AIDS has had a devastating effect in many parts of Africa. Now, 30 years into the epidemic, researchers are learning more about the impact on orphans and other children whose parents get AIDS.
Oxford University researcher Lucie Cluver has spent a decade studying AIDS orphans and other youngsters who live with adults who have AIDS in South Africa.
She found that the disease has a major, long-term impact on these children.
"And one of the biggest impacts we see is mental health, their psychological health," Cluver says. "So, for example, we see that AIDS-orphaned children have very much higher levels of depression, anxiety, and post-traumatic stress than children who have a live parent or children whose parents have died of other causes - including homicide and suicide."
According to Cluver, there are several reasons why AIDS orphans suffer psychological damage. There is stigma attached to the disease, and kids are subjected to gossip, bullying and fear.
Adults with AIDS may be under stress and unable to parent effectively. Also, medical bills, funeral costs, and the loss of a household's breadwinner can reduce a family to poverty. And often children become caregivers for parents sickened by AIDS.
"They're missing school to go and get their medication. They're washing the sick person. They're often taking them to the toilet, cleaning their wounds or washing their bedclothes. So these kids find it very stressful and upsetting. They're very worried about the health, and feel very responsible for the health of the sick person."
That intimate contact with sick parents and infected bodily fluids can sometimes transmit disease, such as tuberculosis.
And even when these young caregivers go to school, they tell researchers that they are so worried about their parents, that they can't concentrate in the classroom.
"And it's constantly on their minds and really making it difficult for them to do well at school," Cluver says. "It's one of the things that they tell us first. It's one of their greatest concerns."
Cluver says her research indicates that psychological problems increase as AIDS-orphaned children become young adults, which is not the case for other orphans.
Writing in Nature, the Oxford researcher says a variety of official and NGO programs are working to help children affected by AIDS, but that more work - and more resources - are needed.
And experts are focusing on the most effective strategies, such as support groups for mental health issues, tuberculosis testing for children, and better access to anti-AIDS drugs for parents, to keep them healthy longer.