Experiences of childhood trauma increases HIV-risk behaviours in young women and men in urban informal settlements in South Africa Andrew Gibbs1, Kristin Dunkle2, Thobani Khumalo1, Nolwazi Ntini1, Laura Washington3, Mpume Mbatha3, Esnat Chirwa2, Samantha Willan2, Yandisa Sikweyiya2, Nwabisa Jama-Shai2, Rachel Jewkes2 1 – Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban 2 – Gender and Health Research Unit, South African Medical Research Council 3 – Project Empower, Durban

Urban informal settlements In Africa, 61.7% of urban dwellers live in informal settlements. Set to increase from 400 million to 1.2 billion by 2050 (UN Habitat, 2015) In South Africa, HIV-prevalence in urban informal settlements twice that of formal settlements (Rehle et al, 2007) Kibera informal settlement in Kenya, 84.5% of women living there had experienced IPV, compared to 39% in the general population (Swart, 2011) What we are seeing globally, in Africa and in Africa is ongoing and high levels of urbanization. States are often unable to manage this rapidly influx of residents and people build shacks as a way to secure housing and security in cities. What we know is that urban informal settlements – have multiple health and social problems - compounded by the lack of government structures and services. More recently there is emerging evidence that informal settlements are sites of high HIV-prevalence and incidence, and IPV

Childhood traumas and HIV-vulnerability Majority of this research focused on North America and Europe South African research suggests childhood trauma is linked to: Depression and suicidal ideation (Choi et al., 2015; Jewkes et al., 2010; Cluver et al., 2015) Emotional, sexual and physical abuse associated with HIV-acquisition (Jewkes et al., 2010) Alcohol abuse (Jewkes et al., 2010) None has focused on childhood traumas amongst young people in urban informal settlements There is also a strong body of literature that suggests that people’s experiences in childhood have long-lasting health effects, lasting long into their adult life. And this has been shown for sexual risk behaviours – as with most research, there is a strong body of evidence from the global north on these relationships. Yet there are relatively few studies from South Africa. The studies there are suggest people who experienced childhood trauma are more likely to…. None of this research has focused specifically on childhood traumas amongst young people living in urban informal settlements, where we know they face huge structural economic and social vulnerabilities currently, which may mean childhood traumas are not so significant. As such we sought to understand the relationship between childhood traumas experienced before the age of 18 and current HIV-vulnerability, including sexual behavior and violence amongst young women and men.

Methods 1 12 items modified Childhood Trauma Questionnaire (Bernstein et al 1994), covering five dimensions of trauma: emotional neglect, emotional abuse, physical neglect/hardship, physical abuse and sexual abuse. Main outcomes, all past year: Three or more main sexual partners in past 12m Three or more khwapheni (casual) sexual partners in past 12m Three or more once-off sexual partners in past 12m Perpetration/experience of sexual and/or physical IPV past 12m Perpetration/experience of non-partner sexual violence past 12m Problematic alcohol use (AUDIT) The childhood trauma scale has been widely adapated and used in South Africa alpha women =0.81, men=0.87 We looked at 6 HIV-related vulnerabilities – all current or past 12m. We asked about women’s experience of IPV and non-partner sexual violence and men’s perpetration of this.

Methods 2 Cross-sectional data 320 women, 320 men recruited into the control arm of Stepping Stones and Creating Futures cluster RCT (16 clusters, 20 men 20 women/cluster) Self-completed questionnaires on cellphones Built separate regression models for men and women for each outcome, controlling for factors including age, education and other risk factors (e.g. controlling behaviours, depression) To give a quick summary of methods. This data comes from a cross-sectional survey of 320 women and 320 men in 16 clusters, that formed the control arm clusters of the Stepping Stones and Creating Futures RCT, which seeks to reduce IPV in urban informal settlements around Durban. We built separate regression models for each HIV-vulnerability, accounting for the clustering of data and controlled for relevant risk factors. We then added in childhood traumas and looked to see whether that remained significant in the models

Results: Socio-demographic Women Mean/%(95% CI) Age 24.4(23.5-25.3) Education Primary or less 9.4(6.3-13.7) Secondary (but not completed) 55.9(49.6-62.1) Completed secondary 34.7(27.7-42.4) Mean earnings past month (Rand) R165(106-225) Experience any physical/sexual IPV past 12m 65.3(60.4-70.0) Experience non-partner sexual violence past 12m 32.8(27.1-39.1) Men Mean/%(95% CI) Age 23.8 (23.0-24.6) Education Primary or less 10.3(6.0-17.2) Secondary (but not completed) 58.3(50.5-65.7) Completed secondary 31.4(23.7-40.1) Mean earnings past month (Rand) R416(299-534) Perpetration any physical/sexual IPV past 12m 58.3(53.3-63.1) Perpetration non-partner sexual violence past 12m 42.0(35.5-48.8) So socio-demographic data: Women and men were both young with the majority under the age of 25. There were low levels of education, in btoh women and men, only one third had completed their secondary education and received a certificate. This was an incredibly poor population, with low mean earnings in the past month reported. Women also experienced high levels of violence, 65% reported experiencing physical or sexual IPV in the past 12m, and 32% reported experiencing non-partner violence in the past 12m. Men’s perpetration of sexual and/or physical IPV was similarly high at around 58%, while non-partner sexual violence perpetration was 42%.

Results: Women Childhood trauma score mean(CI95%) – t-tests  Childhood trauma adjusted odds ratios Past 12months Outcomes Yes No aOR (CI) p-value 3 or more main partners 7.4(6.2-8.7) 5.9(5.1-6.7) 1.02(0.96-1.09) p=0.45 3 or more khwapheni (casual) partners 9.1(7.2-11.0) 6.0(5.3-6.7) 1.08(0.98-1.18) p<0.1 3 or more once-off sexual partners 9.1(7.5-10.7) 5.7(5.0-6.4) 1.08(1.00-1.16) p<0.05 Experience of physical and/or sexual IPV 7.2(6.5-8.0) 4.6(3.8-5.4) 1.08 (1.01-1.15) Experience of non-partner sexual violence 9.3(8.1-10.5) 4.9(4.3-5.4) 1.13(1.06-1.21) p<0.0001 Problematic alcohol use 9.4(7.9-10.9) 5.4(4.8-5.9) 1.07 (1.00-1.15) P<0.05 Results, on the left of the table we can see the mean childhood trauma scores reported by each group, so for women experiencing IPV they had a mean score of 7.2 on the scale compared to those reporting no IPV which was 4.6. In the adjusted models we found that for women, child hood traumas were significantly associated with having three or more once off sexual partners in the past 12m, experiencing physical and/or sexual IPV in the past 12m, experiencing non-partner sexual violence in the past 12m, and having higher levels of problematic alcohol use, as defined by the AUDIT scale.

Results men Childhood trauma score mean(CI95%) – t-tests  Childhood trauma adjusted odds ratios Past 12months Outcomes Yes No aOR (CI) p-value 3 or more main partners 8.8(7.5-10.0) 6.7(5.9-7.6) 1.08(1.02-1.13) p<0.01 3 or more khwapheni (casual) partners 9.2(7.5-10.8) 6.9(6.1-7.7) 1.06 (1.00-1.11) p<0.05 3 or more once-off sexual partners 8.7(7.3-10.1) 7.0(6.1-7.8) Perpetration of physical and/or sexual IPV 9.3(8.3-10.2) 5.1(4.2-6.0) 1.14 (1.07-1.21) p<0.0001 Perpetration of non-partner sexual violence 9.5(8.3-10.7) 6.1(5.3-6.9) 1.07 (1.02-1.13) Problematic alcohol use 9.3(8.2-10.5) 6.0(5.2-6.9) 1.05(1.00-1.10) p<0.1 There are similar patterns for men where childhood traumas in the fully adjusted model were associated with: Having three or more main sexual partners in the past 12m, 3 or more casual partners in the past 12m, 3 or more once-off sexual partners in the past 12m. As well as the perpetration of IPV in the past 12m, and perpetration of non-partner sexual violence in the past 12m.

Discussion/Conclusion Childhood traumas for women and men are intimately linked to their current HIV-vulnerabilities and experience/perpetration of violence against women in urban informal settlements where there are multiple other forms of vulnerability Interventions are needed to: Reduce experiences of trauma in childhood – positive parenting programmes, economic support for families Reduce the impacts of childhood traumas amongst young people later on – group- based trauma-focused therapy Suggests IPV and HIV-prevention interventions need to consider how to deal with childhood traumas shaping current experiences In this study what do we see: despite the wide ranging challenges and experiences of life in informal settlements, which we may have thought had a larger ‘impact’ on current HIV-vulnerabilities, we found that for women and men, childhood traumas remained a significant factor in explaining current HIV-vulnerabilities. It is clear from this that we need interventions to reduce the experiences of trauma during childhood – including positive parenting interventions and economic support to families. A second set of interventions suggest we need to deal with this unresolved trauma of childhood currently amongst young people. Finally, current behavioral interventions for IPV and HIV-prevention never explicitly seek to deal with childhood traumas, despite increasing evidence that they are fundamental to current behaviours. We need to start to think through how to integrate these into current programming

Andrew Gibbs, gibbs@ukzn.ac.za DONORS