Global publications on the international AIDS epidemic report on the existence of an ever-increasing number of orphans and vulnerable children. It has been suggested that by the end of this decade there will be in excess of 25 million AIDS orphans globally, an issue which will require understanding and organisation of long-term medical, psychological and social support. This study provides a systematic review to examine the use, overuse and misuse of the term orphan and explores the benefits and limitations of this approach. It then summarises the knowledge on orphans to date. Using a search strategy of published studies and recent conference abstracts, 383 papers were identified where the concept of AIDS and Orphan was raised. The papers were systematically coded and reviewed to understand when and how a child is labelled an orphan, and to summarise the effect of orphanhood on outcome measures, most notably psychologically and physically. All controlled studies published prior to 2006 were reviewed. A consistent picture of negative effects of parental death (however defined) on a wide range of physical, socioeconomic and psychological outcomes were recorded. Seventeen studies met criteria for in-depth review (empirical, fully published, control group). The majority of studies are cross-sectional (two are longitudinal) and employ a very wide array of measures - both standardised and study specific. This detailed analysis shows a mixed picture on outcome. Although most studies report some negative effects, there are often no differences and some evidence of protective effects from quality of subsequent care and economic assistance. The lack of consistent measures and the blurring of definitions are stumbling blocks in this area.

The objective was to systematically review measures and effects of human immunodeficiency virus (HIV) on neurocognitive outcomes for children. Published studies were identified through the use of electronic databases (Cochrane database, Medline, PubMed, Psychinfo) supplemented by hand searching and coverage of the gray literature. All studies including children with HIV infection, which utilized at least one systematic measure of cognitive functioning, reported on place, sample size, age, and outcome measures, and included a control group were eligible for inclusion. Outcomes were coded for each study and broken down by measures when multiple measures were used. A systematic analysis of all measures used was also undertaken, as was a specific investigation of gender. Meta-analysis was not performed due to the heterogeneity of studies, the noncomparability of measures, and the wide age ranges of children included. Fifty-four studies were identified, of which had control groups. The data are highly North American biased (63%) with European studies accounting for 13% and only two from South America and seven from Africa, where the vast majority of HIV-infected children are found. Eighty-one percent of studies reported a detrimental effect on neurocognitive development, however measured, whilst three reported no differences and four had mixed findings. Thirty-three percent provided data on child gender, but only 8% went on to analyse data according to gender. The numbers are too small for definitive findings, but of note that three quarters found no gender differences. There seems to be some evidence of detrimental effects of HIV infection and exposure on cognitive development, but the lack of systematic measures, controlled trials and age-specific investigations render the literature inadequate. There is an urgent need for internationally agreed and validated measures to be incorporated and for these to record data by age and gender. This will allow for clarity of understanding of the effects, the ability to monitor change as a result of intervention, and to mobilize resources.

This review (under the International Joint Learning Initiative on Children and AIDS)provides a detailed evidence analysis of gender, children and AIDS. Six systematic reviews provide the most up to date evidence base on research surrounding children and HIV on key topics of treatment resistance and adherence, schooling, nutrition, cognitive development and orphaning and bereavement. Traditional systematic review techniques were used to identify all published studies on four key topics, then studies were selected according to adequacy criteria (sufficient size, control group and adequate measures). A gender analysis was performed on included studies, detailing whether gender was measured, results were analysed by gender or any gender-based findings. For family studies, both the gender of the parents and gender of the child are needed. Secondary analysis by gender was performed on existing systematic reviews for treatment resistance and adherence. Of the 12 studies on treatment resistance, 11 did not look at gender. One found boys at a seven-fold risk compared to girls. For medication adherence, gender was not significant. Of the 15 studies on schooling, 12 analysed findings by gender with an overall female disadvantage. Of the 14 studies on nutrition, nine analysed by gender with mixed findings. Of the 54 studies on cognitive development, 17 provided gender data, but only four analysed by gender with few differences established. Of the 15 studies on bereavement, seven analysed data by gender again with mixed findings. Major policies fail to provide gender data for young children. WHO, UNAIDS and the international data sets are not gathered or coded by gender for young children (generally under 15 years of age)despite well-established gender challenges in later life. This review shows that the current evidence base is inadequate. Data on gender variation and outcome are urgently needed to inform policy and research on children and HIV.

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