LITERATURE REVIEW
STRENGTHENING HIV PREVENTION AMONG ORPHANS AND OTHER VULNERABLE CHILDREN AND YOUTH IN SOUTH AFRICA
LITERATURE REVIEW
Strengthening HIV prevention among orphans and other vulnerable children and youth in South Africa
© 2015
Written by Warren Parker, PhD
Published by Department of Social Development HSRC Building, 134 Pretorius St, Pretoria, 0001, South Africa
Disclaimer
This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the Presidents Emergency Plan. The contents are the responsibility of author and do necessarily reflect the views of USAID or the United States Government
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ABBREVIATIONS ART Antiretroviral treatment CBO Community-based Organisation CDG Care Dependency Grants CHAMP Collaborative HIV prevention and Adolescent Mental health Project CSG Child Support Grants DSD Department of Social Development FBO Faith-based Organisation FCG Foster Care Grants GCBS Government Capacity Building and Support HCBC Home and Community-based Care HCT HIV Counselling and Testing HIV Human Immunodeficiency Virus LGBTI Lesbian, Gay, Bisexual, Transgender and Intersex NPO Non-profit Organisation NSP National Strategic Plan OVC Orphans and vulnerable children OVCY Orphans and other vulnerable children and youth PEPFAR The President’s Emergency Fund for AIDS Relief PLHIV Person/People Living with HIV SADC Southern African Development Community SANAC South Africa National AIDS Council SRH Sexual and reproductive health STI Sexual transmitted Infections TB Tuberculosis USAID United States Agency for International Development WHO World Health Organisation
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EXECUTIVE SUMMARY This literature review forms part of a subcomponent of the Government Capacity Building and Support (GCBS) agreement between USAID and the DSD that is focused on strengthening social and individual approaches to prevent HIV infection in children under 18 years and youth aged 18- 24. The aim is to inform understanding of OVCY and HIV prevention in South Africa, and to provide guidance towards strategies and programmes.
Some 350 texts were reviewed including peer-reviewed journal articles, Master’s and Doctoral dissertations and theses, books, and book chapters.
The review draws the following conclusions:
OVCY should be segmented into age-groups recommended by SADC to allow for a life-stage based approach to HIV prevention. These age-groups are 0-6, 7-12, 13-17 and 18-24 years.
Orphaning should be considered as one format of vulnerability which exists alongside other formats of vulnerability such as living in severe poverty, living with disability, exposure to violence and sexual exploitation, exposure to substance abuse, and living with HIV. Phasing out the current and historical emphasis on the distinction between orphans and vulnerable children and youth would allow vulnerability to be understood holistically.
Vulnerability of OVCY should be addressed on a national basis to ensure an adequate focus on vulnerability that prevails in all economically disadvantaged communities irrespective of whether or not they fall into predetermined ‘hotspots’.
Emphasis should be placed on legal provisions to address the sexual abuse of children, including increasing the extent of prosecution of perpetrators of statutory rape. Laws pertaining to these forms of sexual violence should be actively promoted. There is a need to foster safe spaces and trusted persons to whom abuse can be disclosed by victims, as well as a need to provide guidance on reporting and protection of persons affected. It should also be emphasised that persons of either sex may be perpetrators or victims.
Schools and family settings should be utilised as primary entry points for OVC aged 7-12 and 13-17 as well as older youth who are still in school or who reside with families. Reach into tertiary education institutions should be expanded to support OVCY aged 18-24. Secondary entry points would be through SRH services, social services, and community programmes.
OVCY segmentation should include children and youth exposed to sexual and other violence, youth with disability, LGBTI, young sex workers, youth exposed to substance abuse and young PLHIV. Close attention should be given to the emerging proliferation of cheap addictive drugs such as methamphetamine (tik), and combination drugs such as nyaope and whoonga.
Gender analysis should be incorporated into all programmes.
Social protection approaches should be sustained through grants provision and it should be ensured that there is integration of communication related to sexual vulnerabilities in family
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and care settings, as well as ensuring that children’s rights and citizenship are emphasized. Participatory approaches such as Stepping Stones and Prevention in Action should be utilised to support group formation and bolster articulation of rights at community level. In addition, pathways for OVCY to comfortably and confidentially report abuse and rights violations should be clarified and promoted. Collaboration with schools and educators would allow a conduit for such support, although social workers and home-based carers could also provide support.
The Isibindi programme should be sustained and scaled up and current uneven support to NPOs conducting such programmes should be addressed.
Focal areas identified by SANAC for HIV prevention among girls and young women should be integrated into all OVCY programming and nuanced to fit the context of OVCY. Important emphases include delaying sexual debut, reducing sex with older partners among girls and young women under 20, reducing pregnancy among girls and young women under 20, reducing multiple sexual partnerships, increasing consistent condom use among girls and young women aged 15-24, and increasing uptake, adherence and retention of eligible PLHIV on ART.
Research and analysis towards expanded policies and strategies to inform programming priorities and scale-up should be conducted. Capacity development of key personnel should be prioritized as part of scale-up processes.
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CONTENTS 1. Background ...... 7 2. AIM AND METHODS ...... 9 2.1 Aim ...... 9 2.2 Methods ...... 9 3. LITERATURE REVIEW ...... 10 3.1 Vulnerability and demographic data ...... 10 3.2 Orphanhood ...... 14 3.3 SADC guidance on OVCY ...... 15 3.4 OVCY-related policies ...... 17 3.5 Vulnerability of OVCY to HIV ...... 20 3.5.1 Physical and sexual violence ...... 21 3.5.2 Sexual risk behaviours ...... 22 3.5.3 Vulnerability and disability ...... 24 3.5.4 Vulnerability and LGBTI youth ...... 25 3.5.5 Vulnerability and young sex workers ...... 25 3.5.6 Vulnerability and substance abuse ...... 26 3.6 Support to address HIV vulnerabilities ...... 26 3.6.1 Families and caregiving...... 26 3.6.2 Social protection ...... 31 3.6.3 Support to young PLHIV ...... 35 3.7 OVCY programmes ...... 37 4. Discussion and conclusions ...... 40 4.1 Defining OVCY...... 40 4.2 Approaches to supporting OVCY ...... 41 4.3 Vulnerability to HIV through sex ...... 42 4.4 Family support ...... 43 4.5 Social protection for HIV prevention ...... 43 4.6 An integrated approach ...... 44 5. IMPLICATIONS ...... 44 5.1 Segmenting OVCY by age and vulnerability ...... 44 5.2 Support to OVCY and addressing sexual risks ...... 47 5.3 Integration ...... 48 6. REFERENCES ...... 49 7. ENDNOTES ...... 62
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1. BACKGROUND Pact, in partnership with Mott McDonald, Isibani Development Partners and Development and Training Services, implements a support programme with the Department of Social Development (DSD) through United States Agency for International Development (USAID) funding. The programme falls within the Government Capacity Building and Support (GCBS) agreement between USAID and the DSD and aims to address the needs of orphans, other vulnerable children and youth (OVCY) to strengthen the response to social and structural barriers that increase vulnerability to the human immunodeficiency virus (HIV), sexually transmitted infections (STIs) and tuberculosis (TB).
This literature review forms part of a subcomponent of the programme that is focused on strengthening social and individual approaches to prevent HIV infection in children under 18 years and youth aged 18-24.
South Africa’s National Strategic Plan on HIV, STIs and TB 2012-2016 includes mitigating the impact of HIV, STIs and TB among OVCY as a key objective, recognising OVCY as a key population, and emphasising scale-up of response to support OVCY.1 The DSD’s National Plan for orphans and vulnerable children (OVC), 2009-2012, outlines six strategies that address HIV vulnerability. These are: Family strengthening Strengthening of community-based response Ensuring appropriate legislation and policies are in place Ensuring appropriate strategies and programmes are in place Ensuring access to essential HIV and AIDS services, and Ensuring mechanisms are in place to achieve strategic objectives.2
The President’s Emergency Fund for AIDS Relief (PEPFAR) emphasizes four domains of response for OVCY: 1) Strengthening families as primary caregivers of children; 2) Strengthening systems to support country ownership, including community ownership; 3) Ensuring prioritized, focused interventions that address children’s most critical care needs; and, 4) Working within the continuum of response to achieve an AIDS-free generation. Guidance also highlights that OVC who are receiving services should continue to be supported after they turn 18, and that strategies to support transition into adulthood should be applied.3
DSD provides resources and support to a subset of Non-profit Organisations (NPOs) to conduct activities that fall within its focal areas of response. These approaches align with the following nine principles:
Principle 1: HIV, AIDS and TB are a developmental issue, including addressing all levels of society– individual, interpersonal, family, community, leaders, stakeholders and sectors.
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Principle 2: An integrated, holistic and comprehensive response that follows a multi-disciplinary approach drawing on the complementary strengths of various sectors and includes integration of prevention, care and mitigation strategies in combination with advocacy, active community engagement and political leadership.
Principle 3: Fostering an enabling environment collaboratively with departments to enable HIV prevention care and support through advocacy and mobilisation of communities, promotion of services, and engagement with community leaders and sectoral stakeholders.
Principle 4: Communities are active agents in the response to HIV, AIDS and TB and broader, with support being provided to poor and vulnerable people, particularly young people and women, towards sustainable livelihoods. Community members, thereby, are empowered to be active champions of their own development and capacities to address HIV, AIDS and TB.
Principle 5: Multi-sectoral partnerships are key, including partnerships with a variety of stakeholders in the development of the DSD strategy to support translation of policies and strategies into action. Partners include state-funded institutions, the business sector, community and sectoral leaders, non-governmental organisations (NGOs), community-based organisations (CBOs), faith-based organisations (FBOs), PLHIV networks, women’s networks and disability networks, among other stakeholders.
Principle 6: Mitigating vulnerability, including accelerating poverty reduction and ensuring effective food-security, access to efficient and accessible social services, and creating cohesive communities and networks that can advocate for services and provide support.
Principle 7: Support throughout life-stages, recognising different stages in life that require a distinctive yet integrated policy response through implementation of a multi-pronged life stage approach.
Principle 8: HIV, STI and TB prevention responses should be evidence informed, complementary and comprehensive, including a balance between biomedical, behavioural and structural approaches that take contextual factors into account.
Principle 9: A rights-based approach is necessary to prevent and mitigate inequality, stigma and discrimination. DSD focuses on rights-oriented advocacy and mobilisation to prevent and mitigate inequality, stigma and discrimination with an emphasis on the protection and promotion of human and legal rights, including the rights of PLHIV, gender rights and principles of gender equity.
DSD programmes linked to HIV and AIDS include a focus on:
OVC through child support grants, implementation of the Isibindi model, an OVC project in three provinces oriented around Community Care Centres and a maternal orphan surveillance system
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Young people aged 15-24 through addressing various dimensions of social crime prevention and victim empowerment
Youth out of school through the Masupatsela Youth Pioneer Programme and the LoveLife Groundbreaker Programme
Families and older persons through integrated service provision to families, home and community-based care (HCBC), and mainstreaming of prevention, care and support to older persons
Sex workers and clients through support to sex worker NGOs
People who abuse alcohol and drugs through the Ke Moja Awareness Programme
Farmworkers through a package of services for farmworkers
People with disabilities through mainstreaming HIV and AIDS into disability programmes.
2. AIM AND METHODS
2.1 Aim The aim of this literature review is to inform understanding of OVCY and HIV prevention in South Africa, and to provide guidance towards strategies and programmes.
2.2 Methods An initial electronic search was conducted using various Internet search engines to identify key themes and to scope the range of literature available. Detailed searches were conducted using Google Scholar, PubMed and other similar search engines to identify research literature. These were complemented by searches of relevant websites, specific journals focused on OVCY issues, and names of authors prominent in the field. Reference lists were also reviewed to identify additional key literature.
Texts were identified through key word searches including terms such as children, orphans, orphans and vulnerable children, youth, South Africa, HIV, HIV prevention, HIV treatment, caregiving, social protection and families. This search identified peer-reviewed journal articles, Master’s and Doctoral dissertations and theses, books, and book chapters. A search was also conducted for key texts within the so-called ‘grey literature’ produced by institutions and organisations including policy documents, research reports and toolkits.
Given that the literature on HIV is reiterative and that knowledge in this field is growing and cumulative, emphasis was placed on contemporary research and other literature, generally, but not exclusively, falling within the period 2008-2015.
Over 350 texts were identified, and these were collated into an Excel spreadsheet. Abstracts were included in the listing, and where abstracts were not available, brief summaries were drawn
Page 9 up and included. The literature was then assessed to determine thematic categories and sorted accordingly. Texts were then reviewed.
3. LITERATURE REVIEW
3.1 Vulnerability and demographic data
The vulnerabilities of OVCY aged 0-24 in southern Africa are In the context of OVCY, framed by psychosocial and economic factors. Particular vulnerability refers to the stressors for OVCY include living in households where co- extent to which the residents are living with or affected by HIV, being involved in immediate and longer-term responsibilities for providing care to ill household members, wellbeing of children and having disabilities and poor mental health, as well as youth is impacted as a product of their family experiencing conflict, severe deprivation or abuse within their circumstances including lived environment, or being HIV positive. Sexual risks and living in poverty in vulnerabilities to HIV flow from such circumstances and are combination with a lack of typically more severe for OVCY than for children and youth who protection and care. are not exposed to these challenges. 4
In 2012, there were 18,574,000 children aged 0-17 comprising 34% of South Africa’s total population of 54-million. 5 Key data include the following (see Table 1):
Poverty: More than half of all children aged 0-17 (55%) live in poverty with rates being over 70% in the Eastern Cape and Limpopo, and lower than 35% in Gauteng and the Western Cape.6 Poverty is a determining factor for vulnerability of children.
Orphaning: Some 19% of children aged 0-17 in South Africa are orphans. Among this group, 3% have lost a mother, 12% have lost a father, and 4% have lost both parents. Provinces with the highest proportions of orphans who have lost at least one parent are KwaZulu-Natal (25%), Eastern Cape (24%) and Free State (22%), in comparison to lower proportions in Gauteng (15%) and Western Cape (9%).7 A contributing factor to the high proportion children being identified as paternal orphans is the absence of fathers whose status is ‘unknown’.
Living with neither parent: While the majority of children aged 0-17 reside with at least one living parent, 23% of of all children live with neither parent. Among these children, 81% have at least one parent who is alive and living elsewhere.
Support Grants: Support grants are provided to children aged 0-17 in South Africa according to varying criteria linked to poverty and care arrangements. Some 62% of children are supported through grants including Child Support Grants (CSG), Foster Care Grants (FCG) and Care Dependency Grants (CDG).
Disability: Around one in 25 children aged 10-14 and one in 44 children and youth aged 15-24 in South Africa are living with a disability. Forms of disability taken into account include seeing, hearing, communication, mobility, concentration and self-care.
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School attendance: School attendance among children aged 7-17 is very high in South Africa, with 97% of all children attending school. Attendance by sex is the same for males and females.
Table 1: Children and youth aged 0-24 in South Africa – population, orphaning, disability, schooling data8
Indicator No. / % Total children 0-17 (2012) 18,620,000 Children 0-17 as % of SA population (2012) 36% Total children and youth 15-19 (2014) 5,217,560 Total youth 20-24 (2014) 5,267,117 Proportion of children 0-17 living in poverty 55% Children 0-17 (2012) Living with both parents 35% Living with mother 39% Living with father 3% Living with neither parent 23% Proportion of children 0-17 living with neither parent (23%) who are not orphans – i.e. who have 81% at least one parent living elsewhere (2012) Total number and proportion of orphans 0-17 (2012) 3,540,000/19.2% Maternal 3.3% Paternal 11.5% Double 4.4% Number and proportion of children 0-17 living in child-headed households (2012) 127,000 0.5% Number and proportion of children aged 0-17 living in poverty (2012) 10,347,000 56% Number of children 0-17 supported by Child Support Grants – CSG (2012) 10,927,731 Number of children 0-17 supported by Foster Child Grants – FCG (2012) 536,747 Number of children 0-17 supported by Care Dependency Grants – CDG (2012) 114,993 Proportion of children with a disability – seeing, hearing, communication, mobility, concentration, 4.1%/2.6%/2.4% self-care (10-14/15-19/20-24) Number, proportion and gender parity index of children 7-17 attending schools 10,884,000 97% 1.01 (gender equal)
One third of children aged 0-17 fall into the 12-17 year age range, where exposure to HIV through sex is more likely. In mid-2014r there were 5,217,560 children and youth aged 15-19, and 5,267,117 youth aged 20-24 living in South Africa.9 Key data related to sexual vulnerability include the following (see Table 2):
HIV incidence: Risk of exposure to HIV increase as children and youth become sexually active. There are however also risks of HIV incidence in childhood in South Africa, which is illustrated by new infections occurring among girls aged 2-14 (incidence, 0.25%). No new infections were found to have occurred among boys in this age group. HIV incidence was highest among females aged 15-24 of all age and sex categories in the country at 2.54%.10
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HIV prevalence: HIV prevalence is overall higher among girls and young women aged 15-24 in comparison to boys and young men. For example, HIV prevalence is eight times higher among females aged 15-19 and more than three times higher among females aged 20-24 in comparison to males in the same age ranges. 11
Living with HIV: There are more than one million children and youth aged 0-24 living with HIV. As HIV prevalence data indicates, the majority of young people living with HIV (PLHIV) are girls and young women. 12
HIV prevalence among orphans: HIV prevalence is higher among orphans aged 0-18 in comparison to non-orphans (3.8% vs 2.5%) and is highest for maternal orphans at 7.5%. Mother to child transmission of HIV is likely to contribute to HIV prevalence levels in this age group. 13
Pregnancy: Teenage pregnancy levels are high in South Africa with around 12% of sexually active girls and young women aged 15-19 having been pregnant in the past year.14
Sexual risk: Early sexual debut is reported more by boys and young men aged 15-24 than girls and young women (16% vs 5%). Boys and young men are also comparatively more likely to have had two or more partners in the past year (20% vs 5%). However, girls and young women aged 15-19 are more likely to have sexual partners who are five or more years older than themselves in comparison to boys and young men (33.6% vs 4.1%).
Table 2: Children and youth aged 0-24 in South Africa – HIV prevalence and sexual vulnerability data15
Indicator No. / % HIV prevalence of children 0-14 by sex (2012) 2.3% (M) 2.4% (F) HIV incidence among girls and boys aged 2-14 by sex (2012) 0.0% (M) 0.25% (F) HIV incidence of children and youth 15-24 by sex (2012) 0.55% (M) 2.54% (F) HIV prevalence of children and youth 15-19 by sex (2012) 0.7% (M) 5.6% (F) HIV prevalence of youth 20-24 by sex (2012) 5.1% (M) 17.4% (F) HIV prevalence of non-orphans and orphans 0-18 (2012) Non-orphan 2.5% Orphan 3.8% Maternal 7.5% Paternal 1.8% Double 5.3% Proportion of sexually active girls and young women aged 15-19 pregnant in past year (2012) 12% Sexual debut at age 15 or younger among youth aged 15-24 by sex (2012) 16.7% (M) 5% (F) Proportion of children and youth aged 15-24 with 2+ sexual partners in past year by sex (2012) 20% (M) 5% (F) Proportion of children and youth aged 15-19 with sexual partner 5+ years older by sex (2012) 4.1% (M) 33.6% (F)
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Although the 0-17 age group has, in the past, been applied to describing OVC, more recent thinking considers the vulnerability of youth as a whole, leading to the expanded acronym – OVCY.16 The age range for OVCY encompasses a child or youth aged 0-24 years, recognising that orphaning and vulnerability exist on a continuum, and that orphaning and vulnerability compromise wellbeing of children as they transition into early adulthood.
It is well established in the research literature that OVCY in high HIV prevalence countries are particularly vulnerable to HIV infection in comparison to non-OVCY. Vulnerabilities include higher than average exposure to sexual coercion, sexual exploitation, sexual violence and/or physical violence – all of which contribute to HIV exposure. Adopting risky sexual behaviours and practices are also linked to psycho-social and economic circumstances.17
Based on HIV prevalence data, there are around 1,1 million children and youth living with HIV in South Africa. These include around 380,000 children aged 0-14 and around 715,000 children and youth aged 15-24. Young PLHIV have particular vulnerabilities linked to their HIV status.18
Community perspectives on defining OVCY, as well as the perspectives of OVCY themselves are important to understanding HIV-related vulnerability and risk. 19 Studies have found that externally developed definitions and assumptions about OVCY may be inconsistent with local community constructs of this category of children and youth (including perspectives of OVCY themselves). For example, assumptions that the vulnerabilities of OVCY are dire and can only be solved through external intervention may contrast with community perspectives that view some externally enacted ‘solutions’ as inappropriate and paternalistic.20
Apart from the categories of children and youth outlined in the tables above, there are subpopulations of OVCY that are more vulnerable in relation to HIV as a product of disempowerment and marginalisation. These include children and youth who are exposed to violence or substance abuse as well as those who are lesbian, gay, bisexual, transgender and intersex (LGBTI), and/or who are young sex workers.
In South Africa, children are defined as persons under the age of 18 by the Bill of Rights (108 of 1996, S28:3) and the Children’s Act (38 of 2005, S1). The National Youth Policy defines youth as persons aged 14-35,21 while the United Nations defines youth as being persons falling within the 15-24 year age range. The 15-24 age range has been the focus of most demographic and epidemiological research on youth.22
The age of consent to sex in South Africa is 16 as outlined in the Criminal Law Sexual Offences and Related Matters Amendment (Act 32 of 2007). The Act acknowledges that although children aged 12-15 can consent to sex (penetrative or non-penetrative), it is an offence – defined as statutory rape – for any person to have sex with a child in this age range, even if their consent is given. Mitigating factors for prosecution may be applied if sex occurs between children who both fall within the 12-15-age range, or where there is an age difference of less than two years. Sex with a child below the age of 12 is defined as rape or sexual violation irrespective of ‘consent’ or any other factors.
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The South African Schools Act (84 of 1996, S3.1 and 3.6) prescribes school attendance from the age of 7 and limits school leaving to the age of 15 or end of Grade 9.23 According to the Basic Conditions of Employment Act (75 of 1997, S43), children aged 15-17 can be employed to perform work.
The DSD Social Assistance Act (13 of 2004), provides grants to parents and caregivers to support children under the age of 18, including care dependency grants to support children with disability, and foster child grants. 24
The Children’s Act allows provision or sale of condoms to children aged 12 or older. Contraceptives other than condoms may also be dispensed to children aged 12 and older on the basis of medical advice and examination. The general guideline for consenting to HIV testing is being aged 12 and older.
The Child Justice Act (75 of 2008) ensures that children under the age of 14 cannot be detained in prison, and that children aged 14-17 are detained separately from adults.
3.2 Orphanhood Orphans are defined as children aged 0-17 who have experienced the death of their mother, father or both parents.25
Care arrangements of orphans vary. Paternal orphans are typically cared for by their mothers, while maternal orphans are cared for by their fathers or close relatives. Care arrangements when one parent remains alive may include partners of the living parents, step-parents, older siblings, and extended family members, among others. It has also been observed that becoming orphaned does not necessarily disrupt the continuum of care that a child receives. 26 Factors such as migration, poverty, housing and low marital rates, among other factors, affect direct parental care by biological parents. As noted further above, 23% of children in South Africa do not have at least one biological parent living with them. 27 Most children live with their biological mothers (39%), followed by 35% who live with both parents and 3% who live with their biological fathers.28
Although children living in child-headed households have been identified as most vulnerable, there are only small numbers of orphans are living in such households in South Africa. It has also been found that child-headed households are not exclusively the result of orphaning.29
Definitions of orphanhood are fluid in the research literature. For example, a review of concepts of orphaning found that 70% of studies did not clearly define ‘orphan’, while many studies combined concepts of single and double orphaning without necessarily distinguishing between these forms.30 It was also noted that age ranges of orphans were not always clarified, and where ages were provided, these tended to refer to children either 18 years and younger, or 14 years and younger. Studies focused only on orphans also sometimes used ‘OVC’ as a descriptor for orphans.31 Lack of specificity when addressing vulnerabilities of OVC, and conflation of various
Page 14 categories, make research findings difficult to interpret. This inhibits effective planning and response.32
Fluid conceptualization of orphans, OVC and OVCY, and variations in the extent of orphanhood and vulnerability pose challenges for surveillance.33 Studies of orphaning have been noted to inadequately address or control for confounding factors including HIV status of children and the extent of exposure to poverty, among other factors. It has also been highlighted that orphaning does not uniformly lead to detrimental outcomes for children who are orphaned in comparison to children who are vulnerable but who have living parents. There may be positive outcomes emanating from support and care following orphaning that substantially improves the wellbeing of orphans. 34 Similarly, having living parents doesn’t guarantee superior wellbeing in comparison to wellbeing of an orphan.
The research literature indicates that orphanhood is a differentiating factor for childhood vulnerability to HIV and in sub-Saharan Africa, higher levels of HIV prevalence are linked to orphanhood.35 A general view is that HIV in the region has contributed substantially to parental death, underpinning high incidence of orphaning that has overwhelmed family systems, shifted the burdens of care for children to other relatives or caregivers, and contributed to emotional, social, material, and financial dislocation for orphans themselves. Vulnerabilities related to HIV include exposure to sexual abuse and exploitation and constrained access to health services.36
3.3 SADC guidance on OVCY SADC provides guidance on psychosocial support to OVCY. The approach addresses the continuum of care related to social, emotional, psychological and spiritual wellbeing of OVCY while also addressing basic needs and living conditions. SADC conceptualizes psychosocial support as falling within a schema of layers as depicted in Figure 1:37
Layer 1. Advocacy for basic services and documenting impact of services
Layer 2. Strengthening family and community care and support; Activating social networks (support groups); Providing information on constructive coping methods; Increasing availability of resources and community mental health education
Layer 3. Children, youth, family and group interventions by trained and supervised workers. This includes children and youth who have special coping needs, such as survivors of gender- based violence and those who have experienced complicated forms of grief
Layer 4. Psychological and psychiatric support and specialized traditional healer services for those who experience significant difficulties in basic daily functioning on psychosocial support, wellbeing and/or mental health.
For purposes of focusing responses to address vulnerability, age groups for segmenting OVCY include children aged 0-6, 7-12, 13-17 and 18-24. The latter two age groups are particularly vulnerable to HIV through exposure to sex.
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Focal areas of support for children aged 13-17 include school and community clubs and activities, sport and recreational activities, moral guidance in relation to healthy relationships, community activities and social roles and life skills.
For youth aged 18-24, focal areas include community activities linked to developing socially appropriate roles, youth groups and civic participation, life skills, and support for healthy relationships.
Figure 1: Psychosocial interventions pyramid (SADC).
SADC has also developed a ‘Minimum Package of Services’ for OVCY.38 This includes:
1. Education and vocational skills
2. Health care and sanitation
3. Food security and nutrition
4. Child and youth protection and safety
5. Psychosocial wellbeing
6. Social protection.
Life skills and sexual and reproductive health (SRH) education provided through schools, health services and other institutions are directly relevant to addressing HIV-related vulnerability. With regard to health services, emphasis includes providing access to condoms, contraception, HIV testing, and antiretroviral treatment (ART) among other resources.
To further support HIV prevention, it is necessary to address sexual abuse including potential occurrence within families, care facilities, institutions such as schools and other community contexts. Other approaches to reducing vulnerability include improving access by OVCY to legal
Page 16 and rights support, addressing economic exploitation, addressing vulnerabilities linked to disability, and providing services and support related to substance abuse.
3.4 OVCY-related policies HIV policies and programmes emphasise the importance of taking into account all vulnerable children as well as avoiding the exceptionalising of orphans within their various formats. This includes, for example, avoiding over-emphasis on less common formats such as the relatively small subset of child-headed households that arise through orphaning and other factors.39
Apart from social protection, a number of other key approaches to supporting OVC have been suggested for South Africa. These include establishing Community Child Care Committees to identify and monitor OVC, linking OVC care to adults in the community, establishing cluster care arrangements,40 and provision of ART to ill family members.
ART provision is an important intervention in high HIV prevalence contexts as the net effects of expanded availability of ART include minimizing incapacitating illness and improving capacity to care for children, while also maintaining potential for income-generation.41 A study in Uganda explored improvements in ART access and found that over a three-year period, the prevalence and incidence of orphaning declined significantly – particularly among children whose parents were known to be HIV positive.42 Significant declines in numbers of new orphans were found in Uganda between the initial roll out of ART programmes in 2001-2003 and expanded HIV care from 2006-2009. Orphan incidence declined by nearly 50% from 2.1% to 1.07% over the period.43 Modelling data in South Africa substantiate these findings, with intensified and universal ART access being estimated to have the potential to reduce the total of orphans by 901,700 over the 44 period 2009-2020.
An analysis of AIDS related factors affecting families notes that there are strong beneficial effects to supporting families to mitigate impacts of HIV on children. Cash transfers have been found to alleviate stressors, while provision of a combination of support may reduce the potential negative effects of HIV to negligible levels.45
An assessment of PEPFAR support to OVC programmes in east and Southern Africa46 found that valuable outcomes of programmes included improvements in school enrolments and psychosocial wellbeing. It was also observed, however, that the spread of support was described as uneven and thin, while also noting that evaluation had not been adequately integrated into OVC programing. In some instances, OVC and families had received overlapping benefits through accessing parallel programmes and the absence of a unified intervention model has limited efficiency and effectiveness of interventions. Approaches that were noted to be useful included providing support for school fees, support to clubs for adolescent OVC (particularly girls), and economic support schemes (including savings schemes and income generation).
An analysis of South Africa’s social development budgets by the Children’s Institute highlights four important domains of intervention: 1) Transfers to NPOs; 2) Rollout of the Isibindi project for
Page 17 community-based care and protection; 3) Expansion of early childhood development, reform schools and schools of industry, and 4) The expanded public works programme. Although the domains of support were appropriate, it was found that utilisation of allocated funds for various initiatives was uneven, and the extent of support to NPOs was insufficient.47
Two broad policy approaches in support of children’s rights have been followed in African contexts for OVC support. Rights-based aid approaches give emphasis to protection, while empowerment approaches – which are less widely employed – have the potential to transform vulnerabilities and livelihoods. A ‘children’s citizenship’ approach has been advocated as a guiding principle to ensure the voice of affected OVC are integrated into programme development.48
A review of programme approaches relevant to supporting adolescents and young adults including OVCY, indicates that priority interventions should focus on…49
increasing educational attainment
addressing knowledge and behaviour
providing comprehensive sex education
improving access to condoms
ensuring access to HIV counselling and testing
focusing on gender equity
facilitating access to employment
addressing exposure to sex work and drugs.
The National Plan of Action for Children in South Africa 2012-2017 developed by the Department of Women, Children and People with Disabilities, aligns with various global guidelines as well as with other South African government strategies.50 The mission of the national plan is to ‘promote the realization of children’s rights to survival, development, protection, participation and to mobilise resources on all levels’. Emphasis is placed on child survival, child development, child protection, standards of living and child participation. This approach is aligned with key national goals and the roles of relevant government departments are outlined. Guidance is linked to key outcome indicators and provides sound and relevant principles and approaches for mainstreaming children’s issues including a focus on children transitioning through adolescence as well as HIV-related vulnerabilities of OVCY.
Vulnerabilities related to gender are emphasised in various South African guidelines, and the importance of gender analysis has been highlighted as a key aspect of the work of regional agencies.51
It has been highlighted that the implementation of social protection in South Africa through approaches such as the CSG have improved the circumstances of households – in particular
Page 18 women within households. It has, however, been observed that such support alleviates, but does not necessarily transform, the burdens that fall to women in relation to providing care to families. Closer alignment with broader gender policies and a focus on deepening gender equality has been proposed.52 It has also been suggested that gender analysis of such policies should be applied to differentiate between age-groups and be sensitive to the dynamics of gender disparities in various contexts.53
An analysis of HIV-related psychosocial support to children in South Africa highlights the need to emphasise post-diagnosis support, address stigma, build capacity to respond to the needs of children, address grief and bereavement and promote peer support.54 A range of promising practices are detailed including:
Identifying vulnerable households through one or more index HIV patients, and conducting household HIV testing and support
Guiding and strengthening counselling for children, parents and caregivers
Supporting disclosure through various therapeutic approaches including peer support and mentoring
Addressing stigma at community level including through outreach and via targeted approaches such as engaging schools, mentoring and support groups
Providing dialogue-oriented and art-oriented therapeutic support to grief and bereavement
Building supportive linkages between providers, parents and caregivers.
It has been noted that there is a shortage of mental health professionals and it has been recommended that training of teachers and caregivers be expanded to allow for a wider base of support for OVCY.55
The value of keeping girls in school to support HIV prevention is widely recognized, although it has also been stressed that such interventions should not be conducted in isolation of broader programmes that address contextual vulnerabilities of youth in general. It is emphasised that school-based programmes should address stigma reduction in combination with addressing the array of vulnerabilities and sexual risks faced by youth living in impoverished settings.56
SADC member states all have specific policies targeting OVC. However, programmes are largely focused on the immediate material needs of children and there is a lack of emphasis on more sustainable livelihood and rights-based approaches. Such latter approaches take the immediate needs of OVC into account as well as addressing their long-term physical, emotional, legal, and economic needs (which are viewed as basic rights).57 The Food and Agriculture Organisation recommend that OVC policies include a focus on ‘sustainable livelihood and rights-based approaches’.
Emphasis on disability – a phenomenon that increases vulnerability of OVCY – is noted to be limited in the east and southern African regional HIV response, with minimal reference being
Page 19 made in National Strategic Plans (NSPs) among other policies. This gap contributes to lack of inclusion of OVCY with disability in general, but also limits interest in research and monitoring, hindering understanding of the extent of disability-related challenges.58
3.5 Vulnerability of OVCY to HIV The World Health Organisation (WHO) defines child abuse or maltreatment as including “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power”.59 Perpetrators may include caregivers, parents or others in proximity of the child.
Other concepts that are useful for describing child vulnerability include child exploitation, which involves taking economic or sexual advantage of a child or seeking to profit from a child. Child neglect includes deliberate acts or carelessness related to a child’s physical safety or development.60 While child maltreatment and abuse, including sexual abuse, are distinctly harmful to children, preventing exposure of children to such harms through child protection strategies minimizes risk and promotes child health.
The general impacts of the HIV epidemic on children, including orphans, involve economic changes, changes in place of residence, changes in caregiver and family composition, shifts in day-to-day responsibilities, and changes in access to education, economic assets, and food. Cumulative effects of such changes negatively impact the psychosocial wellbeing of OVC and increase vulnerability to HIV.61 Poverty, orphaning and parental AIDS illness are known to interact, producing more severe effects when they occur in combination.62
An analysis of data from household surveys in 36 countries explored markers for measuring vulnerability in relation to HIV. Measures included the prevalence of ‘wasting’ among children aged 0-4, the extent of school attendance among children aged 10-14, and the prevalence of early sexual debut among children aged 15-17. It was found that orphanhood or living with an ill adult did not uniformly correlate with vulnerability on these measures, but that household wealth/poverty, irrespective of orphan status, was a differentiating measure.63
A study of development outcomes for children in eleven eastern and southern African countries, found that psychosocial support to orphans should be combined with a broader approach that includes poverty alleviation and social protection through financial assistance schemes to address the needs of vulnerable children as a whole.64 A similar conclusion was reached in a study in South Africa that compared orphans and non-orphans living in a high HIV prevalence district in KwaZulu-Natal.65 Few significant differences between the circumstances of orphans and non- orphans were found, highlighting the need for broader community-level approaches that address the wellbeing of vulnerable children in general.
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3.5.1 Physical and sexual violence Exposure to physical and sexual violence in early childhood may lead to lifelong vulnerability and susceptibility to emotional, social and other impairments, while also increasing risk of substance abuse, other early sexual activity, difficulties in relationships with others, and heightened risk of acquiring STIs, HIV and unwanted pregnancy, among other negative health outcomes.66 A study of child sexual abuse globally, identifies four categories of abuse:67 non-contact abuse (sexual solicitation, indecent exposure); contact abuse (touching, kissing); forced penetrative sex (oral, vaginal or anal) or attempted forced sex; and mixed forms of abuse. Around 50,000 cases of violence against children were reported in 2010/11 in South Africa, of which more than half (52%) involved sexual abuse. Nearly two thirds of these cases (61%) were perpetrated against children aged 14 years or younger.68 Violence against children was found to be proportionally higher in the Northern Cape (17%), Western Cape (15%), and Gauteng (10%). Poverty, harmful norms and values, inadequacies in family structure and substance abuse have been identified as factors that exacerbate children’s exposure to violence nationally. Negative outcomes for children include depression, anxiety, suicidal behaviour and substance abuse as well as a range of negative outcomes related to sexual health including unwanted pregnancy, STIs and HIV infection.
Violence victimisation is a psychosocial stressor that has long-term effects. Experiences of violence at school may contribute to truancy and inhibit academic achievement including the extent of school completion. Early experiences of violence may lead to later involvement in violence perpetration. A large study among secondary school students in South Africa found that in the past year, 12% had been threatened with violence by another person at the school, 6% had been attacked or physically hurt, 5% had been sexually assaulted or raped, and 5% had been robbed.69 Most sexual assaults were perpetrated by other learners (91%), and occurred mostly in classrooms (54%) in comparison to other areas of the school. Teachers perpetrated around 4% of sexual assaults.
Child sexual abuse is a criminal offence that impacts the immediate and long-term wellbeing of children. Severe psychological outcomes resulting from sexual abuse include depression, suicide ideation, suicide attempts and sexualized behaviour. Poor parenting practices in combination with opportunities for sexual predation linked to residential and living arrangements allow sexual abuse to occur. Secrecy about occurrences of abuse by victims is perpetuated by respect for adults as well as threats of violence made by perpetrators. Where cases of abuse are identified, constrained resources and services are noted to limit effective response.70
Orphanhood has been found to increase the likelihood of experiencing childhood sexual abuse. Astudy in Zimbabwe reported that relatives, neighbours and ‘boyfriends’ were the most common perpetrators.71 It has also been highlighted that the problem of child abuse will not be reduced without addressing the underlying factors that contribute to occurrence – notably poor social and economic conditions that dislocate child rights and inhibit appropriate care and supervision of children.72
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An analysis of rape cases reported during 2003 in South Africa found that around 15% of instances occurred among children aged 0-11, and 26% among 12-17-year-olds.73 Around 5% of instances occurred within the child’s household and included ongoing sexual abuse. Other instances occurred while playing outside or doing chores or in school settings. A minority of instances were reported by a parent on the basis of suspicion of abuse or complaint by a child.
Sexual assault of children and youth includes victimization of both sexes, although young girls are more likely to be victimized. A 2005 study of children and youth aged 12-22 in South Africa found that 4% had been victims of sexual assault in the past year, with 3% being males and 6% being females. Youth aged 18-20 were more likely to report victimization (6%), followed by children aged 15-17 (5%). Assaults most frequently occurred in schools (21%), homes (21%) or in residential areas (21%).74 A more recent study found that between 77% and 90% of adult males surveyed in four provinces had experienced physical abuse in childhood, with 49% to 77% of females reporting the same. Having experienced sexual abuse in childhood was reported at similar levels between males (18%-25%) and females (14%-20%).75
Analysis of the 1998 Demographic and Health Survey (DHS) in South Africa found that around 2% of young women under the age of 15 had experienced coerced first sex. Younger women were more likely to report coercion, and the largest group of perpetrators were school teachers (33%).76 Families may be complicit in covering up rape or exploitation of daughters living in poverty – for example, avoiding making a report to the police in exchange for money, tolerating acceptance of cash for sex, or being complicit in forcing daughters into marriage.77
A qualitative study in South Africa among vulnerable adolescents aged 14-16 found that poverty, traditional notions of masculinity, normalization of interpersonal violence and commodification of sex contributed to sexual violence among youth. This was further exacerbated by poor adult and community-level protection.78
Domains of response to address physical and sexual violence include support via health services (including physical evaluation and treatment, diagnostic testing, counselling and referral), legal services (including taking of statements, criminal investigation, addressing safety and assisting in prosecution), and social services (including psychosocial assessment, addressing safety, assisting with reintegration and long-term support and referral).79
3.5.2 Sexual risk behaviours Parent-child connectedness holds an important influence on wellbeing within the vulnerability continuum – with lower levels of connectedness being associated with poorer sexual and reproductive health outcomes among children. A study in Tanzania found that poor parent-child connectedness impacted on self-esteem and underpinned risky sexual behaviours. Unplanned pregnancy was also noted to undermine parental connectedness when it occurred among girls. A related aspect was that desire for love and affection, as well as material needs, were being addressed through seeking out transactional sexual relationships, particularly where parental connectedness was weaker.80
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Orphanhood due to AIDS, along with living in a home with a parent who is ill as a result of HIV, contributes to potential exposure to emotional and physical abuse as well as transactional sex among children and youth. Food insecurity further increases vulnerability among girls.81 A review of the impacts HIV and AIDS on children notes that a parent or caregiver death results in changes in living arrangements that may include loss of love and affection as well as potential for stigma and discrimination to occur, disruptions to schooling, and exposure to violence. Higher likelihood of early sexual debut, unprotected sex, multiple sexual partnerships, coerced sex, and transactional sex are particular risks.82
In some contexts, orphans are not more likely to engage in risky sexual activities in comparison to vulnerable children who are not orphans. 83 For example, a study in Uganda found that vulnerability-related factors such as exposure to poverty and food insecurity were more likely to predispose children and youth to transactional sex, other risky behaviours and consequent STI or HIV infection in comparison to orphanhood on its own.84
Types of orphaning influence the extent to which sexual vulnerability to HIV occurs among girls. For example, in Zimbabwe girls who were maternal, double orphans or early paternal orphans were more likely to be living with HIV or have ever been pregnant in comparison to non-orphans, while maternal and double orphans were more likely to have sex earlier, or to have multiple partners.85 A study in rural South Africa found that female orphans aged 15-19 who had lost one or both parents and male orphans of the same age who had lost a father were significantly more likely to have had sex in comparison to non-orphans. Both female and male orphans were significantly more likely to be HIV positive in comparison to non-orphans.86 A comparative study in Zimbabwe found that among females aged 15-18 years, HIV prevalence was more than three times higher and teenage pregnancy more than four times higher among OVC comparison non- OVC. 87
A study conducted in three African countries found that female double orphans were more likely to start sex early, in comparison to other orphans.88 A study in Malawi found orphanhood was significantly associated with earlier sex among orphans aged 12-18 who were male double orphans, or who were female maternal or paternal orphans, in comparison to non-orphans. A study of children aged 14-18 in South Africa found higher likelihood of having ever had sex and having sex at a younger age among orphans than non-orphans. 89 Changes in caregiving arrangements, particularly multiple changes, were found to increase likelihood of earlier sex in a study in Kenya, highlighting the need to monitor and address such instability.90
Approaches to mitigating such effects include providing support to improve parenting and family connectedness among OVC, addressing household food security and improving social support.91
An analysis of DHS data from 19 countries found that OVCY living in households where at least one adult was living with HIV were more likely to have initiated first sex, in comparison to households where there was no adult living with HIV.92 An analysis of DHS data from 10 sub- Saharan African countries found that female orphans aged 15-17 were more likely to have
Page 23 started sex compared to non-orphans in high HIV prevalence countries. Orphaning did not affect the likelihood of having started sex among male orphans.93 An analysis of studies from 12 countries found that orphans were nearly twice as likely to be HIV positive and had higher levels of sexual risk behaviours. A focus on mitigating the effects of parental illness or death was highlighted as a potential approach to minimize risks.94
A study of youth aged 15-24 in South Africa found that 22% had lost a father, 8% had lost a mother, and 3% had lost both parents. These orphans were disproportionally black, living in poorer households, and of poorer education. Female orphans were more likely to be HIV positive, to have ever had oral or vaginal sex, and to have had more than one sexual partner in the past year. Male orphans were more likely to have had vaginal sex, and have not used a condom at last sex.95
An analysis of household survey data in South Africa found that maternal male orphans aged 18- 24 were more likely to have had sex, to have had multiple partners and to be HIV positive in comparison to non-orphans. Orphaning among females had no differentiating effects on HIV risk behaviour.96 Children living in child-headed households may also be stigmatized – as was found in a KwaZulu-Natal study where such OVCY were referred to as ‘whores’ and ‘thugs’.97
3.5.3 Vulnerability and disability While orphaning is one aspect of vulnerability linked to HIV, disability is another important factor that heightens vulnerability. Gaps in research on this aspect of vulnerability in southern Africa have been noted.98 Disability is a crosscutting issue in relation to OVC that requires attention and integration into policies and programmes is necessary. This includes giving attention to disability in the context of early childhood development as well as later life stages – particularly in relation to sexual vulnerabilities.99
Children and youth with disability are vulnerable to sexual abuse and exploitation but are also often assumed by caregivers and others to have sexualities that are non-normative. For example, being assumed to be ‘asexual, virgins, sexually overactive, cursed, dirty or clean’.100 Such misconceptions increase exposure to sexual abuse and HIV, and girls and young women are more likely to be affected. Apart from vulnerability to HIV infection, PLHIV with disabilities may experience other vulnerabilities more intensely. Living with HIV may also increase the likelihood of onset of some disabilities as a result of HIV infection.101 HIV-related resources are less available to persons with disabilities and it has also been noted that access to HIV-related services and support is constrained in South Africa.102
Provision of HIV prevention information in schools for learners with disabilities has been found to be poor, with lack of clarity about appropriate information to be delivered, staff discomfort in delivering information, and fears of promoting sexual activity being identified as limiting factors.103 A study of South African youth aged 15-24 with physical disabilities, found that while there was access to rehabilitation and other support, there was no inclusion of HIV and AIDS information or support. Although there was general awareness of sexual risk and prevention, risk
Page 24 reduction was not prioritized among these youth.104 HIV knowledge among persons with disability in South Africa has been found to be low in general, and is lower among females.105
3.5.4 Vulnerability and LGBTI youth Challenges for youth who are LGBTI include social stigmatization, family rejection, bullying and violence.106 Perpetrators include family members, persons in the community, teachers and other authority figures.
Boys and young men who have sex with other men are more vulnerable to HIV acquisition as a product of the risks of unprotected anal sex.107 Girls and young women who are lesbians are also noted to experience severe abuse in some communities, including so-called ‘corrective rape’, severe physical violence and murder.108
It has been noted that although policy frameworks that fall within South Africa’s National Victim Empowerment Programme, there is a lack of strategies that specifically address discrimination of LGBTI.109 Inadequacies in targeted health service delivery have also been highlighted.110
Intervention guidance highlights that programmes should focus on improving understanding of LGBTI issues among key stakeholders, addressing such issues as part of gender and HIV education in school settings, improving sensitivity to the needs of LGBTI in health and social services, and addressing risk contexts such as correctional facilities. LGBTI youth participation in conceptualizing and implementing responses and being included in programme implementation is also recommended.111
3.5.5 Vulnerability and young sex workers Sex work occurs throughout South Africa, with concentrations along major transport routes, around ports and at alcohol serving venues such as bars, shebeens and hotels. Girls and young women are drawn into sex work as a means of securing income.
There are sliding definitions between transactional sex and formal sex work among young women, although it is acknowledged that sexual relationships in economically deprived settings serve as a means to address immediate survival needs as well as material wants.112 While such relationships may be considered exploitative and disempowering, some young women view transactional sex as emancipating.113
While young sex workers might be strongly committed to condom use for HIV prevention, the extent of control over safer sex is compromised by unsafe working environments, threats of violence, perpetration of physical and sexual violence, and exploitation and manipulation by clients and persons in authority. South Africa’s National Sex Worker Strategy places emphasis on involvement and mobilization of sex workers in the HIV response in conjunction with improving safety and protection, improving accessibility to health and social services, building capacities of service providers and promoting rights and needs of sex workers.114
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3.5.6 Vulnerability and substance abuse Substance abuse within households contributes to vulnerability of children and youth. High risk drinkers and recreational drug users aged 15 years and older in South Africa have been found to have HIV prevalence levels that are more than two times higher than the national average.115 Alcohol and drug abuse is also associated with petty crime, violent crime, gangsterism, gender- based violence, and sexual assault.116
There is limited data on the extent of substance abuse in South Africa, with measurement being constrained by difficulties in measuring the extent of abuse in combination with the illegality of some recreational and addictive drugs. Young people are however, more likely to be drug users in comparison to older adults.117 It has been noted that there has been a growth in the use of methamphetamine (tik), and mixed drugs such as nyaope and whoonga. In some South African communities, the abuse of alcohol and drugs are viewed as making an equal contribution to social ills such as crime, violence and abuse.118
A study on substance use among orphaned and non-orphaned youth in South Africa found that substance use was increasing and appeared to be higher among orphaned youth.119 A review of the literature on drug use among youth in South Africa outlines community-level factors underpinning substance abuse including peer pressure, inadequate parental role-modelling, community tolerance, availability of alcohol and drugs, reduced attachment to spiritual values, unemployment, poverty and violence.120 It is proposed that schools take a leading role in addressing substance abuse including engaging parents and promoting healthy social activities through peer leaders. Individual leisure activities should also be promoted – for example, games of skill and sports.
3.6 Support to address HIV vulnerabilities
3.6.1 Families and caregiving Underlying structural factors impact on wellbeing of adolescents. These factors include poverty, unemployment and gender injustices further influenced by financial concerns within the home environment, as well as sexual abuse and issues such as unresolved paternal identity. Stress in sexual relationships, including stressors such as partner violence and transactional sex, impact on wellbeing of girls and young women.121 A study informing the development of a model for assessing consequences of adult HIV for children highlights the need for targeted interventions that take variations in living circumstances into account.122
A study in Botswana found that parents who were involved in caring for ill persons reduced the time they spent with their preschool children and there was a higher likelihood of leaving their children alone at home. Time commitments for caregiving also reduced the extent of time available for work and increased the extent of financial difficulties.123 A review of the literature on parenting found that behavioural disorders and poor peer relationships that manifest in early childhood contribute to poor adjustment during adolescence and adulthood.124
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A review of research on neglect and abuse among orphaned children in sub-Saharan Africa highlights the following forms of maltreatment:125
Intra-household discrimination – where love, care, food, clothing, schooling and other resources were provided differently to biological and non-biological children. Orphans were allocated excess chores or were required to contribute to income generation.
Material neglect – including severe lack of food or clothing, inadequate living space or isolation.
School neglect – in relation to diminished access to schooling, difficulties in paying school fees, or having to do chores or work instead of schooling.
Child labour – including domestic work, agricultural or market work, being engaged in wage labour, or taking on tasks previously allocated to adults who were ill or frail.
Exploitation – including removal of property or resources.
Emotional abuse – including bullying, harassment, or being made to feel unloved, unwanted or a burden.
Sexual abuse – including by family members or older men in the community, or being drawn into sex work.
Physical abuse – including being harshly disciplined and beaten.
Poverty, stigma, alcohol abuse and being disconnected from biological parents were additional factors that exacerbated exposure to neglect or abuse.
While children who are affected by HIV at family level are exposed to short-term impacts on their wellbeing, there is some evidence of longer-term resilience for many of these children.126 For a minority, however, the effects are multiple and extend over longer periods,127 suggesting that a focused approach that addresses especially vulnerable children is appropriate.128
Providing disability grants to parents and household members who are ill with HIV improves wellbeing of families. In contexts where basic needs are met through such grants, in conjunction with effective ART provision and support, PLHIV in the household improve their capacity to contribute to household responsibilities and the wellbeing of other household members. Grant provision in such contexts is therefore a cost-efficient approach.129
Families are the primary unit of support of children affected by AIDS and family strengthening is a key approach for ensuring sustainable parenting and caregiving. 130 Parenting encompasses biological relationships with a mother and father, as well as relationships with grandparents, siblings or other close family members. Being affected by AIDS in relation to orphaning includes being cared for by one parent after the loss of another to AIDS, or being cared for following the loss of both parents, in which case care provision typically extends to the extended family. Affected children might also serve as caregivers of ill parents, taking on responsibilities such as household chores or being involved in income generation. 131 Care of orphans who have lost both
Page 27 parents also falls to foster families – often older relatives or grandparents. A study in KwaZulu- Natal found that rural grandparents were most concerned with meeting basic needs for housing, food and education, while concerns in urban areas extended to needs related to emotional and psychological support. There was some disharmony emanating from the age gap between carers and children, including challenges related to discipline. While foster care grants are noted to be important to ameliorating some financial needs,132 they do not sufficiently contribute to reducing 133 psychological distress among OVCY.
A study in the Free State found that the quality of care provided by grandparents was comparable to that of other carers, and that access to pensions translated into higher overall household income – although vulnerabilities relating to poverty remained a core underlying concern.134 It has been found that for OVCY living in group homes, there was limited capacity to engage in substantive communication with carers on issues related to sexuality, substance use, HIV, or personal issues including bereavement.135
While the proportion of OVC living in child-headed households is relatively small, such units usually have fewer resources and face particular economic challenges. The special needs of child- headed households in South Africa include needs related to food, shelter, money and education in a context of heightened severity in comparison to other household formats.136 In some instances, children living in child-headed households have been found to have received support from absent parents, other family members, churches and neighbours. 137 Networking at community level has potential to improve co-ordination and effectiveness of response,138 while improving capacities of orphans themselves to access services is also relevant.139
Children from families affected by HIV experience negative psychological outcomes including higher levels of stress, poorer social skills, lower self-esteem and higher levels of sexual risk in comparison to children from families not affected by HIV.140 Parental illness or death produces similar negative psychological outcomes, and double orphaning produces more severe effects. Behavioural problems in AIDS affected children may be rooted in bereavement and stigmatization, as well as exposure to physical and sexual abuse. Food insecurity and stigma have also been found to interact, as have bullying and orphanhood, with combinations of these factors increasing the severity of negative mental health outcomes.141
Psychological wellbeing varies in relation to paternal or maternal orphaning, cultural context of orphaning, age and gender of OVC, and duration of orphaning. Most orphans do, however, have their immediate care needs addressed within a family setting. 142 Parental loss affects orphans of both sexes similarly, eliciting sadness, a sense of isolation, anxiety and fear. In comparison to boys, orphaned girls are more likely to have additional household responsibilities including caring for an ill family member, caring for other children, having disrupted schooling and having less access to food or cash. These findings indicate that gendered vulnerabilities should be taken into account by support programmes.143
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A South African study found that mental health factors that negatively impacted wellbeing of AIDS-orphaned children in comparison to non-AIDS orphans and other children included depression, peer relationship problems, post-traumatic stress, suicide ideation and behavioural problems. These factors are also mediated by poverty, extent of caregiving, and experiences of stigma. Food insecurity, stigma and bullying increased negative outcomes.144 A longitudinal study in South Africa showed that adolescent AIDS-orphans were more likely to exhibit symptoms of depression, anxiety and post-traumatic stress disorder.145 Such challenges may also lead to poorer cognitive performance.146
Mental health outcomes for children who are orphans in comparison to vulnerable non-orphans are sometimes similar. For example, a study in a school setting South Africa found no differences between these two categories in relation to anxiety, depression symptoms and behavioural problems. Levels of self-esteem and resilience were also found to be similar. Vulnerability of both categories was linked to food insecurity and poor health, and girls were more likely to be negatively affected.147 Similar findings were made in a Kenyan study, although the psychosocial support needs of orphans in comparison to vulnerable non-orphans were noted to be greater.148
A study on HIV and migration found links with higher HIV incidence, noting that HIV in combination with migration shifted the way families functioned when ill migrants returned home. In instances where one or both parents were ill, children might be relocated to family members living elsewhere to address care needs. Such geographic relocation posed integration challenges for children.149
Transitioning between care arrangements has been found to impact negatively on orphans – including increasing feelings of isolation, dislocation and instability. Orphans in family or foster care may be expected to contribute more to household chores and have less access to money, gifts and parental love than other children in the household. Such circumstances have been found to increase the likelihood of orphans seeking transactional relationships with men who are older and focusing on improving acceptance of orphans, providing love and other support are likely to reduce vulnerability to unsafe sex.150
Increased family and peer support reduce the negative consequences of orphanhood, and these benefits can be enhanced through emphasis on supporting sound approaches to parenting.151 Taking care of orphans following the death of one or both of a child’s parents involves additional burdens for a host family. Parenting responsibilities may fall to older relatives or grandparents, requiring multiple new responsibilities and capacities. A study in the North West Province found that poverty and lack of money were key concerns among caregivers and it was difficult for carers to meet the bureaucratic requirements for accessing social support assistance.152 Family members were also not necessarily willing or able to provide the necessary financial, physical and emotional support. Orphans were said to sometimes be rebellious and it was difficult for caregivers to understand how to address emotional needs of children. Some maternal orphans have been found to have been rejected by their living fathers, with emotional and material support following maternal death not being provided.
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It has been observed that South African families in HIV affected communities have traditionally taken on the burden of caring for children irrespective of the HIV epidemic. For example, in contexts of poverty and labour migration where birth parents have had to devote excessive time to income generation at the expense of free time for child care.153 While such arrangements may previously have been short-term, the HIV epidemic has necessitated longer-term responsibilities, translating into challenges in three domains:
Economic challenges (including increased costs related to food, shelter, grants documentation, school fees and uniforms)
Challenges related to children’s needs and vulnerabilities (vulnerability to sexual abuse, discipline, physical health, emotional health, bereavement)
Physical and mental health challenges (stigma, carer bereavement, tiredness, carer physical health, stress and shifts in life course aspirations).
A survey of in a community in KwaZulu-Natal found that carers of children exhibited compromised wellbeing in general health and had stress-related symptoms. These stressors were linked to broader socioeconomic constraints.154 Caregiver illness increases negative outcomes for mental health among orphans.155 Conversely, for older carers, receipt of old age pensions alleviates some of these stressors.156
Given the burden placed on OVC carers, support to positive parenting would improve physical and mental wellbeing of carers and OVC alike.157 Bereavement related to death of siblings should also not be overlooked – as was highlighted in a study in KwaZulu-Natal, which found that there was a lack support for such bereavement (particularly among adolescents who were often drawn into caring for ill siblings).158
In some cultural contexts, speaking about loved ones who have died is discouraged. Strategies drawing on peer support can be used to overcome such constraints, allowing space for reflection and grieving.159 Using stories and drama to address grieving and bereavement reduces stress and improves opportunities for OVCY to contribute perspectives and to be involved in decision- making.160 Photovoice, which involves participatory engagement through photography, is and approach that enhances the capacity of OVCY to engage with their circumstances towards problem solving.161 A grief support programme in Zambia utilized small group dialogue among affected orphans and led to improvements in psychological wellbeing and happiness, improving confidence and reducing feelings of loneliness and anger.162 Memory books, when linked to other support approaches, have also been found to improve communication between parents and children and to allow for envisioning and planning for the future.163 It remains necessary to deepen understanding of the range of support necessary to support OVCY through periods of grieving and bereavement. 164
Factors that contribute to child and family resilience include improving self-esteem of children and improving parenting and attachment, while community-level support includes social support
Page 30 from other families and improving peer support.165 To address vulnerabilities of children throughout childhood and early adulthood it is necessary to focus on family strengthening. A developmental approach to holistically address poverty is recommended – in particular, with respect to ensuring access to health services, schooling and income security. A family focused approach, including support to the household, is necessary to address and support most vulnerable children and adults. Cash transfers in various formats are acknowledged to be effective for families in severe distress.166
A study by the South African Human Rights Commission and the United Nations Children’s Fund,167 observed marked positive changes in the socio-economic circumstances of families over the past decade – in particular in relation to access to housing, water, electricity and sanitation, as well as grants. However, many children born into poor circumstances remain vulnerable as a result of limited access to education and employment. Crime and violence are acknowledged to undermine wellbeing, and substance abuse and household violence further exacerbate matters. Emphasis has been placed on the need to improve educational opportunities and improve community health, in conjunction with systematic approaches for poverty reduction. The prevalence of children living in dire economic circumstances is borne out in Statistics South Africa’s from living conditions survey 2008/9, which showed that a third of all South African children lived in households where there was no employed adult.168
3.6.2 Social protection Social protection refers to approaches that seek to reduce poverty, provide support to economically marginalized persons, address impacts of ‘shocks’ such as diseases or other impacts, address depletion of household assets and contribute to addressing imbalances in economic growth. More recent conceptions of social protection include an emphasis on human rights and human development.169
Given that HIV and AIDS constrain livelihoods, social protection for affected individuals, communities and families has been leveraged as a means to mitigate impacts and improve educational, health and economic outcomes for OVCY and families. Social protection includes economic support in various forms such as provision of monetary transfers, microfinance opportunities, food supplementation, expanding and subsidising access to health, welfare and other services, and applying protection through laws, policies and regulations. Receipt of cash transfers has been found to contribute positively to reducing HIV risk behaviours among OVCY.170
Social protection is relevant for HIV prevention in that it reduces HIV infection risks that flow from economic marginalization and gender disempowerment while also being supportive for HIV treatment and care. When linked to a broader development agenda, including bolstering community health and social systems and infrastructure strengthening, social protection contributes to sustainable development.171
It is well acknowledged that South Africa follows a robust approach to social protection, and budget commitments and implementation follow a sound foundation. The CSG includes over 10-
Page 31 million beneficiaries, schooling is widely available, school attendance is very high, and health services are readily accessible. It remains a concern, however, that the most marginalized 172 families ‘fall between the cracks’ and do not access grants or services at all or adequately.
In relation to basic health, cash transfers have been highlighted as a means to improve access to food, with improvements in nutrition contributing to overall wellbeing of children and families.173 Guiding considerations for cash transfers include:
Ensuring that transfers are directed towards priority outcomes
Determining whether transfers be conditional or unconditional
Determining political favourability of such approaches; and
Determining feasibility in relation to administrative systems and budgets.174
While cash transfer programmes provide direct and immediate support, it is also necessary to consider the balance between such programmes and broader initiatives such as food and nutrition programmes, microcredit programmes, public works activities among other forms of social assistance and protection. It has been noted that approaches for identifying the most vulnerable households should be refined and improved in some settings to avoid overlooking OVC that would benefit from support.175
While some cash transfer programmes work towards transitioning recipients off such schemes, it has been argued that it is also relevant to actively promote rights to social protection and to empower ‘entitled claimants’ to access social protection.176 It is highlighted that vulnerable relatives and other poor families should not be relied upon to support OVC without assistance, and that a coordinated approach between international donors, governments, and local NGOs and CBOs should be followed.177
An analysis of HIV-related social protection approaches globally provides insight into approaches that can be replicated in diverse settings.178 This includes ensuring integration of theories of change and inclusion of clear and robust indicators to monitor and determine performance of such programmes.
A systematic review of 35 studies globally, including conditional and unconditional cash transfers, found that both modalities improved the likelihood of school enrolment and attendance of OVC in comparison to those not receiving a cash transfer. There was no significant difference in schooling outcome between conditional and unconditional approaches. It was however found that for cash transfers that were strongly conditional, including compliance monitoring, larger effects were obtained.179 Measurement of mitigating effects of cash transfers in relation to sexual risk include the observation that making transfers to the female head of household conditional on school attendance improves positive outcomes.180
To address sexual vulnerability of adolescent girls to HIV as they transition into womanhood, improving economic assets has been considered in various settings. A study in Uganda compared
Page 32 two approaches – one involving mentor supported group meetings that included a curriculum on reproductive health, finances and establishing savings accounts, and the other involving only the establishment of a savings account. It was found that girls who received only a savings account were more likely to experience sexual harassment and touching, leading to the conclusion that improving social assets more broadly was an important component of the intervention.181
SHAZ!, an intervention in Zimbabwe that focused on providing support through microcredit and life skills to orphan girls, found improvements in knowledge and relationship power, but achieved poor outcomes in relation to loan repayments and business success, which, in turn, limited longer-term effects on pregnancy and HIV prevention.182
An evaluation of a Kenyan government programme providing an unconditional cash transfer of $20 monthly to households for support of OVC, found that the odds of sexual debut among children and youth aged 15-25 in recipient households was reduced by 31%. There were no effects on condom use, numbers of partners or transactional sex. 183
An analysis of anti-poverty programmes in middle-and low income countries found that social transfers, including programmes such as South Africa’s CSG, were relevant for improving schooling, health and nutrition outcomes. It was highlighted that explicit human development and child protection objectives were necessary to ensure protection of children from neglect, abuse and violence while also needing to consider possible adverse effects of interventions on children.184 Other analyses of the CSG indicate that it is important to link programme research to determining a ‘child poverty profile’ while continuously assessing implementation and impact.185 It has also been argued that adding conditionality’s to the CSG might result in unnecessary exclusion of vulnerable children, and that emphasis would be better placed on addressing structural response by strengthening schooling and health provision.186
Receipt of a cash transfer (R250-280 monthly) by primary caregivers in South Africa to support children was analysed to determine protective effects on risky sexual practices such as unprotected sex, transactional sex, sex with older partners, and multiple sexual partnerships among girls and boys. Incidence and prevalence of transactional and age disparate sex was lower for girls in grant recipient households over the study period, but not for other risk behaviours (unprotected sex, multiple sexual partners, sex while drunk or after taking drugs, either in the past year, or ever). There were no impacts on risk behaviours, nor longer-term effects among boys in grant recipient households.187 It has been highlighted that the exact mechanisms of underlying such findings need to be better understood,188 including measuring the direct impacts of behavioural changes on HIV incidence,189 while also assessing complementarity with other HIV prevention programmes and clarifying ‘theory of change’.190
A study of cash alone and cash plus care approaches conducted among OVC in two provinces in South Africa found sexual risk reduction effects for ‘cash alone’ for girls but not for boys, while cash plus care halved risk behaviour for both sexes. Longer-term positive effects were also noted.191 A study in Zimbabwe found that both unconditional and conditional cash transfers
Page 33 were effective for ensuring school attendance among children aged 6-12 years, and there were no marked differences between the two approaches.192
It is argued that linking cash transfer programmes to school attendance includes potential benefits for added exposure to school-based HIV prevention programmes, with additional benefits accruing as a product of improved educational outcomes. It remains, however, that longer-term development, rights and social transformation goals need to be considered to ensure sustained benefits.193
Researchers caution that child support grants, on their own, are unlikely to produce marked effects on HIV vulnerabilities of children and youth, and that other support should be considered.194 A study of social protection in the global south, including South Africa, has noted that such programmes are moving from individual-focused protection to a focus on building protective environments and addressing wider community vulnerabilities. Programmes focusing on human development and child protection together have improved overall impacts.195
Further research into to cash transfers is necessary – in particular to understand: 1) The pathways that produce effects on HIV-related behaviours; 2) The extent to which complementary programmes are necessary; 3) The extent to which conditional and unconditional transfers deliver benefits in relation to cost and practicality; 4) The size of transfers necessary to produce effects; 5) Potential unintended effects of cash transfers; 6) Relevance of cash transfers in various settings; 7) Delivery at scale.196 The need for community participation in the design, monitoring and evaluation of such programmes has also been highlighted.197
While social protection often involves externally derived economic support, community-level responses in poor communities may include a diverse range of activities that similarly alleviate the burden of poverty. For example, self-help groups, networks and NGO responses focused on improving livelihoods that are both empowering and beneficial, demonstrate that the benefits of social protection can be produced through enhancing social capital. Such approaches are also potentially more sustainable.198
A study in Kenya identified various coping strategies and resilience among OVC including making a contribution to household survival and care for family members, being involved in mobilizing support and constructing positive identities. This finding supports the conceptualisation of ‘orphan competent communities’ where OVC and community members engage in reflection, analysis and problem solving to address OVC-related challenges. Supportive social spaces include churches and schools, with participatory methodologies such as Stepping Stones having potential for adaptation to supporting dialogue and building on ‘latent coping strategies’.199 CBOs have potential to support such responses, and can be assisted by community coordination committees that guide and support access to various resources.200
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3.6.3 Support to young PLHIV The needs of children who are living with HIV in South Africa are not well addressed. A study of children living with HIV aged 10-14 found that there although they were interested in learning more about living with HIV, including in relation to sexuality, programmes were not available to address this need.201 Furthermore, age appropriate information was not readily accessible, and there was limited support to processes of disclosure. Improvements in communication resources for children living with HIV, support to disclosure, improved health service access, group-based approaches and capacity building of health care workers have been recommended. Clubs for young PLHIV allow for egalitarian discussion and mutual support between participants, contrasting with hierarchical and sometimes authoritarian communication that occur in care giving and service provision contexts.202 It has been highlighted that a focus on positive responses to living with HIV and resilience among children should be further explored through research.203
Children with HIV positive mothers and those living with perinatally acquired HIV are more likely to exhibit mental health problems in comparison to other children. Cognitive development may also be delayed.204 Diagnosis of mental health problems and mental health support are not generally included in care programmes.205
A study on psychosocial challenges and coping among young PLHIV in South Africa found that bereavement, stigma and discrimination, disclosure and coming to terms with their HIV status were key challenges. Contexts of family poverty exacerbated these challenges. Relevant formats of support include improving access to ART, improving HIV communication, providing support to psychological wellbeing, and improving contexts of caregiving. 206 Improved guidance for caregivers in relation to supporting ART for OVC who are living with HIV is also necessary.207
Processes of HIV disclosure between HIV positive mothers and their children are not well understood and model approaches are needed to support disclosure to children.208 A study of approaches towards disclosure by parents in Kenya found that disclosure planning was usefully combined with improving access to information, teaching children about HIV, attending support groups and linking to spiritual support.209
An exploration of links between ART access and disclosure among adolescent PLHIV concluded that while disclosure was challenging, it was necessary and ultimately beneficial in that it allowed for access to support groups, improved management of ART, and contributed to a sense of confidence and control among young PLHIV over their circumstances.210
Analysis of children in residential care facilities in South Africa found that a disproportionate number were HIV positive, and that the needs of children living with HIV in such facilities may be overlooked. It was recommended that the needs of HIV positive children in residential care be more systematically addressed.211
In many countries with advanced HIV epidemics, growing populations of perinatally infected children are entering their teens, with survival being enhanced by access to ART. Improvements in approaches for providing support to perinatally infected children and youth are necessary.212
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ART regimens specifically designed for children and youth, and peer support approaches show promise,213 while regimes necessary for long-term treatment require continuous assessment.214 A particular concern for children and youth living with HIV is their capacity to adhere to treatment. Approaches to supporting adherence and self-care in African contexts have not been widely explored.215
Adolescents living with HIV are noted to be interested in support to sexual and reproductive health via local health services that is private and confidential, that improves control over disclosure of their HIV status to others, and that is supportive towards developing skills to improve work opportunities. Successful programmes in various southern African countries have included support to peer networks, improvements in service provision, and focused curricula and training for service providers.216
A study in Zambia identified three main barriers to HIV disclosure by adolescent PLHIV to others – lack of parental discussion about sexuality, fear of stigma and concerns that other adolescents would not understand the implications of their status inhibited support to disclosure. Fear of rejection was a particular concern among adolescents negotiating sexual relationships. Interventions should include support to families to engage with disclosure, sexuality and relationships, and ongoing support should be provided to adolescents. A potential role was identified for trusted family members.217
Young PLHIV entering their teens have similar desires for relationships as non-PLHIV. Programmes supporting adolescent PLHIV tend to emphasise abstinence, and do not adequately address sexuality and relationship desires of these PLHIV.218
A study in Tanzania explored sexuality among adolescent PLHIV aged 15-19 found that fears of onward transmission and disclosure inhibited relationship seeking and underpinned desires to postpone or avoid sex. Notions that adolescent PLHIV should be abstinent were reinforced by care givers and home-based care providers, and it was noted that improved access to tailored information and guidance on sexuality, relationships and reproductive health should be developed. 219 It has also been found that information provided by various persons to young PLHIV was inconsistent, contributing to confusion about sexuality and relationships. 220 Approaches to supporting open communication between adolescents, caregivers, service providers and HIV-positive peers are necessary.
A qualitative study in Rwanda found that there was optimism about establishing long-term partnerships and having children among youth PLHIV. Support to life skills and disclosure, as well as supporting family dialogue were considered to be among the processes that would contribute to reducing anxieties and improving wellbeing.221
Support programmes for young PLHIV can improve confidence, as well as capacity to communicate and share experiences with others. Examples of useful approaches include ‘Teens out Loud’ which involves creative writing activities, 222 and ‘Photovoice’, which combines photography and story telling, and contributes to actions to improve living environments.223
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3.7 OVCY programmes A review of PEPFAR programmes directed towards OVC highlights the need to focus on sustainable and effective approaches, giving attention to four domains:224
Stages of child development
Building resilience in families and communities
Balancing government and civil society investment
Conducting research and rigorous evaluation.
Support to early childhood development contributes to building a foundation for later life stages, with potential to minimize and mitigate downstream vulnerabilities. Integration of crosscutting vulnerabilities is specifically important – notably through targeted approaches to address the additional special needs of especially vulnerable OVCY – for example, OVCY with disabilities and OVCY who are PLHIV.
Integrated programmes that draw together ‘adolescent HIV prevention’ and ‘OVC care’as have been recommended. For example, integrating improved access to HIV counselling and Testing (HCT) for a wider age range of children, improving HIV prevention information for children, protecting youth from exploitation, and focusing on family strengthening to realize HIV prevention benefits for OVC and youth alike.225 Programmes to support OVCY are noted to sometimes be hindered by their funding approaches leading to competition between organisations, and limiting innovation by being overly prescriptive regarding the types of 226 interventions to be undertaken.
Peer norms and values among girls living in poor socioeconomic circumstances influence HIV vulnerability, with risk-promoting norms, in conjunction with partner violence, contributing to higher levels of sexual risk behaviour. Peer focused programmes moderate such effects.227 An analysis of approaches to address sexual risks highlights the relevance of a social capital orientation that includes promoting group membership and networking among youth. Providing safe spaces for groups involved in sports, study and religion are relevant, and activities tailored to 228 context, age and gender of participants are seen to be more beneficial.
A study of community perspectives on approaches to address the vulnerabilities of young women in three southern African countries highlighted the need for legal, educational, economic and cultural formats of support delivered through a comprehensive multilevel approach.229 Structural vulnerabilities that were identified included unsafe spaces such as unregulated taverns and bars that provided venues for unsafe sex, poverty linked to transactional sex and sexual exploitation, consumerism that underpinned unrealistic needs and wants, sexual violence linked to alcohol consumption, and inadequacies in parental care. Approaches for moderating vulnerability included:
Providing direct economic opportunities for girls, and to some extent, families
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Keeping girls in school
Improving law enforcement in relation to alcohol venues, alcohol consumption, sexual violence and exploitation
Supporting leisure and recreational activities, including clubs and vocational training
Community mobilisation with a focus on promoting a protective environment, including ‘girl protection committees’
Improving adult-child communication.
A programme in Zimbabwe focused on keeping orphan adolescent girls in school led to a marked reduction in school dropout and early marriage among participants who were initially recruited in grade 6. The main intervention included providing financial and material support in combination with trained helpers (female teachers), who monitored and addressed absenteeism.230 Further research has contributed towards understanding the most cost-effective approach to such support.231 While school-based support provides a useful entry-point for engaging and supporting OVC, programmes need to be designed with clear methodologies and change goals in mind. For example, an exploration of school-based support provided through NGOs in Lesotho and Swaziland illustrated the importance of linkages to OVC support, but highlighted that a minimum package of interventions was yet to be established.232
Soul Buddyz clubs, which were initially mobilized through the Soul Buddyz television series, reach out to 8-12 year olds with a focus on HIV.233 Emphasis is placed on mobilizing children to become agents for change, and giving voice to children’s perspectives and issues. Clubs are sustained through various incentives and are supported by adult facilitators (usually teachers). Participating children gained confidence in voicing their opinions, and improved self-esteem and leadership and participation is viewed positively by parents, caregivers, educators and other community members.
While programmes may encourage dialogue between caregivers or parents and children to reduce sexual risk, such communication may not be adequately framed. For example, communication may be authoritarian, unidirectional or threatening. More frequent and open discussion does however appear to improve outcomes.234
The National Association of Child Care Workers has pioneered the ‘Iisibindi’ (courage) approach to support community-based response to supporting OVC with nearly 300 projects having been implemented country-wide. The programme, which includes linkages with the DSD and PEPFAR, incorporates various empowerment modules including a component that focuses on OVCY and disability, a focus on child and youth care training of local community members providing household support, and training carers to provide a range of direct support and mentoring including a focus on HIV. Development of safe spaces is also emphasised.235
Drawing on domains of cultural practice may be useful for assisting OVC in traditional settings, as these provide an alternative to rights based individual-focused approaches that may be more
Page 38 successful in urban settings. A multistage therapeutic programme in Botswana demonstrated how rights of passage strengthened group support, affirmation, transformation and longer-term wellbeing of participating orphans.236
Programmes involving home visits to support OVC may have varied outcomes, depending on the capacities and competencies of support providers. For example, an assessment of programmes involving home visits in KwaZulu-Natal to HIV affected families found that visits by lay volunteers were less frequent and less intensive than visits conducted by paraprofessional staff. Improved training of home visitors, including professionalising support providers, would contribute to higher levels of support.237
A review of OVC interventions conducted under the auspices of the Horizons programme highlights the importance of linking OVC care and support services with other services for youth including livelihood support. Gender analysis supports processes of determining programme emphasis, while community engagement and networking as well as capacity building of local organisations underpin potentials for long-term sustainability.238 Ecological models also inform the design of holistic programme approaches,239 while a focus on resilience and integration of the perspectives of OVC as active agents towards enabling community and social environments through emphasis on empowerment.240 A complementary focus on engaging communities to address OVC challenges is relevant – in particular, supporting the interface between community motivations and capacities develop local solutions with support from organisations that have the necessary resources to support activities. The interface between communities and external organisations does however need to be clearly negotiated to ensure that innovations and changes are effective over the long-term. For example, community motivation and involvement in building a centre to support OVC in Kenya was undermined by subsequent closure brought about by tensions between internal and external interests.241
A review of OVC and disability includes a number of examples of targeted programmes conducted in southern Africa. For example, improving life skills and addressing sexual and other vulnerabilities through support provided by the Intellectual Disability Association of Lesotho, participatory approaches conducted in partnership between Handicap International and the Catholic Diocese in Kenya, and peer education and skills building for deaf children through the Nzeve Centre in Zimbabwe.242
The family-based Collaborative HIV prevention and Adolescent Mental health Project (CHAMP) has been conducted over a number of years in South Africa and the United States in two formats – CHAMP and CHAMP+. The approach draws on theory and evidence through collaborative design to address HIV prevention, mental health and economic circumstances of HIV vulnerable and PLHIV adolescents and youth. CHAMP+ was designed specifically to support perinatally infected youth and their caregivers.243 CHAMP uses participatory experiential learning and group- based engagement with families, caregivers and youth. In South Africa, the approach improved knowledge and attitudes towards HIV and improved community networking towards a ‘health enabling community’ for youth and contributed to better family coping.244 Further research on
Page 39 the CHAMP+ approach, renamed VUKA, has led to the development of a refined and replicable model of intervention.245
Support groups for young PLHIV offer opportunities for sharing and mutual support to address issues including knowledge, HIV treatment and care, building self-esteem, and addressing disclosure and confidentiality issues.246 Family support approaches include nurse home visits to low-income pregnant women and mothers, as well as early childhood development programmes,247 while poverty alleviation programmes are linked to improving mental health outcomes of AIDS-orphaned children.248 Perinatally infected children also benefit from mother- child support sessions, and initiation of such approaches when children are younger is anticipated to improve longer-term wellbeing.249
4. DISCUSSION AND CONCLUSIONS
4.1 Defining OVCY The literature compiled in this review includes many inconsistencies in defining OVCY, while research study findings are inconsistent in many respects. The conceptual integration of orphans and vulnerable children under the descriptor ‘OVC’ serves to highlight the particular vulnerabilities that accrue to orphans that are not similar for non-orphans who are vulnerable. However, the literature also shows that orphans are not uniformly vulnerable in comparison to non-orphans, and singling out orphans may have the effect of masking other categories of vulnerable children – for example, those with disability, or who are living with HIV. As the statistical and other research data illustrate, orphans are not necessarily compromised in terms of their care relative to other children. It can also be anticipated that in the forthcoming years, ART programmes will increasingly reduce the prevalence of orphaning as a product of extending lifespan and improving health and wellbeing of parents, thus reducing HIV-related vulnerability.
In general, researchers and policy-makers do not always adequately define the characteristics of OVCY within studies by their particular characteristics. More often, the extent of orphaning (paternal, maternal or double) is not clarified. Vulnerability is also relative and not necessarily distinct from the specific lived circumstances of orphaning. For example, the statistical data show that a large proportion of children in South Africa do not reside with their parents, whether or not they are living. Furthermore, parental support is not uniform, and homes where parents abuse alcohol or where violence prevails can be expected to have marked negative consequences for children who are not necessarily orphans.
The more recent inclusion of youth 18-24 within the definition of vulnerable children usefully addresses the need to view vulnerability of young people on a continuum, but introduces the need for a broader understanding of the challenges in relation to HIV. For example, OVC programming has largely focused on a younger population where sexual vulnerabilities are
Page 40 limited, whereas OVCY programming necessitates consideration of sexual vulnerabilities that are pervasive.
There is a need to conceptualise and conduct programmes for OVCY aged 18-24.250 While there is potential to adapt and expand existing programmes, it can be anticipated that the needs of OVCY who are no longer in school may not readily be accommodated in these approaches. Household support programmes such as Isibindi do, however, have potential to readily integrate OVCY concerns. As with other aspects of vulnerability, participatory group and peer approaches are relevant. Bolstering linkages to services have also been highlighted, and expanding access to psychosocial and economic support remains relevant.
The inclusion of youth necessitates closer focus on sexual vulnerabilities experienced by subgroups of vulnerable youth – in particular, youth with disabilities, youth involved in transactional sex and sex work, youth exposed to substance abuse, LGBTI youth and young PLHIV. In the case of the latter, for example, it is important to distinguish between the support needs of young PLHIV who acquired HIV perinatally, those who acquired HIV through sexual abuse, and those who acquired HIV through sexual relationships. Vulnerability related to disability is also complex, given variations in lived experience between various forms of disability.
The research on lived experiences of OVCY as well as research on interventions addressing OVCY well illustrates that gender is a cross-cutting feature of OVCY in relation to vulnerability in general and HIV vulnerability in particular, with more severe vulnerabilities and challenges accruing to girls and young women. It is therefore vital to address gender and gendered variations in all OVCY work.
4.2 Approaches to supporting OVCY A prominent feature of support to OVCY is the strong emphasis given to psychosocial support. Such support extends across early childhood and adolescence. Only a few programmes specifically address vulnerable youth aged 18 and older within an OVCY-focused continuum.
The South African government has mounted a robust response to supporting OVC under 18 years through various government departments. This has been complemented by partnerships with donor agencies – in particular, USAID/PEPFAR – as well as various NGOs. Broad-based social protection strategies and programmes have been widely implemented and have included community engagement and participation through formations such as Community Child Care Committees and programmes such as Isibindi.
It should also be noted that South Africa’s robust response to addressing HIV through ART provision markedly improves health of adult PLHIV and reduces HIV mortality. This has a direct bearing on reducing the extent of orphaning, while also reducing vulnerabilities related to household illness. However, the provision of ART to youth, including related issues such as adherence have not adequately explored in the research literature. The spread of support is uneven and it is relevant to ensure that programmes are appropriately targeted.
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Although there are wide variations in HIV prevalence nationally, children and youth living in poverty – and who are therefore vulnerable – are to be found in high proportions in all South African provinces. Such distribution of vulnerability should be addressed by programmes.
With regard to HIV prevention, the draft South African National AIDS Council (SANAC) strategy for HIV prevention among girls and young women highlights six priority strategies to accelerate HIV prevention. 251 These are:
Delay sexual debut
Reduce sex with older partners among girls and young women under 20
Reduce pregnancy among girls and young women under 20
Reduce multiple sexual partnerships
Increase consistent condom use among girls and young women aged 15-24
Increase uptake, adherence and retention of eligible PLHIV on ART.
These focal areas have direct bearing on HIV prevention among OVCY. While the strategy specifically focuses on girls and young women, only three of the priority strategies are female- specific, and one – ART access – is not age specific. In the case of OVCY, sex with older partners and condom use could equally be emphasised for males.
Apart from these focal outcomes, it is also necessary to particularly focus on children and youth aged 15-24 with disability – the vast majority of whom are vulnerable as a product of disability. Similarly, attention should be given to young LGBTI, young sex workers, and young PLHIV whose vulnerability flows their HIV status. Young PLHIV are important actors in the HIV prevention response – both in relation to their potential to be involved in avoiding onward transmission of HIV and in being involved more broadly in the HIV prevention response.
It should also be emphasised that mental health is an important general issue pertaining to OVCY. Addressing mental health of OVCY through psychosocial support improves wellbeing as well as having a bearing on HIV prevention. Apart from direct support to addressing issues such as grief and bereavement and addressing coping and resilience in the context of vulnerability, mental health support has potential to reduce vulnerabilities linked to violence, abuse, coercion as well as orientations towards risky sexual behaviours.
Substance abuse is noted to be a burgeoning problem among youth in South Africa, and it appears that programmes to prevent and/or treat abuse in poorer communities are largely absent. There is an urgent need to adequately understand how to prevent initiation of abuse in the first instance, while also addressing rehabilitation and treatment on an ongoing basis.
4.3 Vulnerability to HIV through sex Physical and sexual violence occur at high levels in South Africa, and although the extent or differentiating features of vulnerability and occurrence in relation to OVCY has not been
Page 42 determined through demographic or epidemiological research, it can be anticipated that such vulnerabilities are higher among OVCY than non-OVCY. A particular vulnerability that has been identified for OVCY in various southern African countries, is that link between orphanhood and sexual abuse, which is linked to dislocations in care. OVCY are also particularly vulnerable to sexual exploitation and there is also a predisposition towards seeking emotional and material support as a product of inadequate care, food insecurity, and other aspects of living in poverty.
Studies show that the extent of vulnerability to such risks vary in relation to being an orphan, type of orphaning, gender, disability and other factors.
4.4 Family support Clearly, the extent of parental care – which includes care provided by carers other than biological parents – has a strong bearing on the resilience and coping capacities of OVCY. Since vulnerabilities of OVCY exist on a continuum, support to early childhood development and care during childhood has a bearing on later wellbeing. Orphans are particularly vulnerable, given that care arrangements may be uneven, and foster arrangements may include discrimination, neglect, exploitation and abuse. Support to families with a specific focus on addressing the needs of OVCY has potential to minimise and mitigate these factors.
Participatory group and peer oriented approaches to supporting OVCY have potential to address diverse aspects of psychosocial wellbeing.
4.5 Social protection for HIV prevention Social protection involves diverse approaches to supporting economically marginalised persons and households and is well grounded and widely implemented in South Africa. This includes good access to education, health and welfare services in the context of supportive legal and policy frameworks. While this framework is sound, social protection provisions occur in the context of widespread poverty and in geographic locales where living arrangements are suboptimal. Thus household vulnerability – and consequent vulnerability of OVCY is sustained.
In relation to HIV prevention among OVCY, research shows that social protection has a bearing on many facets of HIV-related vulnerability. For example, enrolling in school and maintaining school attendance is HIV protective. Particular successes have been achieved in the sphere of social grant provision, with the CSG on its own, and cash transfers in combination with other support, showing strong impacts on HIV risk reduction. Modalities of such transfers require further research and it is also important to extend analysis to measuring HIV incidence.
It is important that social protection also extends to contexts of risk, tackling particular issues such as substance abuse. Schools have been identified as primary actors in supporting response and fostering alternate activities including games of skill and various sports.
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It is also highlighted that while social protection ameliorates vulnerabilities, attention should be given to long-term sustainability in relation to poverty. In this regard community engagement and participation alongside community development as a whole should be prioritised.
4.6 An integrated approach As has been noted, South Africa has a robust social protection framework for responding to OVC – including extensive experience generated through programmes conducted by government, as well as those supported by donors and local NGOs. This response has a bearing on reducing vulnerabilities related to HIV, and has included components that are HIV-specific.
There is a gap in the focus of OVC work as it relates to the relatively recent inclusion of youth aged 18-24. This group has largely been addressed through national HIV prevention programmes that have not specifically targeted OVCY. As has been outlined in this review, there are particularities of OVCY that require specific formulations of response beyond that which falls into the domain of general HIV prevention programming.
Community ownership in general, and OVCY engagement and ownership in particular, should be encouraged. This would complement existing models of intervention, while also opening up potential for adaptation and innovation by drawing on the lived experience, intellect and creativity of OVCY as they negotiate their way through complex and difficult living arrangements.
To achieve these ends, it should not be overlooked that capacity development of the cadres of social welfare and health workers, as well as others involved in response, should be prioritised. It would also be of value to draw together experts in the field of HIV prevention and OVCY response who are in a position to clarify concepts and definitions of OVCY and to craft strategic guidance and set outcome goals and targets for addressing HIV prevention in South Africa.
5. IMPLICATIONS
5.1 Segmenting OVCY by age and vulnerability At a population level more than half of all children and youth in South Africa are living in poverty, and by definition, fall into the category of OVCY. There are also subgroups of youth who are vulnerable as a product of other circumstances, whether or not they are living in poverty – for example, living with disabilities, being exposed to substance abuse, being exposed to violence including sexual violence, being LGBTI, being exposed to transactional sex and sex work, or living with HIV. These vulnerabilities can be anticipated to deepen vulnerability when occurring in conjunction with poverty.
OVCY are vulnerable to HIV infection at various life stages including infancy (as result of maternal transmission), during childhood as a result of sexual abuse, during early adolescence as a result of early sexual debut, or sexual coercion, and late adolescence and early adulthood as a result of sexual relationships (some of which may be coercive).
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While there are overlapping definitions of childhood, adolescence, youth, age of legal consent, and orphanhood, the SADC age ranges provide a useful guidance for segmenting OVCY are relevant – i.e. 0-6, 7-12, 13-17, 18-24. These age ranges can be linked to various forms of exposure to HIV, various legal and policy guidance, and exposure to schooling. For example:
OVCY aged 0-6 are pre-school age, are at minimal risk of HIV infection (although some may be PLHIV as a result of maternal HIV transmission)
OVCY aged 7-12 are of primary school age, are at low risk of HIV infection (although may be infected through sexual abuse), are largely not sexually active (although 12 year olds can access condoms, contraceptives and HIV testing)
OVCY aged 13-17 are of secondary school age, are at high risk of HIV (particularly girls), and are at a transitional point in their sexuality, may be victims of statutory rape if exposed to sex under the age of 16, and girls may also become pregnant or be young mothers.
OVCY aged 18-24 are likely to be completing school or be out of school, are at high risk of HIV (particularly girls and young women – although HIV incidence increases among boys in their early 20s), girls and young women may become pregnant or be young mothers, and a relatively high proportion of this age group are living with HIV.
OVC aged 0-17 largely reside with one or both biological parents, or with blood relatives, or with foster or other carers. Orphans and vulnerable youth aged 18-24 reside in homes with varying family arrangements, or in residences linked to tertiary education institutions, or are living independently.
Sexual abuse is a particular vulnerability for OVCY in late childhood and early adolescence, and although girls are predominantly affected, this is not to the exclusion of boys. Perpetrators are often resident within the same household or close neighbourhood, or are connected through familial relationships. Disability is also an exacerbating factor for exposure to sexual abuse.
Throughout the data there is evidence that illustrates differentiating vulnerabilities between orphans and non-orphans. However, the demographic data also reveals that vulnerability and orphaning are fluid concepts with considerable variance and inconsistency in vulnerability to HIV infection. In the era of expanded ART in South Africa, illness and death rates of biological parents are likely to be decreasing (as was found in Uganda and shown in modelling for South Africa). Other studies have also highlighted the relevance of broader community approaches that focus on vulnerability as a whole. Although the historical burden of orphaning remains, the extent of new orphaning will be reduced. With regard to psychosocial support, it remains important to include therapeutic support to grief and bereavement.
Implication: OVCY should be segmented into age-groups recommended by SADC to allow for a life-stage based approach to HIV prevention. These age-groups are 0-6, 7-12, 13-17 and 18-24 years.
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Implication: Orphaning should be considered as one format of vulnerability which exists alongside other formats of vulnerability such as living in severe poverty, living with disability, exposure to violence and sexual exploitation, exposure to substance abuse, and living with HIV. Phasing out the current and historical emphasis on the distinction between orphans and vulnerable children and youth would allow vulnerability to be understood holistically.
Implication: Emphasis should be placed on legal provisions to address the sexual abuse of children, including increasing the extent of prosecution of perpetrators of statutory rape. Laws pertaining to these forms of sexual violence should be actively promoted. There is a need to foster safe spaces and trusted persons to whom abuse can be disclosed by victims, as well as a need to provide guidance on reporting and protection of persons affected. It should also be emphasised that persons of either sex may be perpetrators or victims.
Implication: Schools and family settings should be utilised as primary entry points for OVC aged 7-12 and 13-17 as well as older youth who are still in school or who reside with families. Reach into tertiary education institutions should be expanded to support OVCY aged 18-24. Secondary entry points would be through SRH services, social services, and community programmes.
Implication: Segment OVCY who are living with HIV and address unique needs linked to HIV status. Primary entry points for OVCY who are PLHIV include health services, social services and support groups. Organisations and networks of PLHIV could also be engaged.
Implication: Segment OVCY who are living with disability and address unique needs linked to disability status. Primary entry points extend to schools and institutions for children with disabilities, health and social services. Organisations and networks of persons with disability could also be engaged.
Implication: Segment OVCY who are LGBTI. Primary entry points extend to schools, networks and groups addressing the needs of LGBTI, as well as health and social services. Include nuances relevant to sexual risks and other vulnerabilities – for example, higher risk sexual exposure among homosexual boys and young men, and risks of severe violence directed towards lesbian girls and women.
Implication: Segment young sex workers. Primary entry points are venues where sex work is prominent such as transport routes and alcohol serving venues. Health and social services should include sensitivities to addressing this sub-group. Organisations and networks of sex workers could also be engaged.
Implication: Segment children and youth exposed to substance abuse. This includes exposure within family settings where caregivers abuse alcohol or drugs, as well as addressing children and youth who abuse alcohol or drugs. Close attention should be given to the emerging proliferation of cheap addictive drugs such as methamphetamine (tik), and combination drugs such as nyaope and whoonga.
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5.2 Support to OVCY and addressing sexual risks Various programmes in South Africa and elsewhere validate the relationship between the provision of economic support and HIV-related vulnerability reduction. While programmes focused on OVCY have tended to focus on geographic regions – i.e. priority provinces and districts most affected by high HIV prevalence – it is important to take into account that there is a relatively even national distribution of vulnerable children and youth as a product of poverty and unemployment affecting communities throughout the country. Various research highlights the importance of gender analysis.
Social protection through grant provision for vulnerable children and orphans is clearly impactful and remains a vital form of intervention. Grant provision should, however, be more distinctly linked to communication processes that address HIV-related vulnerabilities – in particular, the possibilities and risks of exposure to sexual exploitation, coercion and abuse (including statutory rape). Apart from awareness among families and OVCY themselves, it is important to clarify where and how to report abuse, and also to ensure that systems of support post-reporting are adequate to the task. Improving parent-child connectedness is also recognized as a means to reduce vulnerability to sexual abuse. Fostering a ‘children’s citizenship’ approach might also strengthen OVCY rights in combination with increasing capacity to give voice to rights infringements. This rights-based approach should include understanding and addressing various forms of abuse and exploitation including child labour, emotional abuse, physical and sexual abuse. Approaches such as Stepping Stones could be tailored towards supporting dialogue, reflection and group formation.
The Isibindi approach is clearly effective and should be scaled up, with inclusion and expansion of HIV prevention, care and support communication. The Children’s Institute has also identified the importance of more even support to NPOs, support directed through reform schools and schools of industry, and more considered expansion and linkages to EPWP funding and programming. A focus on livelihoods, building family and community resilience, and improving community-level ownership are relevant orientations for interventions.
OVCY who are HIV positive or are living with disability have particular needs and formats of support should address these particularities. Club and support group approaches are known to be effective. Supporting efficiency of health and social services to assist OVCY should also be emphasized. The CHAMP+/VUKA programme also shows promise.
Substance abuse has been identified as a gap area and requires intensified focus, including identifying and scaling up appropriate prevention, rehabilitation and treatment support.
The draft national strategy for HIV prevention focused on girls and young women outlines a range of key focal areas that will contribute to reduced incidence of HIV. These should be integrated into OVCY programming and nuanced accordingly. For example, approaches to delayed sexual debut should take the occurrence of early sex that occurs as a product of
Page 47 exploitation, coercion and statutory rape. Sex work among girls and young women is also likely to be linked to exploitation and coercion.
Implication: Focus on vulnerability of OVCY on a national basis to address vulnerability that prevails in all economically disadvantaged communities.
Implication: Incorporate gender analysis into all programmes.
Implication: Sustain social protection approaches through grants provision and ensure that there is integration of communication related to sexual vulnerabilities in family and care settings, and that children’s rights and citizenship are emphasized. Adapt and conduct participatory approaches such as Stepping Stones to support group formation and bolster articulation of rights at community level. In addition, pathways for OVCY to comfortably and confidentially report abuse and rights violations should be clarified and promoted. Collaboration with schools and educators would allow a conduit for such support, although social workers and home-based carers could also provide support.
Implication: Sustain and scale up the Isibindi programme, and address uneven support to NPOs.
Implication: Focal areas identified by SANAC for HIV prevention among girls and young women should be integrated into all OVCY programming and nuanced to the context of OVCY.
5.3 Integration Much of the support necessary to address HIV-related vulnerability among OVCY in South Africa is already incorporated into policy and programming. What has been highlighted in the present review is the need to intensify and scale-up successful approaches, ensure an even distribution of support nationally, nuance interventions to ensure HIV vulnerabilities are adequately articulated and addressed, and give attention to identified gap areas. Any expansion of present approaches would also require expanded focus on capacity development directed towards persons and entities involved in the response.
Implication: Engage in research and analysis for towards expanded policies and strategies to inform programming priorities and scale-up. Include capacity development as part of scale-up processes.
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7. ENDNOTES
1 South African National AIDS Council, 2012 2 Department of Social Development, 2009 3 Benham, 2013 4 Southern African Development Community, 2011a 5 Statistics South Africa, 2014 6 Children’s Institute, Children Count, 2014 analysis. www.childrencount.ci.org.za 7 Children’s Institute, Children Count, 2014 analysis. www.childrencount.ci.org.za 8 Data from Children’s Institute, Children Count, 2014 analysis. www.childrencount.ci.org.za; Statistics South Africa population reports; Shisana et al., 2014; SANAC 2014 9 Statistics South Africa, 2014 10 Shisana et al., 2014 11 Shisana et al., 2014 12 Shisana et al., 2014 13 Shisana et al., 2014 14 Statistics South Africa, 2014 15 Data from Children’s Institute, Children Count, 2014 analysis. www.childrencount.ci.org.za; Statistics South Africa population reports; Shisana et al., 2014; SANAC 2014 16 SADC, 2011b 17 Advocates for Youth, 2007 18 Shisana et. Al., 2014 19 See also Schenk et al., 2008 20 Seruwagi, 2012 21 Parliament of South Africa, 2008 22 United Nations General Assembly, 2001 23 Information on age thresholds for children and young people is drawn from Mahery & Proudlock, 2011 24 www.services.gov.za/services/content/Home/ServicesForPeople/Socialbenefits/ childsupportgrant/enZA 25 World Bank, 2004 26 Meintjes & Giese, 2006 27 Around one in eight (81%) children living apart from their parents have living parents residing elsewhere. www.childrencount.ci.org.za. 28 www.childrencount.ci.org.za 29 Meintjes et al., 2010 30 Sherr et al., 2008; Skinner et al., 2006 31 Meintjes & Giese, 2006 32 Daniel, 2011 33 Miller, 2007. 34 Sherr et al., 2008 35 Andrews et al., 2006; Belsey & Sherr, 2011 36 Lalthapersad-Pillay, 2008 37 Southern African Development Community, 2011a 38 Southern African Development Community, 2011b 39 Kruger, 2014 40 Colby-Newton, 2006 41 Bradshaw et al., 2004 42 Makumbi et al., 2012 43 Makumbi et al., 2012 44 Anema et al., 2011 45 Desmond, 2009 46 Brayant et al., 2012 47 Budlender et al., 2013 48 Cheney, 2013 49 Croce-Galis & Hardee, 2014 50 Department of Women, Children and People with Disabilities, 2012 51 Kukrety & Mohanty, 2011 52 Patel, 2012 53 Sabates-Wheeler & Roelen, 2011 54 McCleary-Sills et al., 2013; Heath et al., 2014 55 Donald et al., 2014 56 Jukes et al., 2008 57 FAO, 2010 58 Hannass-Hancock et al., 2011 59 WHO, 2002
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60 Long, 2011 61 Richter, 2004 62 Cluver et al., 2013b 63 Akwara et al., 2010 64 Campbell et al., 2010; See also Biemba et al., 2010 65 Bachman deSilva et al., 2012 66 Pinheiro, 2006 67 Barth et al., 2013 68 DSD, DWCPD & UNICEF, 2012; See also UNICEF, 2014 69 Burton & Leoschut, 2013. 70 Mathews et al., 2012 71 Birdthistle et al., 2011 72 Richter & Dawes, 2008 73 Jewkes et al., 2012 74 Leoschut & Burton, 2006 75 GenderLinks, 2014 (www.genderlinks.org.za) 76 Jewkes et al., 2002 77 Banwari, 2011 78 Petersen et al., 2005 79 Day & Pierce-Weeks, 2013 80 Wamoyi & Wight, 2014. 81 Cluver et al., 2011a 82 Sherr et al., 2014 83 Juma et al., 2013a 84 Juma et al., 2013b 85 Birdthistle et al., 2008 86 Nyirenda et al., 2010 87 Gregson et al., 2005 88 Chae, 2013 89 Thurman et al., 2006 90 Goldberg et al., 2013 91 Mkandawire et al., 2013 92 Magadi & Uchudi, 2014 93 Robertson et al., 2010 94 Operario et al., 2011 95 Operario et al., 2007 96 Peltzer & Tawanda, 2014 97 Haley & Bradbury, 2014 98 Rohleder, 2009 99 Levy et al., 2014 100 Hannass-Hancock, 2009 101 Hannass-Hancock & Nixon, 2009 102 Rohleder et al., 2010 103 Rohleder et al., 2012b 104 Wazakili et al., 2009 105 Rohleder et al., 2012a 106 Nell and Shapiro, 2011 107 Varghese et al., 2002 108 ActionAid, 2009 109 Nel & Judge, 2008 110 Rispel et al., 2011 111 SAFAIDS, 2008 112 Zembe et al., 2013 113 Shefer et al., 2012 114 SANAC, 2013 115 Shisana et al., 2014 116 Fisher et al., 2008; Parry et al., 2009 117 Leggett, Louw, & Parry, 2011 118 Parker & Makhubele, 2010 119 Meghdadpour et al., 2012 120 van Zyl, 2013 121 Nduna & Jewkes, 2012 122 PEPFAR, 2014
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123 Heyman & Kidman, 2009 124 Richter & Naicker, 2013 125 Morantz et al., 2013 126 Stein et al., 2014 127 Sherr et al., 2014 128 Stein et al., 2014 129 Knight et al., 2013 130 Richter & Naicker 2013 131 Andersen, 2012 132 Nyasani et al., 2009 133 Nyamukapa et al., 2010 134 Tamasane & Head, 2010 135 Nestadt et al., 2013 136 Mogotlane et al., 2010 137 Blaauw et al., 2011 138 Mokgatle-Nthabu, 2013 139 Mokgatle-Nthabu et al., 2011 140 Chi & Li, 2013 141 Cluver & Orkin, 2009 142 Weckesser, 2011 143 Nabunya & Ssewamala, 2014 144 Cluver & Gardner, 2007 145 Cluver et al., 2011 146 Escueta et al., 2014 147 Bachman deSilva et al., 2012 148 Puffer et al., 2012 149 Haour-Knipe, 2009 150 Majola, 2011; Henderson, 2013 151 Wild et al., 2013 152 Hlabyago & Ogunbanjo, 2009 153 Kuo & Operario, 2010 154 Kuo & Operario, 2011 155 Cluver et al., 2012 156 Kuo, 2013 157 Lachman et al., 2014 158 Demmer & Rothschild, 2011 159 Van der Heijden & Swartz, 2010 160 Fox & Parker, 2003; Wood et al., 2012 161 Khanare, 2012; Skovdal & Ogutu, 2012 162 Kirkpatrick, 2014 163 Witter & Were, 2004 164 See, for example, processes of ‘forgetting’ explored by Hutchinson, 2011 165 Betancourt et al., 2012 166 Richter et al., 2009 167 SAHRC/UNICEF, 2014 168 Statistics South Africa, 2013 169 UNAIDS, 2010 170 Tenmin, 2010 171 UNAIDS, 2010; Yates, 2009 172 Richter et al., 2010 173 Adato & Bassett, 2012 174 Adato & Bassett, 2012 175 Robertson et al., 2012; Sherr et al., 2009; Vadapalli, 2009 176 Devereux, 2013 177 Foster, 2010 178 McCord & Himmelstine, 2013 179 Baird et al., 2013 180 Bertozzi & Gutiérrez, 2013 181 Austrian & Muthengi, 2014 182 Dunbar et al., 2010 183 Handa et al., 2014 184 Barrientos et al., 2014; Pettifor et al., 2012 185 Gomersall, 2013
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186 Lund et al., 2008 187 Cluver et al., 2013a 188 Doherty et al., 2014 189 Pettifor et al., 2012 190 Cluver et al., 2014a; Pinkerton, & Muhangi, 2009 191 Cluver et al., 2014b 192 Robertson et al., 2013 193 Fieno & Leclerc-Madlala, 2014; Richter, 2010; Yablonski & Bell, 2009 194 Doherty et al., 2014 195 Barrientos et al., 2014; Roelen, 2011 196 Hiese et al., 2013; Gilmour et al., 2013; Sherr & Mueller, 2009 197 Jones & Samuels, 2014 198 Asaki & Hayes, 2011 199 Skovdal & Campbell, 2010 200 Taylor, 2010 201 Vujovic et al., 2014 202 Kajubi et al., 2014 203 Skovdal, 2012 204 Sherr et al., 2014 205 Malee et al., 2011 206 Petersen, 2010 207 Class, 2014 208 Mkwanazi, 2012 209 Gachanja, 2014 210 Midtbø et al., 2012 211 Moses, & Meintjes, 2010 212 Agwu, & Fairlie, 2013 213 Bain-Brickley et al., 2011; See also Davies, 2013 214 Mofenson, & Cotton, 2013; Sharma et al., 2013 215 Arrivillaga et al., 2013 216 Mburu et al., 2013 217 Mburu et al., 2014 218 Birungi et al., 2009 219 Buszaet al., 2013; See also Lowenthal et al., 2014b 220 Mattes, 2014 221 van Nuil et al., 2014 222 Fair et al., 2012 223 Fourner et al., 2014 224 Nyberg et al., 2012 225 Amon, 2002 226 Belton, 2014 227 Rogan et al., 2011 228 Hallman et al., 2010 229 Underwood et al., 2011 230 Hallfors et al., 2011 231 Miller et al., 2013 232 Osisa, 2012 233 Schmid et al., 2010 234 Bastien et al., 2011 235 Pillay & Twala, 2008; NACCW, 2007; http://www.naccw.org.za/isibindi 236 Thamaku & Daniel, M, 2012 237 Kidman et al., 2014 238 Schenk et al., 2010 239 Senefeld & Perrin, 2014 240 Skovdal & Daniel, 2012; Wood et al. 2012 241 Wallis et al., 2010 242 Levy et al., 2014 243 McKay et al., 2014 244 Bhana et al., 2010 245 Mellins et al., 2014 246 Mupambireyi et al., 2014 247 Chandan & Richter, 2009 248 Cluver et al., 2009
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249 Murphy et al., 2013 250 See UNICEF, 2010 251 Parker, 2014
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