Transactional sex in South African children predicted by familial HIV/AIDS,

abuse and hunger

Cluver, L, Orkin, M, Boyes, M, Kganakga, M, Gardner, F, Makhazi, D, Sherr, L

FOR SALE

Transactional sex in South African children predicted by familial HIV/AIDS,

abuse and hunger

A SERIAL KILLER.

Cluver, L, Orkin, M, Boyes, M, Kganakga, M, Gardner, F, Makhazi, D, Sherr, L

FOR SALE

Collaborative OVC research programme

Universities: Oxford, Wits, UCT,

UKZN

NACCA, NGOs e.g. USAID, UNICEF,

REPSSI, Save the Children

Collaborative research: Science to inform Policy

Linked longitudinal studies, 2005-2012: n=7873 children

Orphan resilience study (2005-2009)• 2005: N=1021 (aged 10-18), 71.5% follow-up• 3 provinces South Africa

National Young Carers study (2009-2012)• Main study: N=6002 (age: 10-18), pilot: 850 children, • 6 randomly-selected sites >30% prevalence, 3 provinces• Urban/rural, 1 year follow-up• Stratified random sampling of census enumeration or tribal areas• 2500 matched child-caregiver pairs

Measures and analysis• Standardised scales, national surveys (census, DHS etc.)• Verbal autopsy method (sensitivity 83%, specificity 75%)• Comparing AIDS-orphaned/other orphaned/non-orphaned/parental AIDS-

illnesss/other-illness/non-illness.• Multivariate logistic regression, log-linear models, structural equation

models, all controlling for socio-demographics

THE SCENE OF THE CRIME…

FOR SALE

Healthy caregiver AIDS-orphaned or AIDS-sick caregiverAIDS dual-affected0tan28a566028

0tan1a56601

0tan3a56603

0tan5a56605

0tan7a56607

0tan9a56609

0tan11a566011 % children reporting sexual risk

Transactional sexSex drunk or on drugsPregnant (girls)

Parental HIV/AIDS predicts child sexual risks

Healthy caregiver AIDS-orphaned or AIDS-sick caregiverAIDS dual-affected0tan28a566028

0tan1a56601

0tan3a56603

0tan5a56605

0tan7a56607

0tan9a56609

0tan11a566011 % children reporting sexual risk

Transactional sex

Sex for: Food Shelter School fees Money Transport

Parental HIV/AIDS predicts child sexual risks

Parental HIV/AIDS predicts transactional sex

healthy caregiver AIDS-orphaned/ AIDS-ill carer

Dual AIDS-affected0tan28a566028

0tan1a56601

0tan3a56603

0tan5a56605

0tan7a56607

0tan9a56609

0tan11a566011

0tan2a56602

0tan5a56605

0tan10a566010

% children aged 14-17 reporting transactional sex

girls

boys

IDENTIFYING LIKELY SUSPECTS.

FOR SALE

healthy c

aregiv

er

other-orphan

other-sick

caregiv

er

AIDS-orphan

AIDS-sick

caregiv

er

AIDS-dual

affecte

d0tan28a566028

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan4a56604

0tan9a56609

0tan12a5660120tan15a566015

0tan13a566013

0tan21a566021

0tan1a56601

0tan5a56605

% children with insufficient food >2 days in past week

Parental HIV/AIDS predicts food insecurity

Parental HIV/AIDS predicts child stigmatization

healthy c

aregiv

er

other orphan

other-sick

caregiv

er

AIDS-orphan

AIDS-sick

caregiv

er

AIDS dual-

affecte

d0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan20a566020

0tan27a566027

0tan21a566021

0tan11a566011 0tan10a566010

0tan26a566026

% children reporting stigmatization

Healthy carer AIDS-orphaned AIDS-sick carer0tan28a566028

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024% children reporting child abuse

Physical abuseEmotional abuseDomestic violenceSexual abuse

Parental HIV/AIDS predicts child maltreatment

Parental HIV/AIDS predicts child psychological disorder

healthy c

aregiv

er

other orphan

other-sick

caregiv

er

AIDS-orphan

AIDS-sick

caregiv

er

AIDS dual-

affecte

d0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan21a566021

0tan1a56601

0tan21a566021

0tan8a56608 0tan9a56609

0tan18a566018

% children with 1+ psychological disorder (clinical-level depression, anxiety, post-traumatic stress)

UNCOVERING COLLUSION...

FOR SALE

healthy carer AIDS-affected, abused

AIDS-affected, hungry

hungry, abused AIDS-affected, abused, hungry

0tan28a566028

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan1a56601

0tan5a566050tan6a56606

0tan9a56609

0tan19a566019

% children 14-17 reporting transactional sex

boysgirls

Cumulative impacts of parental HIV/AIDS, abuse and hunger on child transactional sex

0 risks 1 risk 2 risks 3 risks 4 risks 5 risks0tan28a566028

0tan4a56604

0tan9a56609

0tan14a566014

0tan19a566019

0tan24a566024

0tan29a566029

0tan28a566028

0tan2a56602

0tan3a56603

0tan7a56607

0tan11a566011

0tan25a566025

% children (14-17) reporting transactional sex

boysgirls

Risks: Stigma Extreme poverty Abuse Psychological distress Family AIDS

Increased risk factors, increased child risk of transactional sex

Healthy family AIDS-sick parent Abused & hungry AIDS-sick parent, abused, hungry

0%

10%

20%

30%

40%

50%

60%

1%

7%

13%

57%

% girls aged 15-24 reporting transactional sex

Cumulative impacts 15-25 year oldsCluver, L, Orkin, M, Boyes et al, (2011) ‘Transactional Sex amongst AIDS-orphaned & AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children (structural equation modeling)

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

AIDS-orphan

SEXUAL HEALTH RISKS

Abuse

AIDS-sick

parent

Psych. distress

Stigma

Poverty

Education risks

.08

.13

.22

.06.10

.15

.15

.32

.43

.72

.15

.18

.14

.24.12

Pathways of risk for AIDS-affected children

mean χ2(679) Bollen-Stine mean χ2/df

RMSEA SRMR CFI TLI

640.06 p=.001 1.57 .032 .044 .939 .930

Implications for intervention

• Children in AIDS-affected families at higher risk for sexual exploitation and HIV-infection.

• Preventing transactional sex for AIDS-affected children needs social protection not behavioral interventions

• Interactive model of risk shows modifiable pathways from familial AIDS to child sex risk.

• Reducing extreme poverty, abuse, stigma and psychological distress could interrupt these risk pathways

• Social protection programs must be HIV-sensitive: both to children in AIDS-affected families, and to HIV risk outcomes.

• Cluver, L (2011)‘Children of the AIDS pandemic’. Nature, 474 27-29.• Boyes, M. E. & Cluver, L. (2012). Performance of the Revised

Children's Manifest Anxiety Scale in a sample of children and adolescents from poor urban communities in Cape Town. European Journal of Psychological Assessment

• Boyes, M, Mason, S, & Cluver, L (2012). Validation of a brief stigma-by-association scale for use with HIV/AIDS-affected youth in South Africa. AIDS Care.

• Cluver, L, Orkin, M, Boyes, M & Gardner, F (2012) Persisting mental health problems among AIDS-orphaned children in South Africa. Journal of Child Psychiatry and Psychology.

• 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, 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) Depression 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 & 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

• Operario, D, Underhill, K, Chuong, C, Cluver, L. (2011) HIV infection and sexual risk behaviour among youth who have experienced orphanhood: systematic review and meta-analysis. Journal of the International AIDS Society, 14, 25.

• 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

• 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.

• 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.

• 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

• 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, Orkin, M., Boyes, M. E., Madisha, L., and Baban, R. (in press). Child development in sub-Saharan Africa: Identifying challenges and planning solutions. In M. Tomlinson, C. Hanlon, L. Swartz, P. Cooper, and A. Sameroff (Eds). Infant and child development in Africa: Perspectives from the continent. City

• 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.

The Nuffield Foundation

Thank you. www.youngcarers.org.za

National Department of Social Development

The National Research Foundation

HEARD, University of KwaZulu-Natal

The John Fell Fund

The Claude Leon Foundation

The Economic & Social Research Council