**1.5 Prevalence of Child Sexual Abuse in Zambia**

Zambia is a country in sub-Saharan Africa where the problem of CSA is compounded by HIV prevalence of 19.7 % in urban adults compared 10.3% in rural adults (p<0.00001)(ZHDS 2007). There are no studies on the prevalence of CSA in Zambia. The OSC was established specifically to offer post exposure HIV prophylaxis to children sexually abused.

Lusaka is the capital of Zambia with a population of close to 2 million (ZHDS 2007).

UTH houses the only medical school in the country and the schools of Registered Nurses and Midwifery. The paediatric department is the busiest deparment within the UTH catering mainly for management of the aqcutely ill. Most of the children before the establishment of the OSC were cared for at the department of obsterics and gynaecology. Though there is significant emphasis on prevention of mother to child HIV transmission in Zambia, HIV transmission through CSA had been a neglected issue. The contribution of CSA to the HIV pandemic remains unknown. However, the impact of HIV on children has been evaluated.

Children have been much affected by the HIV/AIDS epidemic in Zambia, where over 30,000 children are HIV positive (UNAIDS Report 2007). Perinatal transmission accounts for the majority of pediatric HIV infections where HIV prevalence is high. However, sexual exposure remains an important risk factor in children in the post-weaning period. While HIV transmission rates attributable to sexual abuse are unknown, pediatric victims of sexual abuse are at a higher risk of HIV transmission due to physical trauma and due to the fact that multiple exposures often occur prior to discovery of the abuse (Lindegren ML et al 1998).

In a pilot study conducted at the UTH in 2003, 99% of sexually abused children reporting to the gynecology ward were female, which also placed them at a higher risk for HIV acquisition (Chomba et al 2006).

Although epidemiologic data for the prevalence of child sexual abuse (CSA) in Zambia is not available (Collings 2002), recent establishment of one stop centres will help in providing some information on factors associated with child sexual abuse thus help to unravel the extent of the problem.

Literature from countries surrounding Zambia documents the existence of a CSA epidemic in the region. Prevalence studies rely on cross-sectional study design, most often surveying school children about their experiences of sexual abuse. In a review article of child sexual abuse in sub-Saharan Africa, Lalor et.al. report that between 3.2 and 7.1% of all respondents

Risk Factors in Sexually Abused

psychosocial counseling,

Emergency contraceptives

cases nor neglected children.

gonorrhoea, trichomonas, and spermatozoa).

youth.

**4. Methodology** 

treatment of sexually transmitted infections (STIs.)

Referral to HIV Clinic for HIV positive children (PTSD)

Evaluation of Post Traumatic Stress Disorders

Children Reporting to the One Stop Centre at University Teaching Hospital in Zambia 117

In most western countries Child Advocacy Centers (CACs) are not located within medical institutions and offer a more comprehensive package to include physical abuse as well as child neglect (Downing 2002, Hansen 1998). We chose to establish the multidisciplinary centre within the pediatric department because most the sexually abused children came to the attention of the health workers because of medical complications (Chomba,Kasese-Bota Haworth, Fuller, Amaya, 2006) and in order to offer PEP to abused children, which was only available at the UTH. The centre would not provide services for isolated physical abuse

The One Stop Centre was established in the pediatric department on 26th April 2006. A location was selected where there was minimal foot traffic, and there are no conspicuous notices indicating its function to help preserve the confidentiality of the children and their guardians attending the center. The Centre included a physical examination room and several interview rooms including one with a two way mirror, microphone and speakers which allows one person to interview (usually a medical person) whilst the police officers and counsellors take notes from another room. The centre is equipped with comfortable

The Centre has employed one medical doctor who oversees medical examinations and attends to court cases, one clinical officer who performs physical examinations; one police officer who documents on police medical forms and ensures that they are delivered to the prosecutors; one social worker who follows up children in the community and advises on

Intake interviews are conducted with the caregiver and child separately (if the child is able). Information on demographic characteristics and abuse history is collected. A medical/laboratory form includes the following tests: HIV, RPR, pregnancy, Hepatitis B and forensic specimens (High vaginal swab for wet prep, gram stain and culture to identify

Mental health assessments for the youth include the Post-traumatic stress disorder – Reaction Index, the Strengths and Difficulties Questionnaire, and My Feelings About the Abuse. This last measure specifically examines the construct of shame, which is considered to be critical in the Zambian culture. The mental health assessment administered to the

A systematic flow has been designed to promote excellence in the care of sexually abused

2. Once the family has both forms, they are directed to the centre where they are greeted by the social worker and/or nurses. Youth and their care-givers are immediately asked

child-friendly waiting facilities (TV set, toys and educational materials).

caregivers about the abused child is the Child Behaviour Checklist.

1. Family register at UTH main desk and receives a treatment form

if the abuse happened within the last 72 hours.

rehabilitation; and three nurses who assist the physician and the clinical officer.

report unwanted or forced sexual intercourse before the age of 18 years (Lalor 2004). Jewkes et al. surveyed 11, 735 South African women between the ages of 15 and 49 years about their history of rape during childhood. Overall, 1.6% reported unwanted sexual intercourse before the age of 15 years of age. 85% of child rape occurred between the age of 10 and 14 years and 15% between the ages of 5 and 9 years (Jewkes, Levin et al. 2002). In a study in Zimbabwe, Birdthistle reports that among unmarried, sexual active adolescents, 52.2% had experienced forced intercourse at least one time. 37.4% of first sexual intercourse acts were forced (Birdthistle IJ 2008). In a study of 487 university students in Tanzania, 11.2% of women and 8.2% of men reported unwanted sexual intercourse. The average age at the time of abuse was 13.6 years (McCrann D 2006). Collings et al (Collings 2002) surveyed a sample of 640 female university students in South Africa and found that 34.8% had experienced contact sexual abuse before the age of 18 years. Another study among high school students in South Africa (Nadu 2002), found that almost 20% were victims of parental or guardian sexual abuse. Additional research suggests that the prevalence of child sexual abuse in sub-Saharan Africa is similar to other countries across the world (Lalor 2004).
