Child health and maltreatment in the context of HIV and AIDS ICASA, 6 December 2011. Dr. Lucie Cluver, Oxford University & University of Cape Town

Thank you The Economic & Social Research Council HEARD, University of KwaZulu-Natal National Department of Social Development The Nuffield Foundation The Claude Leon Foundation The John Fell Fund The National Research Foundation

2004: 15 million AIDS-orphaned children Total worldwide research on their psychosocial health: Rotheram-Borus et al 2001, New York Sengendo & Nambi 1997 Uganda Forehand et al 1999 New Orleans

2011: 18 million AIDS-orphaned children Ethiopia 2005 Bhargava Li et al 2009 China Chatterji et al 2005 Rwanda Rotheram-Borus et al 2001, New York Betancourt 2010 Rwanda Fang et al 2009 China Makame et al 2002 Tanzania Atwine et al 2005 Uganda Sengendo & Nambi 1997 Uganda Forehand et al 1999 New Orleans Onuoha 2009 Uganda Poulter 1996 Zambia Nyamukapa et al 2006 Zimbabwe Manuel 2002 Mozambique Ruiz-Casares 2009 Namibia Cluver et al 2007 South Africa Wild et al 2006 South Africa

Research projects Longitudinal study of AIDS-orphaned children 1025 children, 4-year follow-up National study of Young Carers in AIDS-sick homes 6000 children + 2500 adults Stratified random sampling Urban/rural, 3 provinces of S.Africa Young Carers KZN 5238 matched carer and child pairs, rural & urban KwaZulu-Natal Young Carers pilot study 850 children, qualitative

Collaborative research: Science to inform Policy Collaborative OVC research programme Universities: Oxford, Wits, UCT, UKZN NACCA, NGOs e.g. UNICEF, REPSSI, Save the Children

like my father (Boy, 12, rural) AIDS-orphaned children I don’t concentrate in school. I am worried about my mother. She looks like she is going to die like my father (Boy, 12, rural) Cluver, L. & Gardner, F. (2007) Risk and protective factors for well-being of children orphaned by AIDS in Cape Town, South Africa: a qualitative study of children’s views AIDS Care 19(3) 318-325.

AIDS-orphanhood: more psychological problems Cluver, L, Gardner, F & Operario, D (2007). Psychological distress amongst AIDS-orphaned children in urban South Africa Journal of Child Psychiatry & Psychology & Allied Disciplines 48(8) 755-763

Longitudinal evidence: AIDS-orphaned getting worse, faster Cluver, L, Orkin, M, Boyes, M & Gardner, F (early view Sept 2011) Persisting mental health problems among AIDS-orphaned children in South Africa. Journal of Child Psychiatry and Psychology.

Children with HIV/AIDS-affected caregivers I don’t feel OK the whole day in class. When I leave my parents sick I ask permission to go back home. I decide not to go to school because I don’t concentrate – I think of them (Girl, rural, 10) Cluver, L, Operario, D, Lane, T, Kganakga, M (in press). Educational shortfalls among ‘Young Carers’ in the South African AIDS Epidemic. Journal of Adolescent Research.

AIDS-sick caregivers: Equal impact to AIDS-orphanhood  Cluver, L (2011)‘Children of the AIDS pandemic’. Nature, 474 27-29.

Education, health and sexual health risks ‘I don’t know what is happening in my life because when my mother is sick, I don’t go to school. I have to look after her and my little brothers and sisters’. (Boy, 17, urban) ‘

Familial AIDS predicts child educational difficulties Cluver, L, Operario, D, Lane, T, Kganakga, M (in press). Educational shortfalls among ‘Young Carers’ in the South African AIDS Epidemic. Journal of Adolescent Research.

Mechanisms of educational difficulty Extreme Poverty R2=.08 .24 .12 Missing School AIDS-orphan R2=.04 .12 .22 .41 .11 AIDS-sick carer Attention Problems R2=.20 .10 .44 Internalising Problems R2=.19

Familial AIDS predicts emotional and physical abuse Cluver, L, Orkin, M, Boyes, M, Gardner, F, & Meinck, (2011) ‘Transactional Sex amongst AIDS-orphaned & AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS

Familial AIDS predicts neglect, domestic violence and sexual abuse

Familial AIDS predicts transactional sex

Cumulative impact on risk of transactional sex: family AIDS, abuse, poverty Cluver, L, Orkin, M, Boyes, M, Gardner, F, & Meinck, (2011) ‘Transactional Sex amongst AIDS-orphaned & AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS

Child sickness % past-month sickness

Child TB and caregiver AIDS-sickness OR: 5 Multiple logistic regression controlling for: Child age, child gender, *urban/rural location, safe drinking water, household toilet facilities, household assets, food insecurity, household employment, caregiver other-sickness, child exposure, exposure to bodily fluids, carer disability *AIDS-orphanhood risk only if AIDS-sick caregiver

Child TB treatment (bad and good news)

Resilience

Buffering impacts of abuse: Testing Richter, Foster & Sherr’s resilience model Family relationships Improved sibling support (p<.001) Improved parental praise (p<.001) Poverty prevention Food parcels (p<.001) School feeding schemes (p<.001) Community-level interventions Religious leader support (p<.001) Teacher support (p<.001) Home-Based Caregiver support (p<.001) Rochat’s work Kuo’s review 2009 mental health of caregivers (all p<.001, using stepwise logistic regression & loglinear modelling at .001)

Food security and stigma Cluver, L & Orkin, M (2009) Stigma, bullying, poverty and AIDS-orphanhood: Interactions mediating psychological problems for children in South Africa. Social Sci Medicine.

Caregiver mental health Depression amongst HIV+ mothers Rochat et al 2011, Sherr et al 2011 Poor mental health for caregivers of AIDS-affected children Kuo & Operario 2009 Caregiver and child mental health closely linked Stein et al 2008 Rochat’s work 46% Kuo’s review 2009 mental health of caregivers Kuo, Cluver et al (2010) Children and Caregiver mental health in the context of HIV. OVC in Africa Conference, Johannesburg.

Abuse More physical abuse More emotional abuse More sexual abuse Cluver et al 2011 More sexual abuse More domestic violence More intentional neglect new analyses Lower parental praise Kuo et al, Lachman et al ongoing All mediated by caregiver stigma, hunger & disability Cluver, L, Orkin, M, Boyes, M, Gardner, F, & Meinck, (2011) ‘Transactional Sex amongst AIDS-orphaned & AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS

Building models of wider resilience using African evidence-base SCHOOL Reducing bullying School feeding Free schools Changing school responses to non-attendance CHILD Improving medical care Screening for tuberculosis PMTCT Psychosocial interventions FAMILY ARVS for caregivers Reducing abuse Responding to abuse Cash transfers Food gardens Improving caregiver mental health Disclosure Parental praise Family responses Rochat’s work Kuo’s review 2009 mental health of caregivers COMMUNITY Reducing stigma Religious leader support Home-and Community-Based caregivers (HCBC) Mentoring

Of the fourteen in the TAG team Two girls had babies (both were fourteen). One had been diagnosed HIV-positive. She was being moved to a rural area and was worried she couldn’t access ARVs there Five had dropped out of school.

‘I’m not the only one going through this ‘I’m not the only one going through this. There are many other kids in the same situation. I would like to say to them that they mustn’t give up. They must just accept it and at the end of the day believe that they will succeed at something. They mustn’t give up. TAG team member, 14 yrs. www.youngcarers.org.za

Cluver, L, Orkin, M, Boyes, M, Gardner, F, & Meinck, (2011) ‘Transactional Sex amongst AIDS-orphaned and AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS Cluver, L, Orkin, M, Boyes, M & Gardner, F (2011) Persisting mental health problems among AIDS-orphaned children in South Africa. Journal of Child Psychiatry and Psychology.  Cluver, L (2011)‘Children of the AIDS pandemic’. Nature, 474 27-29. Cluver, L, Operario, D, Lane, T, Kganakga, M (2011). Educational shortfalls among ‘Young Carers’ in the South African AIDS Epidemic. Journal of Adolescent Research. Kuo, C, Operario, D & Cluver. L (in press) Depresssion amongst carers of AIDS-orphaned and other children in Umlazi Township, South Africa. Global Public Health. Cluver, L, Bowes, L & Gardner, F (2010) Risk and protective factors for bullying victimisation amongst AIDS-affected and vulnerable children in South Africa. Child Abuse and Neglect Cluver, L, Kganakga, M, Boyes, M (in press) ‘Children affected by HIV/AIDS: Psychsocial Interventions for School-Aged Children’. Eds Sherr, L, Heyman, J, Kidman, R. Children Affected by AIDS: Moving from Research to Action. Oxford University Press. Cluver, L & Orkin, M (2009) Stigma, bullying, poverty and AIDS-orphanhood: Interactions mediating psychological problems for children in South Africa. Social Science and Medicine. Cluver, L, Finch, D & Seedat, S (2009) Predictors of post-traumatic stress symptomology amongst AIDS-orphaned children. Journal of Traumatic Stress, 22 (2) 106-113 Cluver, L, Gardner, F & Operario, D (2009). Effects of poverty on the psychological health of AIDS-orphaned children. AIDS Care 21 (6) 732-741 Cluver, L, Gardner, F & Operario, D (2008) Effects of stigma on the mental health of adolescents orphaned by AIDS. Journal of Adolescent Health 42 (4) 410-418 Cluver, L, Gardner, F & Operario, D (2007). Psychological distress amongst AIDS-orphaned children in urban South Africa Journal of Child Psychiatry & Psychology & Allied Disciplines 48(8) 755-763 Operario, D, Cluver, L, Pettifor, A, MacPhail, C and Rees, H (2008) Orphanhood and Completion of Compulsory School Education Among Young People in South Africa. Journal of Research on Adolescence 18(1), 173-186 Cluver, L & Operario (2008) Review: Intergenerational linkages of AIDS: Vulnerability of orphaned children for HIV infection. Institute of Development Studies Bulletin, 39(5) 28-35 Cluver, L & Gardner, F (2007) The Mental Health of Children orphaned by AIDS: A review of International and South African Research. Journal of Child and Adolescent Mental Health 19(1) 1-17 Cluver, L. & Gardner, F. (2007) Risk and protective factors for well-being of children orphaned by AIDS in Cape Town, South Africa: a qualitative study of children’s views AIDS Care 19(3) 318-325. Operario, D, Pettifor, A, Cluver, L, MacPhail, C and Rees, H (2007), Prevalence of Parental Death among young people in South Africa and Risk for HIV Infection: Results from a National Representative Sample. Journal of Acquired Immune Deficiency Syndromes (JAIDS) 44, 93-98. Cluver, L. & Gardner, F. (2006) Psychological well-being of children orphaned by AIDS in Cape Town, South Africa Annals of General Psychiatry. 5, 8. BioMed Press. Cluver, L, Gardner, F & Operario, D (2009). Effects of caregiving on psychological distress amongst AIDS-orphaned children in South Africa. Vulnerable Children and Youth Studies Richter, L, Stein, A and Cluver, L (2009) Infants and young children affected by AIDS. HIV/AIDS in South Africa 25 years on: Psychosocial perspectives. Eds Rohleder, P, Swartz, L, Kalichman, S, Simbayi, L. Springer Press. Cluver, L, Bray, R & Dawes, A (2007) Monitoring the worst forms of child labour and child exploitation: Harmful child labour, trafficking of children, child commercial sexual exploitation, and use of children in the drug trade. In Dawes, A., Bray, R. & van der Merwe, A.: Monitoring child rights and wellbeing: A South African Approach. Cape Town, HSRC Press Cluver, L, Operario, D (2008) The intergenerational link between the impacts of AIDS on children, and their subsequent vulnerability to HIV infection (peer reviewed): Joint Learning Initiative for Children affected by AIDS.