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Helping Children cope with HIV and AIDS: The experiences and role of Childline

Joan van Niekerk, National Co-ordinator, Childline South Africa

Joan Van Niekerk, National Co-ordinator, Childline

Over the past decade, Childline has noted increasing numbers of children telephoning the crisis-line about various problems connected with the death of one or both parents. In 2001, the KwaZulu-Natal Branch noted that approximately 40% of all children who phoned in requiring a follow-up service, reported the loss of a parent.

Many children do not know the cause of death in these instances. It is clear that even within the family group, and especially in relation to children, there is secrecy about cause of death being HIV/AIDS. However, from the way in which children describe the illness and condition of the parent, it seems reasonable to attribute a significant proportion of these losses to the HIV/AIDS pandemic.

It is also clear that children become even more vulnerable to all forms of abuse and exploitation when their parent has died. Childline receives reports of children being taken in by extended family or neighbours, only to be used as domestic servants, sexually and physically abused, deprived of food, shelter, clothing, education and health care. These are children who have already been traumatised through witnessing the progressive decline of their parent(s), having usually taken on their nursing care at home, as well as having to process their own grief. Seldom is a child in this situation offered bereavement counselling. Many of these children are shunned by their families and communities due to the stigma that is still attached to HIV/AIDS, despite its high prevalence.

The baby that was saved by anti-retrovirals (two co-habiting wives whose husbands have been lost to HIV/AIDS) returning from the clinic. Courtesy, the African Art Centre (Artist: Lobolile Ximba). Artists Action Around AIDS exhibition, Durban Art Gallery.

Linking these children to care and resources is often problematic. Child Welfare Societies and other civil society organisations that have traditionally provided care and

protection for children are overwhelmed by the numbers of those orphaned and abandoned, coupled with a lack of adequate structural resources and capacity. Government subsidies to children's services have not kept pace with the increasing numbers of children requiring these services. In some Provinces, for example KwaZulu-Natal, government welfare services to children are woefully slow to respond to children's needs. KZN Childline has recorded hundreds of referrals to State welfare services for children in urgent need that have clearly not been attended to.

Child victims of sexual assault

In 1993, the first child diagnosed as HIV-positive as a result of sexual abuse was referred to Childline therapy services. She was just under two years old. Both of her parents were HIV-negative. Her caretaker was changing her nappy one day and noticed that the child had a vaginal discharge and her genital area did not "look normal". She drew this to the mother's attention, who promptly took the baby to the doctor, where the child was diagnosed with gonorrhoea as the result of being sexually abused. The doctor also took blood from the baby and requested the pathology laboratory to screen for all sexually transmitted illnesses. Neither he nor the child's mother anticipated an HIV-positive result, and they were devastated when the result was returned. The baby was re-tested and so were her parents, but the result was confirmed. The mother became severely depressed, and for months struggled to cope. The child was pre-speech at the time and to this day, neither the family nor Childline knows who sexually assaulted her. She was the first of many, many more…

Sadly, it is estimated that only 15% of all sexually assaulted children disclose the abuse within the 72-hour period required for effective use of PEP. Children do not report the abuse promptly because they are easily intimidated, often deeply shamed by the event, fear the loss of needed resources where the abuser is the breadwinner, may feel guilty and responsible for what has happened, and are afraid of being punished. One of our biggest challenges in the child protection field is to facilitate disclosure of sexual assault before infections (and pregnancies in the older child) take hold. In reality, the abuse is reported only when the child is symptomatic.

Over the last 10 years, Childline Offices have begun to work with increasing numbers of children who are HIV-positive as a result of sexual abuse. This is particularly apparent in KwaZulu-Natal, but actual numbers are difficult to ascertain for a number of reasons:

• Some parents refuse HIV testing for their children. Although superficially, this may appear to be uncaring, some caretakers are so devastated by the rape of their child that they tell us they simply cannot cope with this extra burden and therefore do not want to know. With the advent of post-exposure prophylactic (PEP) medication after sexual assault, Childline staff try to persuade every victim's parent who reports sexual assault to attend a medical facility as rapidly as possible. This is sometimes very difficult. Frequently, the victim / caretaker lacks transport or the means to attend hospital; sometimes, even when the report is made timeously to the South African Police Services, the matter is not dealt with promptly and the victim is not taken to a medical facility in time for PEP to be effective.
• Childline has encountered incidents where children have not been given appropriate medical care and testing after sexual assault.
• Sometimes caretakers do not return to the medical facility for repeat testing and/or collection of test results. This is sometimes due to a lack of means, especially where the child and parent live some distance from the medical facility.
• Sometimes, pre- and post-test counselling for the caretaker and child is not given, or is given but inappropriately. Many older children and caretakers do not know what tests and treatments have been administered.
• Parents and children may choose not to disclose test results to the counsellor. This is, however, unusual as most caretakers / parents who are informed about the HIV/AIDS test results are so devastated by an HIV-positive result for their child that this is often the first issue presented in therapy for discussion.
  

Services to the HIV-positive Sexually Assaulted Child and Family:

• Many children and parents need extensive counselling on the test result. It is essential not to assume that pre- and post-test counselling in our busy State hospitals and clinics is either available to every patient or conducted in such a way that the information can be assimilated. Children are often not included in the counselling sessions at all and so the parent / caretaker often faces the dilemma of whether and what to tell the child about the test result.
• Sometimes families and children are not informed of the HIV result and this is only noted on the SAPS docket with the J88 - the forensic medical examination form. Childline has been contacted by the State Public Prosecutor to assist in a situation where the HIV-status of the child was unknown to the parent / caretaker until the trial of the accused in the sexual assault case.
• Many parents need extensive counselling on care of their HIV-positive child, as well as counselling for themselves. Some see the test result as almost an immediate death sentence for the child. Parents and caretakers are therefore counselled and referred for further information on practical issues relating to child care, the management of normal childhood accidents at home and at school, nutrition, inoculations etc. Counselling also needs to focus on the feelings of the caretaker / parent - many are incapacitated by guilt, shame, grief and anxiety.
• Parent and caretakers need guidance as to how much to share with the child, depending on its age and level of maturity. Childline advocates for appropriate openness for a number of reasons:

  a. Childline subscribes to the rights of children to have information and be involved in decisions affecting their lives when this appropriate to their age and level of maturity. This right is contained in the United Nations Convention on the Rights of the Child, ratified by the South African Government.

  b. A caretaker cannot continuously be with the child and children.

  c. Childline does advocate for learning about appropriate self-care as children achieve higher levels of maturity and have to learn to cope with the scrapes and cuts that are part of normal childhood.

  d. Many sexually abused children, especially those who are abused in seductive relationships, become sexualised as a result of the abuse. They need extensive counselling as they are often vulnerable to repeated incidents of sexual victimisation, and engagement with other children and adolescents in sexual behaviour. Responsible management of their sexuality is therefore an important focus of therapy and counselling for them.

• Tragically, many children who have become infected through sexual abuse only come to Childline's attention when they are very ill. They tend to deteriorate into HIV/AIDS-related illnesses rapidly because of poor sanitation and nutrition and exposure to repeated infections. Helping the caretaker/family to manage the terminally ill child and working with the child directly are important components of Childline's care of infected children.
  

To what extent is the myth that sex with a virgin will cure HIV/AIDS responsible for the increase in sexual assault on children?

This is impossible to assess this theory accurately. Childline comes across this myth in our work with youth, especially youth in disadvantaged circumstances and communities. Childline has twice been told of the myth by young offenders who have infected children and cited it to explain their abusive sexual behaviour.

Reliable data for measurement of the prevalence and impact of the myth is problematic because, firstly, most sexual offenders vehemently deny the sexual assault and few are convicted. Although the criminal justice system claims a conviction rate of 7% on all reported cases of sexual abuse, the CIETAfrica research gives a very different picture (www.cietafrica.org.za). It therefore becomes very difficult to understand the motivation behind the sexual assault when offenders deny the offence itself and are rarely convicted.

Yet, because the "virgin cure" still abounds, Childline has expanded its activities in child abuse prevention and education activities to ensure that in every programme, elements of responsible sexuality and HIV/AIDS prevention are included.

Clearly, the HIV/AIDS pandemic is touching the lives of all South Africans. However, the impact of the pandemic on vulnerable children is of special and urgent concern, even more so because children need the protection and care of adults and have no "voice" except through the adults in their world.

Childline South Africa is a national affiliation of Child Help-lines. There are regional Childline Offices in seven of the nine provinces in South Africa - Eastern Cape, Free State, Gauteng, KwaZulu-Natal, Mpumalanga, North West, and Western Cape. ChildLine's toll-free crisis help-line for children, and adults with concerns about children, however, serves the entire country, including the Limpopo and Northern Cape provinces.

The core services that are common to each Childline regional office are:

• Managing the crisis line and responding to the calls that are made to the toll-free number – 0800 055 555. At present approximately 50 000 – 55 000 calls are made to the crisis-line every month. Although many calls are test calls, significant numbers of children telephone the crisis-line to talk about and ask for help with significant problems affecting their lives such as poverty, physical, sexual and emotional abuse, violence in the home, alcoholism/drug use of a parent/caretaker, information about HIV/AIDS, sexual behaviour, other sexually transmitted diseases, abandonment and relationship problems. Adults with concerns about children also call about similar issues as well as discipline, streetchildren, begging children, and abandoned children.
• Prevention and education about child abuse and children’s rights. Over the past decade there has been a significant increase in reported child abuse (as reported on www.saps.gov.za). It is difficult to know whether the increase is a real increase in incidents of child abuse, or whether children are more aware of abuse and to whom abuse can be reported. In Childline’s opinion the increase can be attributed to both factors. What is of note is the large increase of reported sexual abuse of very young children. Sexual assault of young children does not go unnoticed because of the injuries that are frequently sustained during such an assault. Ten years ago, the rape / sexual assault of a child under the age of seven years was a rarity. During 2002, approximately 40% of +/- 1500 children referred for psycho-social treatment services after sexual assault in KwaZulu-Natal are aged seven years and younger. In the Pietermaritzburg Childline treatment service, of the 100 children referred for therapy after sexual assault during the period January to April 2003, 63 were aged seven years and younger. All the Childline Regional Offices are therefore engaged in programmes in schools and communities to educate children and adults about children’s rights and child abuse, as well as promoting life-skills education, in an effort to reduce incidents of abuse and to encourage the development of alternative self-management skills to deal with anger, frustration, alternatives to corporal punishment when disciplining a child, and responsible management of sexuality and relationships.

Some of the regional Childline offices also offer:

• psycho-social treatment for the child and family / caretaker after physical, sexual and emotional abuse
• court preparation for the child witness
• networking and co-ordination across sectors to facilitate optimal management of reported child abuse
• treatment/rehabilitation services for offenders who have committed offences against children, particularly young sexual offenders who are themselves children
• Participation in local, provincial and national policy and legislation development.