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4. The HIV/AIDS Epidemic, Kin Relations, Living Arrangements, and the Elderly in South Africa.
Pages 117-165

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From page 117...
... In particular, the levels and age patterns of the incidence of HIV and future increases in prevalence are likely to have a large impact on kin relations, residential patterns, household organization, and the well-being of family members. Faced with the escalating burden of excess morbidity leading to the disruption of normal activities and functions, families and households are likely to adopt coping strategies to contain the damaging effects of the epidemics.
From page 118...
... . Thus what we observe among the African population of South Africa may be replicated in other countries with similar patterns of intergenerational relations.1 1The advent of a pension system in South Africa may be changing some of these patterns of generational transfers and may be consequential for the coresidence of the elderly and some or all of their adult children.
From page 119...
... Our central objective in this paper is rather modest, since we only estimate the effects of HIV/AIDS on residential patterns of the South African elderly and evaluate observable changes in their living arrangements over a decade. We eschew assessment of other effects of the epidemic on the elderly but argue that these may be reflected, at least in part, in changes in residential arrangements.
From page 120...
... These models yield estimates of the expected availability of adult children for the elderly, lower bounds for the prevalence of sickness among the children born to elderly people, and 10- to 15-year projections of changes in the availability of adult children and the prevalence of sickness. Second, we use the macromodel to contrast some of the epidemic's expected outcomes derived from the model with observed changes in living arrangements of the elderly over time and across provinces.
From page 121...
... It was attributed to polygynous unions whereby, at the father's death, all children born to his widows become orphans. In Tanzania, Urassa and colleagues (1997)
From page 122...
... Second, there is a rearrangement of the household to adjust to the needs of caring for sick adult children. These changes may lead to increases in headship among the elderly and to a more influential presence of households composed of elderly parents, their adult children, and grandchildren.
From page 123...
... One study uses microsimulation, in combination with aggregate demographic analysis, to estimate how patterns of coresidence of elderly parents in Thailand would adjust in response to the HIV/AIDS epidemic (Wachter, Knodel, and VanLandingham, 2002)
From page 124...
... , a measure of the conditional probability of residing with one of the surviving children.5 Since excess mortality associated with HIV/AIDS affects D(x,t) , one could argue that the difference between estimates of demographic availability in contexts with and without HIV/AIDS is sufficient to identify the effects of HIV/AIDS on living arrangements of the elderly.
From page 125...
... Because the median duration from infection to full-blown AIDS and mortality in sub-Saharan Africa is about 7.5 years (Boerma, Nunn, and Whitworth, 1998) , one cannot expect to see large changes in patterns of living arrangements until some time after the onset of the epidemic.
From page 126...
... will be observed, leading one to conclude that the HIV/ AIDS epidemic is inconsequential for living arrangements. Identification Conditions in South Africa In South Africa, identification problems are exacerbated by the fact that the period of fastest growth of the incidence rates in HIV/AIDS coincided with a period of tumultuous social and demographic transformations that occurred just before and after the collapse of apartheid.
From page 127...
... In line with these theories, the changes brought about by apartheid might have led to an erosion of social control over family members and a weakening of emotional ties that sustain traditional adherence to the family and its patriarch. Disintegration of the traditional intergenerational relationships has implications for the living arrangements of the elderly, for whom modernization assumes a shift from a preference for coresidence with adult children and grandchildren to a preference for solitary living.
From page 128...
... . Third, to address the first identification condition and distinguish the effects of HIV/AIDS on the living arrangements of the elderly from those of migration, our analyses will compare conditions across South African provinces, which differ in levels of HIV/AIDS prevalence and magnitude and direction of migration flows.
From page 129...
... DATA ON LIVING ARRANGEMENTS Data Sources Our observation of changes in P(x) relies primarily on the analysis of the last apartheid census taken in 1991, the 10-percent public sample of the first postapartheid census taken in 1996, and the 10-percent public sample of the 2001 census.
From page 130...
... Second, all three data sets contain information on the relationship of each household member to the household head. This information is necessary to calculate the distribution of living arrangements of the elderly, widowhood and orphanhood rates, and other indicators pertaining to the residential arrangements of the elderly.
From page 131...
... The success rate of imputation of grandchild status was evaluated by implementing this procedure based on 1993 data on 1996 census data in which grandchild status is known. The success rate of imputation was 86.94 percent.
From page 132...
... By 2001, six provinces displayed adult HIV prevalence rates higher than 20 percent. The remaining ones, Western Cape, Limpopo, and Northern Cape, displayed low to moderate levels of HIV.
From page 133...
... Yet some of the consequences of HIV/AIDS are likely to be experienced by the elderly in low-prevalence regions as well as by those living in high-prevalence regions. Consider, for example, the hypothesized increased proportion of the elderly living with grandchildren but no adult children in areas with high HIV prevalence.
From page 134...
... The forward projection exposes the target's children to the risk of HIV infection and death due to AIDS. This is done by applying rates of HIV incidence (transition from the healthy state to HIV+)
From page 135...
... the probability that a target's female children born alive when the target was age x – y at time
From page 136...
... are extremely low, the assumption is not at all limiting. Even if the assumption departs from reality, our calculations will be in error only if the childbearing patterns to which targets not affected by HIV and the mortality and HIV incidence pattern of her children are different from those that apply to target persons who were infected prior to the target year.
From page 137...
... Required Inputs Estimation of model outcomes depends on six pieces of information. The first and most important are the yearly HIV incidence rates from the onset of the epidemic until time t.
From page 138...
... Note that the incidence rates in all three settings peak around the same year but at different levels, suggesting heterogeneity of ceilings and of stable incidence rates but not a different timing for the epidemic. Households of the Elderly and HIV/AIDS Prevalence Estimates of HIV prevalence can be used in simple ways to calculate the prevalence of elderly households with at least one HIV-infected adult child.
From page 139...
... Adjusted HIV adult incidence .04 HIV Incidence .02 0 1985 1995 2015 2025 2005 Year FIGURE 4-1b Estimated adult HIV incidence (density)
From page 140...
... in the province, and gk(r) is the fraction of all households containing an elderly member that include exactly r adult members.
From page 141...
... are associated with real cohorts of adult children, they need not be monotonically decreasing. In fact, they should not be, since they must reflect, on one hand, the combined effects of mortality and of HIV incidence on the other.
From page 142...
... 142 AGING IN SUB-SAHARAN AFRICA Prob_survival_1995 Prob_healthy_1995 Prob_healthy_2005 1 .8 Probabilities .6 .4 10 15 20 25 30 35 40 45 50 55 Cohort Age in 1995 FIGURE 4-3a Survival and healthy survival, South Africa, 1995-2005. Cumulated_hiv_1995 Cumulated_hiv_2005 Survival_hiv_1995 Survival_hiv_2005 .4 .3 Probabilities .2 .1 0 10 15 20 25 30 35 40 45 50 55 Cohort Age in 1995 FIGURE 4-3b Cumulated HIV and HIV survival, South Africa, 1995-2005.
From page 143...
... The bereavement load for elderly associated with adult children ages 20-30 in 2010 grows from 0.20 in 2005 to a staggering 0.35 in 2010. This means that the probability of an adult child dying of HIV/AIDS before attaining ages 20-35 in 2010 is on the order of 0.35.
From page 144...
... 144 AGING IN SUB-SAHARAN AFRICA Prob_survival_2000 Prob_healthy_2000 Prob_healthy_2010 1 .8 Probabilities .6 .4 .2 10 15 20 25 30 35 40 45 50 55 Cohort Age in 2000 FIGURE 4-4a Survival and healthy survival, South Africa, 2000-2010. Cumulated_hiv_2000 Cumulated_hiv_2010 Survival_hiv_2000 Survival_hiv_2010 .4 Probabilities .2 0 10 15 20 25 30 35 40 45 50 55 Cohort Age in 2000 FIGURE 4-4b Cumulated HIV and HIV survival, South Africa, 2000-2010.
From page 145...
... The weights are the time distribution of children ever born for elderly of the specified age.
From page 146...
... But the damage caused by the epidemic may be even larger than what these figures suggest. In fact, although the increase in the number of the elderly with no surviving children is a key determinant of the probability of the elderly living alone (Palloni, 2000; Wolf, 1994)
From page 147...
... In order to investigate these, we turn now to results from the 1991, 1996, and 2001 data. ANALYSIS OF CENSUS DATA Orphanhood and Widowhood Before turning to an examination of the observed living arrangements of the African elderly from the three South African censuses, we calibrate our ability to detect gross effects of HIV/AIDS from each data source.
From page 148...
... and because information on parental survival was not collected in the 1991 census, we estimate linear regressions of the logarithm of the proportion of orphans on the logarithm of prevalence by provinces from 1996 and 2001 census data. The estimated regression coefficients can be interpreted as elasticities or, equivalently, as the proportionate change in orphanhood relative to a proportionate change in HIV prevalence.
From page 149...
... Patterns of Living Arrangements of the African Elderly The taxonomy of living arrangements of the elderly adopted here is suggested by the outcomes of the macrosimulation model. We focus on four main residential arrangements of the elderly: (1)
From page 150...
... living with one or more orphaned grandchildren. Similar to our previous analysis of orphanhood and widowhood, we explore the relationship between living arrangements of the African elderly age 60 and above and HIV prevalence across the nine South African provinces by estimating a linear regression of the logarithm of each type of living arrangement of the elderly in 1991, 1996, and 2001 on the logarithm of HIV prevalence.
From page 151...
... = -2.24 -.11ln(HIV) R-sq =.06 FIGURE 4-6 Proportion of African elderly living alone or in a couple and HIV prevalence.
From page 152...
... = -.65 + .02ln(HIV) R-sq =.01 FIGURE 4-7 Proportion of African elderly living with an unmarried or widowed child over 15 and HIV prevalence.
From page 153...
... . In order to unequivocally associate changes in the living arrangements of the elderly with the impact of HIV/AIDS, Figure 4-9 shows the relationship between HIV and the fraction of the elderly living with a dual orphaned grandchild in 1996 and 2001.
From page 154...
... = -1.59 + .24ln(HIV) R-sq =.11 FIGURE 4-8 Proportion of African elderly living with a grandchild under age 15, no adult children, and HIV prevalence.
From page 155...
... FIGURE 4-9 Proportion of African elderly living with dual orphan under age 15, no adult children, and HIV prevalence. 155 SOURCES: 1996 and 2001 censuses, 10-percent samples.
From page 156...
... The results from the macromodel suggested that the fall in the number of healthy children and the growing loss of children to AIDS may leave the elderly with fewer or no surviving children to live with and may increase the propensities of grandparents to take in their grandchildren to ease the burden on their sick adult children or to care for their orphaned grandchildren. Our descriptive analysis of changes in the living arrangements of the elderly as they relate to the growth of HIV prevalence has revealed flickers of evidence suggesting the effect of HIV/AIDS.
From page 157...
... These data collection efforts can elicit direct information on residential preferences, changes in availability, and changes in actual living arrangements in subgroups affected and not affected by HIV/AIDS. Another promising approach to enhance knowledge of the effects of the HIV/AIDS epidemic on the elderly and to isolate the most important contributors to observed patterns in living arrangements is the implementation of microsimulations that combine the realistic modeling of the HIV/AIDS epidemic, of kin availability, and of coresidence.
From page 158...
... However, since the HIV incidence rates between ages 49 (attained the year the epidemic started) and 60 (attained in the middle of the census year 1996)
From page 159...
... The first and most important are the yearly HIV incidence rates from the onset of the epidemic until time t. The second is the incubation function that determines the waiting time in the infected state.
From page 160...
... In all provinces and in South Africa nationwide, the adjustments apply to the years after 2003, not before. In this sense, the uncertainty surrounding the estimates of HIV incidence is larger in the post-2003 period than before, when the estimates are at least more closely anchored to the trajectory of observed prevalence.21 This fact makes the calculations of the key quantities via forward projections less sensitive to errors associated with the use of incorrect Gammaadjustment factors because post-peak epidemic incidence rates will affect 21This is a generous statement, for the "observed" prevalence is not so: it is estimated via procedures that are not always reproducible and rest on observed prevalence in small and selected samples of pregnant women.
From page 161...
... In all cases, we use the North female pattern of mortality from the Coale-Demeny model life tables.24 Estimation of Fertility and of f and w Estimates of f were obtained from the age pattern of fertility implicit in the Coale-Demeny stable models. We made no extra efforts to approximate 22An important limitation of our estimates is that the estimated incidence curve depends heavily on the provincial antenatal clinic-based estimates of HIV prevalence that we found published.
From page 162...
... . Evidence from national population-based surveys on bias in antenatal clinic-based estimates of HIV prevalence.
From page 163...
... . Black South African families with older members: Opportu nities and constraints.
From page 164...
... . Living arrangements of older persons.
From page 165...
... in the RSA. Supple ment to South African Medical Journal, 23-26.


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