FOR SALE
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
Collaborative research: Science to inform Policy
Collaborative
OVC research
programme
Universities: Oxford,
Wits, UCT, UKZN
NACCA, NGOs e.g.
USAID, UNICEF,
REPSSI, Save the
Children
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 AIDSillnesss/other-illness/non-illness.
• Multivariate logistic regression, log-linear models, structural equation
models, all controlling for socio-demographics
FOR SALE
THE SCENE OF THE CRIME…
Parental HIV/AIDS predicts child sexual risks
% children reporting sexual risk
12
10
8
6
Transactional sex
4
Sex drunk or on drugs
Pregnant (girls)
2
0
Healthy caregiver
AIDS-orphaned or AIDSsick caregiver
AIDS dual-affected
Parental HIV/AIDS predicts child sexual risks
% children reporting sexual risk
12
10
8
Transactional sex
6
Sex for: Food
Shelter
School fees
Money
Transport
4
2
0
Healthy caregiver
AIDS-orphaned or AIDSsick caregiver
AIDS dual-affected
Parental HIV/AIDS predicts transactional sex
% children aged 14-17 reporting transactional sex
12
11.5
10
girls
8
6.7
6
boys
4
3.3
2
0
healthy caregiver
AIDS-orphaned/ AIDS-ill carer
Dual AIDS-affected
FOR SALE
IDENTIFYING LIKELY SUSPECTS.
Parental HIV/AIDS predicts food insecurity
% children with insufficient food >2 days in past week
40
36.5
35
32
30
25
22.9
20
16
15
14.2
13.8
10
5
0
healthy
caregiver
other-orphan
other-sick
caregiver
AIDS-orphan
AIDS-sick
caregiver
AIDS-dual
affected
Parental HIV/AIDS predicts child stigmatization
% children reporting stigmatization
60
57.6
55
50
45
42.2
41.1
40
35
28.8
30
25
22.7
21.8
20
15
10
healthy
caregiver
other orphan
other-sick
caregiver
AIDS-orphan
AIDS-sick
caregiver
AIDS dualaffected
Parental HIV/AIDS predicts child maltreatment
% children reporting child abuse
25
20
Physical abuse
15
Emotional abuse
Domestic violence
10
Sexual abuse
5
0
Healthy carer
AIDS-orphaned
AIDS-sick carer
Parental HIV/AIDS predicts child psychological disorder
% children with 1+ psychological disorder (clinical-level depression,
anxiety, post-traumatic stress)
55
49.3
50
45
39.4
40
35
40.5
32.6
30
25
22.8
22.4
20
15
10
healthy
caregiver
other orphan
other-sick
caregiver
AIDS-orphan
AIDS-sick
caregiver
AIDS dualaffected
FOR SALE
UNCOVERING COLLUSION...
Cumulative impacts of parental HIV/AIDS, abuse and
hunger on child transactional sex
30
% children 14-17 reporting transactional sex
25
20
20
15
boys
girls
10.6
10
7.7
6.6
5
2.1
0
healthy carer
AIDS-affected,
abused
AIDS-affected,
hungry
hungry, abused
AIDS-affected,
abused, hungry
Increased risk factors, increased child risk of transactional sex
% children (14-17) reporting transactional sex
30
26.3
25
20
Risks: Stigma
Extreme poverty
Abuse
Psychological distress
Family AIDS
boys
15
girls
12
10
8.8
4.8
5
3.2
0.7
0
0 risks
1 risk
2 risks
3 risks
4 risks
5 risks
60%
50%
Cumulative impacts 15-25 year olds
57%
Cluver, L, Orkin, M, Boyes et al, (2011) ‘Transactional Sex amongst AIDS-orphaned &
AIDS-Affected Adolescents Predicted by Abuse and Extreme Poverty’. JAIDS
% girls aged 15-24 reporting transactional sex
40%
30%
20%
13%
10%
7%
1%
0%
Healthy family
AIDS-sick parent
Abused & hungry
AIDS-sick parent,
abused, hungry
Pathways of risk for AIDS-affected children
(structural equation modeling)
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.032
.044
.939
.930
Pathways of risk for AIDS-affected children
Education
risks
AIDSorphan
.13
.06
.18
.10
Poverty
.32
Stigma
Psych.
distress
.12
.24
.43
.08
.22
.14
.72
.15
.15
Abuse
.15
SEXUAL
HEALTH
RISKS
AIDSsick
parent
mean χ2(679)
Bollen-Stine
640.06
p=.001
mean
χ2/df
1.57
RMSEA
SRMR
CFI
TLI
.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 stigmaby-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 AIDSorphanhood: 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 wellbeing 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.
Thank you.
www.youngcarers.org.za
The Economic &
Social Research
Council
The National Research
Foundation
HEARD, University
of KwaZulu-Natal
The Nuffield
Foundation
National Department
of Social Development
The Claude Leon
Foundation
The John Fell
Fund