Success in child health not matched by efforts to curb sexual abuse and violence

In prioritising child and adolescent health, we need a quantum leap to rid our society of its ills.

Over the past 10 years, SA has achieved remarkable successes in child health. The number of children who die before the age of five years has decreased. We are on track to meet our 2019 under-five mortality target, which has decreased to 32 per 1,000 live births.

Remarkable successes have also been documented in reducing deaths among adolescent girls. The probability of them dying before the age of 25 decreased dramatically between 2000 and 2017.

HIV prevalence among pregnant adolescent girls aged 15-19 years also decreased from 15.4% to 11.3% between 2001 and 2017. This has helped keep the proportion of pregnant women living with HIV stable at about 30% since 2004.

Improved policies to prevent HIV transmission from mother to child have resulted in a sharp and significant decline in new HIV infections in children.

Despite almost one-third of children being exposed to maternal HIV infection during pregnancy, transmission of HIV from mother to child by the end of breastfeeding decreased from 31.2% in mid-2004/2005 to 5.2% in 2016/2017.

For every 100 children born to HIV-positive women on antiretroviral (ARV) treatment and virally suppressed (with a maternal HIV viral load lower than 50 copies per mL), only one child will be infected with HIV by six months, and three by 12 months.

Such successes are phenomenal.

However, any euphoria is quickly doused by several realities. First, the number of children aged 0-14 years who are HIV-negative yet exposed to maternal HIV infection in SA has more than doubled, from 1.3-million in 2004 to 3.2-million in 2017. This is the highest number within any country globally, representing 21.5% of the global population of HIV-exposed but uninfected children.

There is evidence that HIV-exposed uninfected children, born to mothers who are not optimally managed, or who started ARV treatment during pregnancy or postnatally, may be at higher risk of death, poor growth, recurrent acute or chronic respiratory (chest) illness and poor neurodevelopmental outcomes if they are not cared for appropriately.

These HIV-exposed uninfected children require routine care (such as immunisation, breastfeeding support and growth monitoring). They also need HIV-related care, such as maternal ARV drugs to keep maternal HIV viral load lower than 50 copies per mL (viral suppression), especially during breastfeeding, infant ARVs during breastfeeding and regular infant HIV testing are necessary, during, and six-weeks post-cessation, of breastfeeding.

Special care needs to be taken to screen for respiratory illnesses and manage possible neurodevelopmental delay. Exposure to maternal HIV and ARVs increases the risk of prematurity.

This necessitates expansion of our labour, delivery and newborn-care services to optimise the management of potentially larger numbers of premature and low-birth-weight (less than 2.5kg) babies.

Second, SA is experiencing an epidemic of gender-based violence and violence against children. Recent analyses from a large Birth to Twenty Plus (Bt20+) study, led by the DST-NRF Centre of Excellence in Human Development at Wits University, among children born in Soweto in 1990, found that 99% of these children had experienced or witnessed some form of violence.

About 40% of those children had multiple experiences of violence in their homes, schools and communities. A greater proportion of boys (44%) had experienced all forms of violence, compared with girls (30%).

The study estimated that about 355,000 cases of sexual abuse had occurred among children aged 15-17. It said that girls were twice as likely as boys to be victims of forced penetrative sex and that more boys than girls were affected by non-contact sexual abuse such as exposure to pornography.

The Bt20+ data shows that sexual abuse among boys is widespread and increases with age — from 16% of 13-year-olds to 29% of 18-year-old boys reporting sexual abuse, either in the form of unwanted touching or coerced oral or penetrative sex.

Of concern is that our efforts have, until recently, focused on adolescent girls and young women. Yet young boys, adolescent boys and men have been neglected. That they cannot be left out is substantiated by the fact that they are perpetrators and victims of violence, and that the mortality rate among males aged 15-24 years has not declined since 2011.

Initiatives such as Mentor the Boy Child and Take a Boy Child to Work need to gather momentum so that young boys can be mentored to take on non-violent, non-aggressive dispositions that respect young girls, women, other boys and men, and that do not fuel homophobia.

In summary, despite our successes with child and adolescent health, we need to accelerate improvements over the next few years, and children need to take centre stage.

We need to invest in the development of the boy child from a young age, creating safe environments for children, growing enthusiastic adults and entrepreneurs and building a culture of mutual respect in order to safeguard the health of children today and that of future generations. This could facilitate the quantum leap we need to rid our society of its current ills.

• Goga is the deputy director of the health systems research unit and interim director of the HIV prevention research unit at the South African Medical Research Unit and a contributor to the South African Child Gauge 2019, which is published by the Children’s Institute, University of Cape Town