1. Lorraine Sherr, Sarah Skeen, Mark Tomlinson, Ana Macedo Exposure to violence and psychological well-being in children affected by HIV/AIDS in South Africa and Malawi

2. Violence against children Violence against children occurs in every society A quarter of adults report being physically abused as children Children exposed to violence more at risk for a number of negative outcomes Substance use Risky sexual behaviour/ HIV infection Perpetrati on of rape and sexual violence Being bullies Being abusive parents Being victims of violence

3. Society Community Family Child Gender inequality High alcohol use Community violence Developmental disability Chronic illness Intimate partner violence Parental substance use HIV stigma/social isolation Shared risk factors for children affected by HIV and violence against children

4. State of the research Sub-Saharan Africa: lack of empirical evidence about the prevalence and risk factors for violence against children Most research from the region on PTSD symptoms in adolescents, mainly South Africa Very little about young children AIM: assess the rates of child violence exposure in homes and communities and link to mental health status in children 4 – 13y affected by HIV

5. UCL and Stellenbosch University – Phase 1 funded by SIDA-NORAD, through HelpAge – Supported by Coalition for Children Affected by AIDS Child Community Care study

7. Baseline 989 children and primary caregivers Participation in CBO programme Follow up 15 months later

8. Results: 28 CBOs 24 rural, 4 urban 71.4% set up by people from the community 89.3% services delivered by local people More than half were multiply funded (53.6%). 12 out of 28 had an office space for administration and building and garden to work with children.

9. Sample characteristics 989 children and their carers – 84.3% in South Africa Children – 4 – 13 years, M=8.9 (SD=2.84) – 48.6% boys – 13.7% HIV positive – 30.9% lost one parent, 26.7% lost both parents Carers – 94.9% female carers, mean age 43.5 (SD=15.0) – 19.4% HIV positive

10. High rates of exposure to violence

11. Child depression p≤0.001

12. Trauma symptoms p≤0.0001

13. Self-esteem p≤0.0001

14. Emotional & behavioural problems All p≤0.0001

15. p≤0.0001 Exposure to violence and delinquent behaviours (10-13y only)

16. p≤0.001 Harsh discipline and delinquent behaviours (10-13y only)

17. Multivariate analysis: mental health outcomes β reported,* Significant at p˂0.05, ** Significant at p˂0.01, ***Significant at p˂0.0001. South Africa AgeMale HIV positive Domestic violence Comm- unity violence Harsh physical discipline Harsh psych- ological discipline Depressive symptoms -0.07-0.04-0.020.01.17***0.030.02 Trauma symptoms -.23***-0.003-.08*-0.02.17***.16***0.06 Self Esteem.87*.12**-0.02-0.14-.17***-0.007-.18***-0.03 Int & Ext problems 0.03-.14***.07*.08**.07*.24***.12***

18. Multivariate analysis: delinquent behaviours (age 10-13y only) Predictors of delinquent behaviour: – Living in South Africa (Adjusted OR: 3.03, 95% CI: 1.63-5.66, p<0.0001). – Exposure to any type of domestic violence (Adjusted OR: 1.89, 95% CI: 1.23-2.85, p=0.002), – Exposure to community violence (Adjusted OR: 2.39, 95% CI: 1.57-3.62, p<0.0001). Age, gender, HIV status and exposure to harsh discipline practices were not statistically significant predictors of delinquent behaviour.

19. Conclusions Exposure to violence was associated with a range of negative mental health outcomes and problematic externalizing behaviours in children affected by HIV In particular, violence in the home predicted most negative outcomes (depressive symptoms, trauma symptoms, low self-esteem, emotional and behavioural problems).

20. Conclusions Considerable exposure to community violence Not associated with depressive symptoms, but was associated with trauma as well as behavioural difficulties. Country differences E.g. higher violence exposure and delinquent behaviours in South African children

21. Conclusions CBOs tend to focus on nutrition and health issues in the context of HIV However, growing realization of their potential as resource for strengthening families Calls for development of parenting programmes that are low cost, accessible and culturally appropriate CBOs well- placed to work directly with families - should have an integrated violence prevention focus.

22. Thank you The carers and children who participated in the study Zena Jacobs and the research team in Khayelitsha, Cape Town Funders and partners