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 Page 2 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 Page 3 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 Page 4 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. Page 5 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 .............................................................................................