Effects of parental HIV on children’s education: a qualitative study at Mashambanzou Zimbabwe

Abstract

We investigate mechanisms that influence the effects of parental HIV on the education of children. The study was conducted at Mashambanzou Care Trust in Harare, Zimbabwe. We sampled low-income HIV-positive and HIV-negative mothers who had a total of 71 children in their care. HIV-positive mothers were on treatment and women in the sample had at least one school-going child. We use a framework that describes the channels that influence the direct and indirect effects of the HIV status of a parent on investments in their children’s education. We find that the main reported mechanisms that influence this relationship are financial barriers exacerbated by HIV, children taking care of sick parents or siblings (child carers), and gender-differences in how parental illness affects children. In addition, we find that children of HIV-positive mothers do not always have birth certificates, which is a major barrier to school and exam registration in Zimbabwe.

KEYWORDS:

• Parental HIV
• children
• gender-differences
• socioeconomic
• poverty

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Introduction

Mother-to-child (or vertical) transmission of HIV is responsible for most infections of children aged 0–14 years (UNAIDS, 2020). In 2011, the Zimbabwean government implemented an accelerated national prevention of mother-to-child transmission (PMTCT) program.¹ As a result, in 2018, 94% of HIV-positive pregnant women had access to antiretroviral (ARV) medicine and 11,000 new-born infections were prevented (UNAIDS, 2018). This is a crucial achievement in HIV-prevention in Zimbabwe given that women constitute 61% (730,000 out of 1.2 million) of the adult HIV population in the country (UNAIDS, 2018). There are about 130,000 children aged 0–19 years currently living with HIV in Zimbabwe, which is about 2% of the total population of children (UNICEF, 2019). In contrast, the adult HIV prevalence rate in Zimbabwe is about 12.7% (UNAIDS, 2018). Therefore, it is safe to assume that there are more children living with HIV-positive parents than there are HIV-positive children. HIV-positive children face a multitude of issues related to their health, education, and social wellbeing. Hence, several studies have examined the direct effects of HIV on children’s education in Zimbabwe (e.g. Bandason et al., 2013; Luseno et al., 2015; Pufall, Gregson, et al., 2014; Pufall, Nyamukapa, et al., 2014). However, not much is known about the educational attainment of children with HIV-positive parents. This is an important issue because these children may face educational challenges related to parental illness.

The education of children with HIV-positive parents may be affected through: (a) reduced availability of parents due to the illness-related issues; (b) the association between parental health and offspring health through vertical transmission of HIV, and children caring for sick parents (c) intergenerational transmission of socioeconomic status including financial problems, and gender-differences related to sociocultural dynamics (Boardman et al., 2012; Goudge et al., 2009; Pedersen & Revenson, 2005 Smith, 2004;). If a parent is facing health challenges for which he/she cannot afford treatment, it may be difficult for the parent to provide financial support for the children, including for their educational needs. Following the political and economic crisis of 2000–2008 that was characterized by hyperinflation and economic sanctions, the Zimbabwean government significantly decreased the expenditure on operational costs for schools. This led public schools to heavily rely on school fees and levies (or tuition). The average school fees per child each year is about 70 USD (Moyo, 2020). This can be a significant amount for low-income families. Therefore, school fees can be a major source of distress in households in Zimbabwe.² Children with parents who cannot afford to pay school fees or buy school uniforms may be sent home until the payments are made (Mpofu & Chimhenga, 2016). This puts children with low-income HIV-positive parents in Zimbabwe in a precarious position because they are on the intersection of poverty and HIV (Duffy, 2005). In general, individuals from lower socioeconomic groups in Zimbabwe, i.e. the poor, are more vulnerable to HIV infection (Lopman et al., 2007).

In some instances, children with HIV-positive parents in Zimbabwe become caregivers for their parents, which can be emotionally and psychologically challenging (Robson et al., 2006). Consequently, girls and boys may be affected by parental illness differently as girls are more likely to be carers for a sick parent (Smith, 2002). This is because, in general, the burden of care for sick family members typically falls on female family members (Olenja, 1999). Also, vertical transmission or exposure to the disease may affect a child’s school due to physical or cognitive ramifications of the disease (Bagenda et al., 2006; Nozyce et al., 2014). In general, parental illness may affect or exacerbate physical, psychological, and/or socioeconomic outcomes of children, which also affects their schooling (Ferrand et al., 2007; Floyd et al., 2007; Sieh et al., 2010).

This paper aims to explore the mechanisms that drive the effects of HIV infections of parents on educational attainment of their children in the context of Zimbabwe. It is important to examine this group of children because there is a strong relationship between mothers’ and children’s education in Zimbabwe (Pufall et al., 2016). We identify and explain the major drivers of this relationship, which will help inform policies that target educational attainment of HIV-affected children.

Literature review

Findings of studies that investigate effects of HIV on intergenerational transmission of education in sub-Saharan Africa (SSA) are mixed. Akbulut-Yuksel and Turan (2013) found that the association between the education of HIV-positive mothers and their children’s education was 30% less than that of HIV-negative mothers in 13 SSA countries. Cluver et al. (2012) found that young and adolescent HIV carers in South Africa missed school days, experienced hunger and had concentration problems at school. Similarly, Pufall, Nyamukapa, et al., (2014) found that young carers in Zimbabwe attended less school. On the other hand, Cluver et al. (2013) found that parental AIDS-illness was not directly associated with educational access in South Africa.

Past research has also shown that parental involvement in children’s learning has a positive influence on student achievement (e.g. Auerbach, 1989; Desimone, 1999; Hill & Tyson, 2009). A meta-analysis conducted by Wilder (2014) shows that regardless of the definition of parental involvement or the measure of student achievement, the relationship is consistently positive. The relationship between the two was strongest if parental involvement was defined as parental expectations for academic achievement. However, the relationship was weakest if the parental involvement was defined as assistance with homework. In some cases, unhealthy parents were not involved with their children’s academic achievement because of physically, mentally, and/or emotionally incapable. In addition, they may have less time to be involved with their children’s academic achievement. Specifically, parents with HIV/AIDS face issues related to physical health symptoms, complex medical regimens, and fear of death (Rotheram-Borus et al., 2001).

Intergenerational transmission of health status can directly and indirectly affect children’s educational attainment. First, vertical transmission (mother-to-child) of HIV directly affects children’s education through the physical, mental, and emotional issues related with the illness. For example, Anabwani et al. (2016) found that HIV-positive children missed school days due to medical appointments. In addition, HIV-positive children reported having problems at school. Children becoming caregivers for their parents (child carers) mainly show the indirect effects of parental illness on children’s academic achievement (Boardman et al., 2012). Being a child carer may increase stress levels, anxiety, and depression (Pedersen & Revenson, 2005).

Parental health may be related to the level of socioeconomic resources available. These resources are subsequently related to the educational outcomes of children. According to Smith (2004), individuals who experience a major illness have lower earnings compared to healthy individuals. Goudge et al. (2009) also highlights that chronically ill adults face financial constraints, limited social networks, interrupted drug supplies, and their livelihoods are exhausted from previous illness and death. In addition, individuals of lower socioeconomic status tend to have worse health outcomes (Smith, 2004). In particular, there is a disproportionately higher HIV incidence rate among individuals of lower socioeconomic status (Bunyasi & Coetzee, 2017).

Most of the aforementioned studies are quantitative. While quantitative studies provide evidence on effects or impact, they are likely to not fully capture the mechanisms that influence relationship. It is therefore difficult to understand the social realities of the participants in quantitative survey studies. The exploratory nature of qualitative studies allows for a better understanding of how and why individuals behave in a particular manner. As such, this study seeks a better understanding of the issues faced by HIV-positive mothers in transmitting education to their children. Qualitative studies that examine how HIV affects intergenerational transmission of education have mainly focused on the relationship between orphans and grandparents (e.g. Harms et al., 2010; Jepkemboi & Aldridge, 2014). There are currently no qualitative studies that solely focus on HIV-positive parents and their children in Zimbabwe (Zinyemba et al., 2019).

In particular, we use the framework of Boardman et al. (2012) who presented three channels through which parental illness affects educational attainment of children. These are: (a) reduced availability of parents due to the illness-related issues; (b) the association between parental health and offspring health through vertical transmission of HIV and children caring for sick parents (c) intergenerational transmission of socioeconomic status including financial problems, and gender-differences related to sociocultural dynamics. The framework was developed by reviewing literature that examined effects of parental illness on the educational attainment of adolescents. Firstly, it was found that children with parents who are involved in their school and social lives have better educational and economic outcomes when they become adults. This is because illness can inhibit parents from helping their children with homework and other school-related activities. Secondly, children with ill parents may not be able to spend time on homework or other school-related activities compared to children with healthy parents. Finally, parental illness may lead to the transmission of socioeconomic problems from the parent to the child. Through this framework, we demonstrate these mechanisms in the context of Zimbabwe. This is the first study to simultaneously examine these mechanisms in SSA using data from participants with and without HIV.

Methods

This study explores the mechanisms that influence how parental HIV affects education of children in Zimbabwe using a qualitative approach. Interviews were conducted in collaboration with the Mashambanzou Care Trust (MCT) – an interdenominational non-profit organization (NGO) based in Harare (the capital city) that seeks to provide medical care and support to low-income HIV-positive individuals. MCT has direct access to over 5000 HIV-positive individuals in ZimbabweDue to ethical reasons, socioeconomic barriers, health-related reasons, and stigma the identification of HIV-positive individuals can be difficult. The collaboration with MCT allowed for access to HIV-positive respondents.

Study area and sampling

The study was conducted in February 2020 in Harare, Zimbabwe. We employed a purposive sampling strategy by establishing contact with MCT. As explained above, MTC is an NGO that provides treatment, care, and support interventions for HIV-positive individuals of all ages in Zimbabwe. MCT was established in 1989 and has a patient-care focus and family-centered approach to HIV response interventions. MCT targets HIV-positive individuals with socioeconomic challenges that inhibit them from obtaining treatment. The organization has a 30 bed-capacity facility and caters to over 5000 people living with HIV of all ages in resource-constrained (urban and rural) communities. There is no other facility that offers holistic and direct services to people living with HIV in Zimbabwe. Therefore, this link with MCT allowed us to have direct contact with potential respondents who have constant access to treatment and regular counseling related to stigmatization, among other things. The target group for this study included women who did not live on the facility but commute to the facility for treatment or to accompany a partner who is receiving treatment at the facility.

Given the stigmatization of people living with HIV in Zimbabwe (Mateveke et al., 2016), it was important to ensure that the recruitment process prioritized the safety and comfort of the participants. Hence, MCT’s evaluation manager, social workers, and medical staff facilitated the recruitment process of the respondents. In order to examine how parental HIV affects schooling outcomes of children, non-bedridden HIV-positive mothers who were at least 18 years old and had at least one school-going child, were selected and invited to participate. We targeted mothers because their education strongly influences educational outcomes of children and in general, women are the primary caregivers of children (E. Pufall et al., 2016; Waterhouse et al., 2017). A few HIV-negative women above 18 years with at least one school-going child were targeted and identified by MCT in the same communities. These HIV-positive women and HIV-negative women verbally confirmed their status and their partner’s status. HIV-negative women verbally confirmed that their partners were HIV-negative. It is important to include both HIV-positive women and HIV-negative women of a lower socioeconomic status in order to distinguish issues related to belonging to a low socioeconomic status group and issues related to HIV.

Ethical approval

We obtained ethical approval from the Medical Research Council of Zimbabwe and from a University Ethical Review Committee. Informed consent forms were provided to each participant in Shona (a native language) and English before participating in the study and was asked to sign the form to be able to participate. The study with MCT was independent and there are no conflicts of interest to declare. The data for the interviews used in this paper is stored in a publicly available database.³ The study was conducted as part of doctoral dissertation that examined effects of HIV on children and youth’s educational attainment in Zimbabwe (Zinyemba, 2021). At the start of each interview, the participant was reminded and reassured that she had the right to discontinue the interview at any point in time. The data were managed and stored according to Maastricht University’s Data Management Code of Conduct.

Data collection and interview guide

Individual semi-structured in-depth interviews were held with 16 participants who met the selection criteria (of women above 18 years with at least one school-going child). Of these, 13 participants were HIV-positive women and three were HIV-negative. The number of participants is relatively small because MCT facilitated the sampling process and only included participants who were physically, emotionally, and mentally capable of participating in the study. In addition, all participants commuted from their respective communities from various parts of the city to the MCT facility where all interviews were held. In addition, MCT targets individuals of a low socioeconomic status, most of the beneficiaries live in densely populated suburbs that are characterized by poor infrastructure, informal employment, long, and costly commutes to most parts of the capital city, and limited utility services (i.e. electricity and water). Hence, most women who met the criteria are difficult to get hold of, had limited funds to commute to MCT, or could not take time off their formal/informal work to participate in the study. We also had difficulties with recruiting more HIV-negative participants because of the aforementioned issues and the potential HIV-related stigma that could be associated with HIV-negative participants who needed to be physically present at MCT during the interviews.

The interviews were held over the course of 2 days. Each participant was compensated $15 (USD) for transportation, their time, and other inconveniences related to the opportunity cost of participating in the interviews.⁴ The interviews were digitally recorded and averaged 24 min. Having an experienced interviewer for HIV-related studies allowed the women to speak more freely and answer questions directly. The interviews were conducted mostly in Shona and English when necessary. An interview guide was used during the interview process; however, discussions were held on burgeoning issues. The questions in the interview guide were motivated by the above-mentioned theoretical framework of Boardman et al. (2012) that presents the pathways that influence the relationship between HIV and intergenerational transmission of education. Specifically, the interview questions were on the challenges that mothers face issues in sending their children to school, whether their children faced challenges at school, whether there were gender-related differences in schooling outcomes of their children, and whether there were any supports available for them to facilitate their children’s schooling. The interviewer followed up on emergent and relevant issues that were not in the interview guide (see Appendix 3 for the interview guide).

Analysis

The interviews were transcribed in English. We used the theoretical framework of Boardman et al. (2012) described above to conduct a thematic analysis with the help of NVivo 12. We focused on the three mechanisms namely reduced availability, the association between parental and offspring health, and intergenerational transmission of socioeconomic problems to identify codes in NVivo. Basic themes related to how these mechanisms exhibited the effects of parental HIV on intergenerational transmission of education were developed based on the data. These basic themes were then grouped into organizing themes. The organizing themes were then categorized according to the global themes, which were predetermined by the theoretical framework of Boardman et al. (2012) used for the analysis. This framework is centered around effects of health and socioeconomic status on educational outcomes of children. The results were then interpreted in light of the research aim.

Results

In total, 13 HIV-positive mothers and three HIV-negative mothers participated in the study. The age range of the mother is 32–44 years. Of the 16 mothers, eight were married or in partnership and eight classified themselves to be single, separated, or widowed. Three women had completed primary education, two had some high school, eight reached O’level stage (basic secondary), one reached A’level stage (complete secondary), and two had diplomas. Four women were formally employed, nine women were informally employed, and two were sex-workers, and one was unemployed. Only one child was HIV-positive. Annex 1 shows the characteristics of the mothers, who participated in the study.

The characteristics of the participants are in Annex and those for children are exhibited in Annex 2. Annex 1 and 2 show that of the 16 mothers in our study, there were 61 children, which averages to 3.8 children per mother (HIV-negative women average 2.3 children). However, there were 10 additional non-biological children from extended family members who lived in some of the households (see Annex 1). Annex 2 shows that most of the children who were not attending school or dropped out of school are children of HIV-positive participants. About 80% of the mother had some high school education or higher. However, none of them had university degrees.

The themes in the theoretical framework used in this study, were reevaluated several times and after refining them, 4 global themes and 15 organizing themes were identified by creating theme nodes in NVIVO (see Table 1). The results are presented according to the global themes.

Table 1. Coding frame of themes.

Mechanism	Global Theme	Organizing theme	Basic theme
Reduced availability of the parent due to the illness and related financial hardship	Financial issues brought about or exacerbated by HIV presenting barriers to investment in education Financial issues brought about or exacerbated by HIV as a barrier to investment in education	Limited income, underemployment, or unemployment Single-income homes Lack of finances and time for children’s schooling School dropout or non-attendance Enrollment issues Extended family	- Parents are informally employed and work long hours. Therefore, they lack the time to pay attention to their children’s schooling needs. -Late payments from informal employment. -Informal job payments are made in kind. -Children live in single-income households because husband or partner is ill, unemployed or deceased. -There is little to no money to pay for school fees and school supplies. Most of income goes to food. -Parents split their time and financial resources between HIV-related treatment and financial generating activities -Children did not attend school for extended periods of time due to lack of finances to pay for school fees or buy school supplies. -Children have no birth certificates to register in public school -Children live in families with extended family members which exacerbates the financial constraints within the household.
Association between parental and offspring health through vertical transmission of HIV status and children caring for sick parents	Vertical transmission of HIV from parent Child carer (i.e. children providing are to their parents and siblings)	Physical illness from the disease Emotional and psychological effects of the disease Helping with raising siblings Helping parents with informal work Reminding parents about their healthcare routine	-Physical and psychological effects of being HIV positive will affect schooling. -Children distancing themselves from parents, school, and the community in order to not deal with stigma. - Older children helping their parents raise their siblings - Children assisting parents with selling goods during school term - Children given the responsibility to remind their parents to take their medication
Intergenerational transmission of socioeconomic status	Gender issues (i.e. parental HIV affects boys and girls differently)	Girls caring for sick parents Girls helping with household upkeep Girls helping parents financially by obtaining employment Girls alleviating parents from financial burden by leaving the household	- Girls dropout to help sick parents. -Girls help HIV-positive mothers with chores and raising younger siblings. -Girls take on employment or help with income-generating activities in order to financially assist their parents. -Older girls drop out of school to get married

Availability of the parent

The negative effects of HIV on children’s education were exemplified by how this disease affects their parent’s health and socioeconomic wellbeing. Parents need to use their productive time attending to their own health appointments and then later make up for the lost productive time. Thereby leaving very little time to attend to their children’s needs. Most HIV-positive mothers indicated that they do not spend time with their children given that they spend a lot of time on income-generating activities, attending to their own health, or their husband’s health. Some of the participants expressed that their partners were not working due to the fact that they are deceased, ill, or unemployed. Like many Zimbabwean households, some participants also had other non-biological children from extended family with whom they live and support financially. According to them, this makes their families bigger and adds to the financial constraints. Moreover, all participants indicated having a low income and some stated that they do not have supplementary income from their partner, so it is extremely difficult for them to pay school fees for all their children. This has led some mothers to engage in sex work in order to meet the financial needs of their children. We present some quotes translated from Shona to English below:

I am the breadwinner in the family as I provide food for my family, ensure that my children go to school and that my husband gets medical treatment. (HIV-positive mother)

I strongly feel that HIV drew us back a lot when we both worked back then providing for the family … It affected my prospects of securing other better jobs because employers sometimes would tell each other that I was HIV-positive hence that I was prone to get sick anytime. (HIV-positive mother)

Challenges are there because most of the time I get to collect few bottles because there is a sharp increase in the number of people who collect plastic empty bottles out there. The bottles that I collect per day are getting lesser of which from selling those few I need to pay for my rentals where I stay. (HIV-positive mother)

My children are psychologically affected by the fact that their father is sick, each day they are always asking and checking on how their father is doing. At times I end up taking photos for them to see that their father is still alive and how he is doing. I would also get to record some audios for them to hear their father's voice. (HIV-positive mother)

I ended up earning a living through that (sex work) because it was way better than continuing with part-time work. When I would do part-time work at times I would get paid after a long time or upon completing the given tasks but when I was now into sex work I would my money then and there. (HIV-positive mother)

In some cases, participants reported that their children were not enrolled in government schools or were not able to register for national exams because their parents lacked finances or legal documents that are needed to obtain birth certificates for their children. Participants indicated that some private colleges charge higher fees than government schools and are less lenient towards children who have delays with paying school fees or buying school supplies. Hence, some children do not attend school for periods of time and sometimes are repeatedly sent home for not having school uniforms or school supplies. HIV-positive women did express that they have difficulties in paying school fees because they are either ill, unemployed, and/or did not have a working husband who was able to supplement their income. Additionally, some of their children did not have birth certificates, so they could not attend government schools and register for national exams. These concerns were expressed, among others, in the following ways:

All my seven children stay at home as none of them is in school right now. Each day of their lives is difficult as in some cases we fail to get some food to eat. After having failed to get food for the family, it then stresses me more as the mother. Given my condition that I am HIV-positive I end up getting continuous headaches and sometimes I get sick as a result of the stress. (HIV-positive mother)

My children have only been attending school through private college home setups, none of them have set foot on government schools. This has been so because all my children did not have birth certificates. (HIV-positive mother)

She dropped out of school when she was doing her Grade 3 but failed to proceed with school when his father refused to get a birth certificate for her. (HIV-positive mother)

I once went to Mutare to secure birth certificates for my children. I was told to bring my national identification card which was in Harare during that time. I am yet to go back to Mutare and collect birth certificates for my children. I am only being stopped from travelling because I am currently sick and receiving treatment. (HIV-positive mother)

He dropped out of school after finishing his Form 3. He is currently selling bananas at Mbare and the money he is getting is not enough. Most of the time he brings home some food after selling bananas. (HIV-positive mother)

Association between parental and offspring health

Only one participant reported a child who is HIV-positive. As explained by the participant, this is an orphaned child of extended family members (i.e. brother and sister-in-law), both parents died of AIDS. In this particular instance, the participant reported that the status of being HIV-positive and of being a double orphan has psychological effects on the child, which ultimately affects the educational attainment. This child is likely to not perform well in school after dealing with the trauma of the parent’s death while processing own HIV-positive status.

I often got calls that the first-born child Simba was refusing to take his ART treatment from the clinic he was registered. I then talked to him and offered him some HIV counselling using myself as an example on how continuously taking some medication can restore someone's health. I tried to find out the reason why he was not collecting his medication and if it was because he was failing to get some money for transport. This was after I had heard that he was taking some drugs and dancing at musical shows to get money. (HIV-positive mother)

Children of HIV-positive mothers in our sample have to carry the burden of keeping the status of their parents a secret due to fear of stigma. They also have the burden of reminding their parents about taking their medication (about twice daily). There were no reports of children taking care of sick parents because their family had the support and access to MCT (medical and social) services and staff. However, there were some reports of children experiencing emotional problems related to their parent’s mental and emotional issues.

My children are capable of keeping family secrets. They do not share information pertaining my HIV status with outsiders. Each time I would get sick my youngest daughter who is six years old even check with me to find out if I would have carried my medication with me. Even when I came to Mashambanzou Care Trust for treatment recently, it was my six-year-old daughter who packed my medication for me in the bag I was using. We even developed a unique code known to just us that even when you were to visit and be in the house, if it is time for me to take my medication my children will remind me without you knowing anything. (HIV-positive mother)

At times even when we have visitors in the house, when it is time for me to take my medicine, they do not wait till the visitor would have left they remind me to take my pills on time. Even my youngest born son will bring me water when it is time for me to take my medication. (HIV-positive mother)

The interviews with HIV-positive mothers in our study revealed that some children care for their parents. In particular, some children have to help their sick mother or father with daily activities such as eating and toileting. Given that their parents cannot afford to pay for helpers to assist with medical care and there is no government assistance with proving caregiving resources to households in need, children with HIV-positive parents take on the role of providing care for their sick parents.

My children are taking care of him. Suppose if he wanted to use the toilet, he would just use the ‘pot’ that is readily available for him. He will just use the pot and he put it in the bucket after use. I will then dispose of the waste. (HIV-positive mother)

Intergenerational transmission of socioeconomic status

The interviews indicated that children of HIV-positive mothers face socioeconomic issues that are similar to children of HIV-negative mothers. For example, HIV-positive participants indicated that older children take care of their younger siblings while their parents are at work. Participants also indicated that children may also help their parents with informal work after school (e.g. selling goods). We also observed that some children obtained low education levels that were similar to their mothers. This may be explained by the caregiving and work-related activities described by the parents.

My daughter is very intelligent, she helps me when selling things and she is good at calculating the change. (HIV-positive mother)

My children are currently under the care of my twenty-one-year-old girl. She has been watching over her siblings given that I am here at Mashambanzou currently receiving treatment. (HIV-positive mother)

The participants in our sample did not show any bias in the education of boys over girls. They expressed that they value the educational attainment of boys and girls similarly. However, some participants reported that older girls dropout of school to find employment so they help their parents or to get married. HIV-negative mothers’ daughters were all in school and were not helping their parents with income-generating activities. According to our respondents, girls with HIV-positive parents typically take on the responsibility of their parents’ health and ensuring that their parents and siblings have a place to live and food to eat. In our interviews, we found that all girls with HIV-negative parents are not married and continue with their education.

I do not consider a child's gender as a yardstick when it comes to schooling opportunities. All my children are equal hence they deserve equal opportunities when it comes to their schooling. Given an option to get financial assistance for a few of my children, I will allow the oldest children the chance to go to school while those younger will wait for their chance to also go to school. (HIV-positive mother)

My third born daughter often looks for part-time jobs to help me in taking care of the family. (HIV-positive mother)

She [daughter] always tells me of how difficult it is for her to leave me with my condition and starting a family away from me. She feels she has a big part to play in helping me in looking after my family. (HIV-positive mother)

My eldest child was the one who took care of me and cooked for me. When I got sick, my daughter stopped going to school. She is the one who took the responsibility of taking care of me. (HIV-positive mother)

HIV-positive mothers in our sample expressed that they had difficulties with helping their children with social mobility through education. Therefore, their children are likely to inherit the socioeconomic status of their parents. On the other hand, one HIV-negative mother expressed that she is able to prioritize her children’s schooling needs and ensure that they are met. This in turn increases the chances of social mobility for her children.

My children face challenges in that at times they go to school without eating, without food to carry to school and at times without books. It is deeply affecting my children a lot as they always wonder why they cannot go to school with all the necessities required by the school while other children can afford to go to school with everything. They got uniforms from a well-wisher for them to wear to school. (HIV-positive mother)

I keep receiving encouraging comments from her teachers because they already see a brighter future for if she continues on the path that she is going. She currently the class monitor in her form 4 class. I hope they will always be good Samaritans out there to continue assisting her so that she continues going to school. She loves school. (HIV-negative mother)

There are some socioeconomic status problems that we found to be common among HIV-positive and HIV-negative women. The main problem is gender-based violence. In both groups, some of the participants reported experiencing intimate partner violence and rape. Their children may be directly affected by witnessing their mother being abused by their father or by their mother experiencing emotional problems related to the trauma of rape or other forms of violence. This affects children’s schooling through the reduced availability of their mother due trauma-related issues and also the child’s own physical, emotional, and psychological issues related to witnessing violence or intergenerational transmission of trauma (mother-to-child).

I am still in fear of leaving him with our children as he can possibly harm them, I once feared that he can even deliberately poison them. At times our eldest son is sent away from our living room for no reason. Be it that he is sick or not, my husband has always been abusive to me and my children. (HIV-positive mother)

He was emotionally abusive as he would say hurtful things when he was drunk. After shouting at me he would leave the house. (HIV-positive mother)

I did not have any problems with his family, the only challenge that I faced was that he was abusive, he would physically assault me over petty issues. (HIV-negative mother)

 … my first child daughter came as a result of rape when I was coming from church. I do know the father of my child and he is currently in the rural areas. The issue was just handled as a family issue and he never got arrested because they just said that he was known in the community. The rape incident was just covered up by the families. (HIV-positive mother)

The next time he came to where we stayed, that weekend I had not gone home so he came and he raped me. I was about to go for the school holidays at the time and I was nineteen years old at the time. (HIV-positive mother)

Discussion

The results of this study are consistent with the theoretical framework and show that HIV illness affects how the mothers in our study contribute to their children’s schooling. For example, we find that compared to the few HIV-negative mothers in our study, HIV-positive mothers are more time-constrained due to medical, social, and financial issues, which are time intensive and affects the time they are able to spend on their children’s activities such as homework. We also find that children with HIV-positive mothers may spend time caring for their mothers or siblings. This in turn affects their schooling by limiting the time they spend on schoolwork. Our results also indicate similarities and differences in the experiences of HIV-positive and HIV-negative women of lower socioeconomic status in Zimbabwe. Zimbabwe is a developing country. Therefore, a significant portion of households rely on informal work for their livelihood. It is not surprising that our results show that children of HIV-positive and HIV-negative mothers live in households that are resource and financially constrained. This corresponds with the third component of the theoretical framework that stated that the education of children with ill parents can be affected by the intergenerational transmission of a parent’s socioeconomic status. That is, children with HIV-positive parents inherit the social and economic constraints of their parents such as poverty, which affects their schooling. Coupled with the low educational status of some HIV-positive mothers, the education of HIV-positive children may be even more affected. In addition, some issues such as gender-based violence are universal among HIV-positive and HIV-negative women. However, there were unique burgeoning issues that emanated from the interviews conducted with HIV-positive women in our localized sample. These include sex work, raising children of (deceased or sick) extended family members, children not having birth certificates, and their children not attending school for long periods (or dropping out). It is still not clear whether the results will hold up in a larger study.

The mechanisms in the study are interconnected in that some issues presented in one of the mechanisms in the theoretical framework result from another aspect. For instance, due to the fact that some HIV-positive children live in single-income homes due to the fact that their mothers are divorced/separated, widowed, or have a sick husband. As a result, their mothers end up working long hours or engaging in sex work in order to make up for the reduced income, thereby spending less time with their children (reduced availability). In turn, some of their children will then take care of the sick father or their younger siblings (association between parental and offspring health), and older girls drop out of school to help their mother with work (intergenerational transmission of socioeconomic status). Older girls have the pressure to help their mothers raise their younger siblings. Girls may also find employment, help their mother with informal work, or get married early (like their mothers). This could be due to cultural reasons because girls and women play a central role in caregiving in Zimbabwe (Robson et al., 2006). This gender bias towards child carers being female is persistent in Zimbabwe due to sociocultural constructions that classify domestic chores, caring responsibilities, and domestic informal work as feminine (Robson et al., 2006). There was no gender role or bias for children who remind their parents to take their medication. Reminding parents about their medication can be quite burdensome on the children because dose mistiming of HIV medications is linked to poorer health outcomes (Gill et al., 2010).

In many Zimbabwean families, the extended family is the basis for orphan care and education (Nyamukapa & Gregson, 2005). Hence, HIV-affected families may also face the burden of raising other children from deceased or ill family members. We found that the issue of extended family was more common with HIV-positive mothers. One of the reasons was that some of the mothers had siblings and close family members who had died of AIDS. In one case, a single HIV-positive mother had three biological children and three children from deceased (extended) family. The HIV-negative women in our sample did not have children from extended family and had at least one consistent source of income within the household. On the other hand, most of the HIV-positive women had even more limited income, had children who were not attending school for long periods and had more members in their household.

Not having birth certificates to register for school was a major barrier to public education and access to public funding for HIV-positive mothers. Birth registration can be a difficult issue for low-income parents due to the strict and rigid requirements needed to register. Specifically, for impoverished parents in Zimbabwe, it is costly to obtain a birth certificate and it can be difficult if a parent is divorced or deceased (Chereni, 2016). Marital status (single motherhood), wealth status, and geography, are some of the factors that have been found to affect birth registration in Zimbabwe (Musizvingoza et al., 2023). While these predictors are not unique to HIV-positive mothers in Zimbabwe, these characteristics are likely to be exhibited more by HIV-positive women. In some cases, psychological issues related to parental illness and helping their parents with household maintenance as well as finances also affect children’s education (Ferrand et al., 2007; Floyd et al., 2007; Sieh et al., 2010). This induces an educational gap between children with HIV-positive parents and children with HIV-negative parents.

Children with HIV-positive parents may end up in the same socioeconomic environment that is similar to that of their parents. In particular, they are likely to experience disruptions in their schooling, which affects their prospects of having a better future. The interviews that we conducted through MCT showed that while many low-income women face socioeconomic problems in Zimbabwe, children with HIV-negative parents remain in school and may not deal with the financial, social, and mental burden of having sick parents, which puts them at an advantage of completing school and live better lives in the future. On the other hand, most children with HIV-positive parents are not enrolled in school, do not attend school, or have dropout due to financial barriers, being a child carer, and gender-roles related to sociocultural values (e.g. early marriage). All biological children of HIV-positive mothers we interviewed, are HIV-negative which provides more evidence that PMTCT programs have been successful (UNAIDS, 2018).

This study has some limitations. First, our sample is small relative to the population of HIV-positive and HIV-negative women in Zimbabwe. In addition, our sample has fewer HIV-negative mothers partially because recruiting this group of participants was more difficult given stigma related to being seen at the interview site. Second, the sample of women in our study was recruited via MCT. This was done in order to ensure the safety, physical, and mental health of our vulnerable respondents. Therefore, our results are localized to the sample of women of lower socioeconomic status who reside in Harare and obtain services from MCT. We therefore cannot discuss the case of HIV-positive status parents in high socioeconomic settings. We also acknowledge that other demographic groups in Zimbabwe can experience the issues faced by children of mothers in our study. However, the aim of this study is to highlight what we found from the interviews held in this study. The results from our localized sample corroborate the mechanisms highlighted by the theoretical framework in that we find that HIV-positive mothers are not able to transmit education to their children due to: (a) reduced availability of parents due to their parents attending to illness related issues or working to support the income of a sick spouse; (b) association between parental health and offspring health through children providing care to sick parents; and (c) intergenerational transmission of socioeconomic status resulting in their children having less chances of social mobility.

Conclusion

Our study shows that HIV-positive women, in particular those from low-income groups in the city of Harare, experience issues with providing education for their children. Many children of HIV-positive parents do not have birth certificates. As a result, they are not able to attend government schools and benefit from programs that target children whose parents are not able to pay school fees. For example, HIV-affected children are likely to not benefit from the Basic Education Assistance Model, a government program that provides educational assistance to vulnerable children (Ringson, 2020). HIV-positive mothers in our study mentioned that they sought government assistance through BEAM but have not been successful. In order to resolve the issue of birth certificates, there are some policy changes that are required that can help to eliminate the bureaucratic, financial, and educational barriers that some low-income HIV-positive women face in obtaining birth certificates. There are significant social gaps that are created by the lack of having a birth certificate including not enrolling at a public school, not having access to public funds, and not being able to write national exams, or obtain a government-issued ID. Although orphans have been and still face challenges in their schooling, government and non-government actors who target vulnerable children in Zimbabwe, should also consider children with HIV-positive parents because they are likely to not attend school due to the financial and socioeconomic barriers brought about by their parents’ illness.

Previous studies that have examined effects of HIV infections among parents on education of their children have focused on orphans (who are raised by grandparents). Given that more people have access to antiretroviral therapy, more HIV-positive parents are able to raise their children. However, these parents face health and socioeconomic issues that interfere with their children’s education. This study provides novel evidence that shows that children with HIV-positive parents are in a vulnerable position that is akin to that of orphans. Particularly when it comes to school enrollment, attendance, and retention. Hence, they should also be considered in programs that target educational attainment of other HIV-affected children (e.g. orphans). Future studies should consider the effects of HIV on families of a higher socioeconomic status so as to further understand how this disease affects various demographic groups.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data for this study can be found on this public repository: https://dataverse.nl/dataset.xhtml?persistentId= doi:10.34894/2UOFWA.

Correction Statement

This article was originally published with errors, which have now been corrected in the online version. Please see Correction (http://dx.doi.org/10.1080/00346764.2023.2226373).

Additional information

Notes on contributors

Tatenda P. Zinyemba

Tatenda P. Zinyemba is a Researcher at United Nations University-MERIT and a Fellow at the Graduate School of Business and Economics, Maastricht University.

Wim Groot

Wim Groot is a full Professor and Personal Chair at the Faculty of Health Medicine and Life Sciences, Health Services Research, Maastricht University and a full Professor at United Nations University-MERIT and the School of Business and Economics, Maastricht University.

Milena Pavlova

Milena Pavlova is a full Professor Faculty of Health Medicine and Life Sciences, Health Services Research, Maastricht University.

Notes

1 We would like to thank the participants, the staff at Mashombanzou Care Trust, Kudzai Maridzo, Dr Fortunate Machingura, and Tariro Makanga for their participation and support during this study.

2 According to the World Bank, GDP per capita in Zimbabwe for 2019 is $1464 USD. https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=ZW.

3 To access the publicly avaible data, please see the ‘Data availability statement’ section.

4 This was a recommendation from the ethical board at Medical Research Council of Zimbabwe.

Appendix

Annex 1: Participant demographics

Table

ID	Age	HIV Status	Education level	Marital Status	Employment Status	Partner's Employment Status	Total Biological Children	Additional Children	# of Children Eligible to School	# of Children not Eligible to School	# of Children Attending School	# of Children Who Dropped Out of School
1	34	Positive	O’level	Married	Informal	Unemployed	5	0	4	1	4	0
2	50	Negative	O’level	Married	Cook	Informal	2	0	2	0	1	1
3	44	Positive	Some high school	Separated	Unemployed	Deceased	9	0	8	1	0	8
4	39	Positive	O’level	Married	Informal	Unemployed	5	0	4	1	3	1
5	37	Negative	O’level	Married	Informal	Informal	3	2	4	1	3	1
6	39	Positive	O’level	Separated	Informal	Informal	3	0	2	1	0	2
7	44	Negative	O’level	Separated	Cleaner	Police Officer	2	0	2	2	2	0
8	32	Positive	Completed Primary	Married	Informal	Unemployed	3	0	2	1	1	0
9	32	Positive	O’level	Married	Informal	Unemployed	4	0	4	0	0	4
10	42	Positive	Diploma	Married	Primary Care Counsellor	Unemployed	2	1	3	0	3	0
11	35	Positive	O’level	In partnership	Community Care Giver	Mechanic	3	2	5	0	3	2
12	43	Positive	Completed primary	Widowed	Informal	Security Guard	5	0	5	5	3	2
13	40	Positive	Completed primary	Separated	Sex Worker	Informal	3	3	6	0	3	3
14	46	Positive	Some high school	Separated	Sex Worker	Unemployed	4	2	6	0	3	2
15	36	Positive	A’level	Single	Informal	Mechanic	3	0	2	1	2	0
16	38	Positive	Diploma	Single	Informal	Deceased	5	0	4	1	4	0

Annex 2: Child demographics

Table

		Gender		# of eligible children in school below 19		# of eligible children not in school below 19		# of children behind in school below 19		# of children not eligible for school below 19		# of children who dropped out over 19		# of children over 19 still in school		# of adult children at home over 19		Children HIV status		Birth Certificates
Participant ID	# of children	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls	Boys	Girls	+ve	-ve	Have	Don’t have
1	5	2	3	2	2	0	0	0	0	0	1	0	0	0	0	0	0	0	5	N/A	N/A
2	2	1	1	0	1	0	0	0	0	0	0	1	0	0	0	0	0	0	2	2	0
3	9	2	7	0	0	2	4	2	4	0	0	0	3	0	0	0	1	0	9	6	3
4	5	3	2	2	2	0	1	1	1	1	0	0	0	0	0	0	0	0	5	4	1
5	5	4	1	2	1	1	0	0	0	1	0	0	0	0	0	0	0	0	5	4	1
6	3	2	1	1	1	0	0	0	0	1	0	0	0	0	0	0	0	0	3	1	2
7	2	0	2	1	1	0	0	0	0	0	0	0	0	0	0	0	0	0	2	2	0
8	3	1	2	0	1	1	0	1	1	0	1	0	0	0	0	0	0	0	3	0	3
9	4	2	2	0	0	2	2	0	0	0	0	0	0	0	0	0	0	0	4	0	4
10	3	1	2	1	2	0	0	0	0	0	0	0	0	0	0	0	0	0	3	3	0
11	5	1	4	0	3	0	1	0	0	0	0	1	0	0	0	1	1	1	4	4	0
12	5	2	3	1	2	0	1	0	0	0	0	1	0	0	0	1	0	0	5	5	0
13	6	4	2	2	1	1	1	0	0	0	0	1	1	0	0	1	1	0	6	6	0
14	6	3	3	1	0	0	0	0	0	1	1	1	2	0	0	1	1	0	6	N/A	N/A
15	3	3	0	2	0	0	0	0	0	1	0	0	0	0	0	0	0	0	3	1	2
16	5	3	2	2	2	0	0	0	0	1	0	0	0	0	0	0	0	0	5	5	0
Total	71	34	37	17	19	7	10	4	6	6	3	5	6	0	0	4	4	1	70	33	22

Annex 3: Semi-structured Interview guide

Date:

Name of Interviewer:

Interview code number:

Respondent’s age:

Length of interview:

To set the tone with interviewee, introduce yourself and set some ‘ground rules’ for the interview.

1. Introduction

• My name is ___________.

• Thank you for talking to us today. Our interview will last about 1 h.

• This is an independent study for a PhD study. Your participation in this independent study will not affect any services you receive here at Mashambanzou.

• We are going to discuss about your children’s schooling and issues related to their performance in school.

• This interview is private and confidential – your name will not be used publicly, so don’t hesitate to speak your mind.

• There are no right or wrong answers – it is important to say what you think or feel and not what you think I want to hear.

• You will be recorded but this information will not be distributed.

• Please be reassured that if you feel uncomfortable at any point during the interview, you are free to express this and stop the interview.

• Would you like to participate in this interview?

Verbal consent given: yes/no:

Check whether consent form is signed.

2. Questions

Use probes as needed

Invite Interviewee to briefly talk about themselves. General information about

• Respondent’s highest level of education:

• Respondent’s marital status:

• Husband/partner’s highest level of education:

• Respondent’s profession:

• Number of children:

• Age of children:

• Gender of child(ren):

• Education level of children:

1. What challenges do you face in ensuring that your children obtain their schooling?

2. What challenges do your children face in obtaining their schooling?

3. How does your child’s gender influence their schooling?

4. How does your husband/partner support you in ensuring that your children obtain their schooling?

5. What are your thoughts about school and government support in your children’s schooling?

6. How do you overcome challenges that you have mentioned to ensure your children obtain their schooling?

7. What interventions should be put in place to ensure that your children obtain their schooling?

3. Closing

Do you have any additional comments?

We will analyse the information that you and others provide. We will be happy to provide a copy once the analysis is complete. Thank you for your time.