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

2. 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

3. 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

4. 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

5. 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 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

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

7. 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)

8. 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)

9. 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.

10. 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.

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

12. 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) ‘

13. 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.

14. 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

15. 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

16. Familial AIDS predicts neglect, domestic violence and sexual abuse

17. Familial AIDS predicts transactional sex

18. 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

19. Child sickness
% past-month sickness

20. 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

21. Child TB treatment (bad and good news)

22. Resilience

23. 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)

24. 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.

25. 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.

26. 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

27. 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

28. 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.

29. ‘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.

30. 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,
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)
Cluver, L, Gardner, F & Operario, D (2009). Effects of poverty on the psychological health of AIDS-orphaned children. AIDS Care 21 (6)
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)
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)
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),
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)
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,
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.