. UNAIDS, 2008 Global Summary of HIV and AIDS Epidemic Accessed in 27 Oct 2010
available from UTL: www.unaids.org

31
2. National Centre for AIDS, STI control, National Strategy Plan 2006-2011, UNGASS
Country Report Nepal 2008, available from UTL: www.ncasc.gov.np

3. UNICEF Nepal, 2010 available from http://www.unicef.org/nepal

4. District AIDS Coordination Committee (DACC) Morang Strategy Plan B.S. 2066-2071
(2009/010-2013/14)

5. District AIDS Coordination Committee (DACC) Morang Progress Report 16 July 2010

6. UNAIDS- Accessed through UTL: www.unaids.org

7. Progress Report for children Affected by HIV/AIDS December 2009 UNICEF and United
for Children, United for AIDS

8. Children and AIDS Fourth Stocktaking Report, 2009 by United for Children, United for
AIDS jointly UNICEF, WHO, UNFPA and UNAIDS

9. Orphans and vulnerable children affected by HIV/AIDS in Brazil: where do we stand and
where are we heading? Article in Portuguese França-Junior I, Doring M, Stella IM Accessed
in 27 Oct 2010 available from UTL: http://www.ncbi.nlm.nih.gov/pubmed

10. The impact of HIV/AIDS on families and children--a study in China Anhui Center for
Disease Control and Prevention, Hefei, China Accessed in 27 Oct 2010 available from UTL:
http://www.ncbi.nlm.nih.gov/pubmed

11. "Towards Universal Access Scaling up HIV services for women and children in the
health sector" the progress report 2009 by UNICEF, UNAIDS and WHO

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12. Article on "'protection and care for children affected by HIV&AIDS" by UNICEF Nepal
accessed in 29 October 2010 available from UTL: http://www.unicef.org/nepal/5522
CABA.htm

13. Evidence base for children affected by HIV and AIDS in low prevalence and
concentrated epidemic countries: Applicability to programming guidance from high
prevalence countries- Authors Lynne Miller Franco; Bart Burkhalter and followed by et al.
accessed in 29 October 2010 available from UTL: http://www.unicef.org/nepal/5522
CABA.htm

14. A Situation Assessment of Children Affected by AIDS in Nepal, Report 2009 by Save
the children, MoH, HIV-AIDS and STIs Control Board, National Centre for AIDS and STD
Control, CREHPA and Save the Children.

15. World Health Organization available UTL: www.who.org

16. International Labor Office Nepal/International programme on the elimination of child

labor report on HIV&AIDS and working children in Nepal, January 2004, Kathmandu Nepal.

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