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Protecting Children in the Age of HIV and AIDS

11 Sep 2013
Gretchen Bachman, Senior Technical Advisor and Team Lead, Orphans & Vulnerable Children - USAID Office of HIV/AIDS PEPFAR OVC Inter-Agency, Technical Working Group Co-chair,
Investment in programs that address child maltreatment and gender-based violence, in tandem with social protection schemes that relieve stress on fragile families, is essential to achieving an AIDS Free Generation. While the causal relationships between AIDS, poverty and abuse are complex and not always clear, what is clear is that the combination creates a toxic environment for children.

The relationship between child abuse and HIV and AIDS is particularly multi-faceted. Child sexual abuse can directly increase the risk of exposure to HIV and other STDs and, along with other forms of abuse, can have devastating effects on a child’s functioning over time. Western studies have shown that a history of "adverse childhood experiences", including several forms of abuse, underlie preventable risk factors for the transmission of HIV such as injecting drug use, promiscuity, and ever having a sexually transmitted disease (HIV among others)1. Emerging evidence from several African countries points to a similarly strong relationship between experience of child sexual abuse and physical abuse and a range of later risk factors, including age at first sex, alcohol and drug use, and intimate partner violence.2

A child’s HIV status can increase the likelihood of being maltreated and increase the chance of them being placed in institutional care without the love and support of a family.3 The presence of HIV or AIDS in a family may also increase abuse and sexual risk behavior although the causal links are not clear. The stress of HIV or AIDS and its potentially impoverishing effects, a pattern of inter-generational violence, harmful cultural norms, and separation from family may individually or concurrently play a role in creating an environment that puts a child at heightened risk for maltreatment. For example, in South Africa a recent longitudinal study of 723 children found that adolescents who are AIDS-orphaned and/or living with an aids sick caregiver are highly vulnerable to severe physical and emotional abuse, and girls in such situations, in particular, were more likely to engage in exploitative transactional sex.4

Recent studies in lower and middle income countries demonstrate that the prevalence of child abuse is far more prevalent than many people, including policy makers, may realize.5 Child abuse surveillance has spurred the political will and provided the data necessary to launch a response to children in Western countries and has the potential to do so in lower and middle-income countries.6 The introduction of regular surveillance systems that measure the prevalence of violence against children together with the establishment of routine reporting systems that track outcomes of child protection efforts are some of the key investments made by programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR). Related efforts to bolster child protection systems, from informal community responses to formal government and civil sector actors, prioritized by PEPFAR include supporting an enabling policy and legislative environment, strengthening the social welfare work force, and establishing capacity to respond to gender-based violence and other forms of abuse.7

Although these child protection investments are crucial they must be paired with concomitant social protection programs to relieve stress on parents and other caregivers, in particular financial strain. Efforts to reduce financial strain through social protection programs, such as cash transfers that provide a reliable source of funds to families in desperate circumstances, are gaining momentum within HIV and AIDS programs.8 Cash transfer programs in high prevalence HIV settings show increasing promise in terms of child protection outcomes and reduction of risk behaviors.8,9 Importantly, cash transfer programs also appear to positively impact the quality of care for persons living with HIV and may consequently contribute to preserving family structures.11

Other interventions to support parents are also gaining ground. PEPFAR’s Blueprint for an AIDS Free Generation identifies parenting programs as an area of focused intervention to help children achieve their full developmental potential. Parenting interventions studied in higher income countries have demonstrated impact on a number of factors pertinent to the HIV and AIDS response including prevention of child maltreatment and reduction in adolescent risk behaviors. Such programs however range greatly in design, intent and effectiveness and, most importantly, they are not easily replicated in terms of cultural appropriateness or cost.12 For these reasons, building the evidence base on effective parenting programs in low to middle income countries with high HIV prevalence will be a focus area for PEPFAR moving forward.

Incredible advances in HIV treatment occurred with the discovery of therapeutic regimens that combine three drugs to create multiple obstacles to virus replication. While there is no pill to reduce vulnerability in the age of AIDS, the triple combination of social protection, child protection and parenting may well prove to be the game changer for children as PEPFAR approaches its second decade.

The views included in this commentary do not necessarily reflect the views of the United States Agency for International Development or the President’s Emergency Plan for AIDS Relief.

Sources:

1Hillis, Susan D., et al. "Adverse childhood experiences and sexually transmitted diseases in men and women: a retrospective study." Pediatrics 106.1 (2000): e11-e11. 2Richter, Linda, et al. "Reported Physical and Sexual Abuse in Childhood and Adult HIV Risk Behaviour in Three African Countries: Findings from Project Accept (HPTN-043)." AIDS and Behavior (2013): 1-9. 3Doring, Marlene, et al. "Factors associated with institutionalization of children orphaned by AIDS in a population-based survey in Porto Alegre, Brazil." Aids 19 (2005): S59-S63. 4Cluver, Lucie, et al. "Transactional sex amongst AIDS-orphaned and AIDS-affected adolescents predicted by abuse and extreme poverty." JAIDS Journal of Acquired Immune Deficiency Syndromes 58.3 (2011): 336-343. 5Reza, Avid, et al. "Sexual violence and its health consequences for female children in Swaziland: a cluster survey study." The Lancet 373.9679 (2009): 1966-1972. 6AlEissa, Majid A et al. A commentary on national child maltreatment surveillance systems: Examples of progress. Child Abuse & Neglect. 2009. n.p. http://www.biomedsearch.com/nih/commentary-national-child-maltreatment-surveillance/19854510.html 7"Pepfar Blueprint: Creating an AIDS Free Generation," The Office of the Global AiDS Coordinator, November 2012 < http://www.pepfar.gov/documents/organization/201386.pdf> 8Miller, Elizabeth and Michael Samson (2012) "HIV-sensitive Social Protection: State of the Evidence 2012 in sub- Saharan Africa." Commissioned by UNICEF and Produced by the Economic Policy Research Institute, Cape Town. 9Baird SJ, et al. "Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomized trial", The Lancet 2012; 379: 1320-29 10Barrientos, A., J. Byrne, J.M. Villa, P. Peña (2013). ‘Social Transfers and Child Protection’, Working Paper 2013-05. UNICEF Office of Research, Florence 11Miller, C., and M. G. Tsoka. "ARVs and cash too: Caring and supporting people living with HIV/AIDS with the Malawi Social Cash Transfer." Tropical Medicine & International Health 17.2 (2012): 204-210 12Richter, L., "A Review of Published Literature on Supporting and Strengthening Child-Caregiver Relationships (Parenting)," USAID AIDSTAR One Project, May 2013, < http://www.aidstar-one.com/focus_areas/ovc/report/parenting_lit_review>